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NEW ORLEANS – A reasonable stepwise approach to pharmacotherapy for agitation in outpatient dementia begins with a judiciously chosen SSRI as first-line therapy, with the second-line consisting of augmentation with a benzodiazepine, M. Philip Luber, MD, said at the annual meeting of the American College of Physicians.
If this combination doesn’t provide satisfactory improvement after adequate dosing for sufficient duration, only then is it time to turn to an atypical antipsychotic agent as a higher-risk/higher-reward third-line therapy, added Dr. Luber, professor of psychiatry and associate dean for graduate medical education at the University of Texas, San Antonio.
He emphasized, however, that medications are not the first-line therapy for agitation in outpatients with dementia. That distinction belongs to psychosocial interventions.
“Utilize a social worker to assist the family in modifying the environment: family settings and people, regular routines, consistently orienting the patient, keeping stimulation at a low to moderate level. When that’s done right, it can really dampen down a lot of agitation,” he said.
Dr. Luber noted that the formal randomized trial evidence base for SSRIs as first-line pharmacotherapy and benzodiazepines as second-line is quite limited. But in conversations with geriatric psychiatrists and other health care professionals around the country who are working in this area, he has found broad agreement that this is a good strategy.
“A lot of folks don’t realize that [SSRIs] are actually very useful in the treatment of agitation in dementia. But you want to choose one with fewer side effects and drug-drug interactions,” Dr. Luber said.
Two SSRIs that fit the bill are escitalopram (Lexapro) and sertraline (Zoloft). Start low and increase the dose slowly, provided circumstances allow. Expect a therapeutic response to emerge in weeks, not days. And, in this elderly population, be sure to monitor for hyponatremia.
When considering augmentation, remember that “using benzodiazepines in the elderly is controversial, particularly with agitation in dementia. There is very little randomized clinical trial data on benzodiazepines in dementia. Actually, though, there are lots of clinical trials of benzodiazepines in dementia that feature benzodiazepines as rescue medication. So, clinically, there’s an awareness that the drugs work, but they haven’t been studied except as rescue medication,” he explained.
The phenomenon of paradoxical agitation occurring in elderly patients on benzodiazepines “is something to be careful about, but in fact it’s pretty uncommon. Just watch for it,” he added.
Dr. Luber is among many geriatric psychiatrists who preferentially turn to clonazepam (Klonopin) because its relatively long half-life allows for twice-daily administration.
“Think about using it regularly rather than PRN. You want to stay ahead of the agitation rather than behind it,” he advised.
Patients with liver disease are better served by a shorter-acting benzodiazepine such as lorazepam (Ativan), which is not oxidized in the liver.
Also controversial is use of atypical antipsychotics as third-line pharmacotherapy, “but many geriatric psychiatrists would agree with me that the next step if the patient is still agitated despite an SSRI augmented with a benzodiazepine is to consider a trial of an atypical antipsychotic,” Dr. Luber said.
He pointed to risperidone (Risperdal) and aripiprazole (Abilify) as agents with a good track record for treatment of agitation in dementia. He urged primary care physicians to be familiar with the risk of serious and even potentially fatal side effects as described in the black box warning.
“There are tough choices involved in treating patients with this disorder. Use shared decision making with the patient or family,” Dr. Luber said.
He reported having no financial conflicts of interest regarding his presentation.
NEW ORLEANS – A reasonable stepwise approach to pharmacotherapy for agitation in outpatient dementia begins with a judiciously chosen SSRI as first-line therapy, with the second-line consisting of augmentation with a benzodiazepine, M. Philip Luber, MD, said at the annual meeting of the American College of Physicians.
If this combination doesn’t provide satisfactory improvement after adequate dosing for sufficient duration, only then is it time to turn to an atypical antipsychotic agent as a higher-risk/higher-reward third-line therapy, added Dr. Luber, professor of psychiatry and associate dean for graduate medical education at the University of Texas, San Antonio.
He emphasized, however, that medications are not the first-line therapy for agitation in outpatients with dementia. That distinction belongs to psychosocial interventions.
“Utilize a social worker to assist the family in modifying the environment: family settings and people, regular routines, consistently orienting the patient, keeping stimulation at a low to moderate level. When that’s done right, it can really dampen down a lot of agitation,” he said.
Dr. Luber noted that the formal randomized trial evidence base for SSRIs as first-line pharmacotherapy and benzodiazepines as second-line is quite limited. But in conversations with geriatric psychiatrists and other health care professionals around the country who are working in this area, he has found broad agreement that this is a good strategy.
“A lot of folks don’t realize that [SSRIs] are actually very useful in the treatment of agitation in dementia. But you want to choose one with fewer side effects and drug-drug interactions,” Dr. Luber said.
Two SSRIs that fit the bill are escitalopram (Lexapro) and sertraline (Zoloft). Start low and increase the dose slowly, provided circumstances allow. Expect a therapeutic response to emerge in weeks, not days. And, in this elderly population, be sure to monitor for hyponatremia.
When considering augmentation, remember that “using benzodiazepines in the elderly is controversial, particularly with agitation in dementia. There is very little randomized clinical trial data on benzodiazepines in dementia. Actually, though, there are lots of clinical trials of benzodiazepines in dementia that feature benzodiazepines as rescue medication. So, clinically, there’s an awareness that the drugs work, but they haven’t been studied except as rescue medication,” he explained.
The phenomenon of paradoxical agitation occurring in elderly patients on benzodiazepines “is something to be careful about, but in fact it’s pretty uncommon. Just watch for it,” he added.
Dr. Luber is among many geriatric psychiatrists who preferentially turn to clonazepam (Klonopin) because its relatively long half-life allows for twice-daily administration.
“Think about using it regularly rather than PRN. You want to stay ahead of the agitation rather than behind it,” he advised.
Patients with liver disease are better served by a shorter-acting benzodiazepine such as lorazepam (Ativan), which is not oxidized in the liver.
Also controversial is use of atypical antipsychotics as third-line pharmacotherapy, “but many geriatric psychiatrists would agree with me that the next step if the patient is still agitated despite an SSRI augmented with a benzodiazepine is to consider a trial of an atypical antipsychotic,” Dr. Luber said.
He pointed to risperidone (Risperdal) and aripiprazole (Abilify) as agents with a good track record for treatment of agitation in dementia. He urged primary care physicians to be familiar with the risk of serious and even potentially fatal side effects as described in the black box warning.
“There are tough choices involved in treating patients with this disorder. Use shared decision making with the patient or family,” Dr. Luber said.
He reported having no financial conflicts of interest regarding his presentation.
NEW ORLEANS – A reasonable stepwise approach to pharmacotherapy for agitation in outpatient dementia begins with a judiciously chosen SSRI as first-line therapy, with the second-line consisting of augmentation with a benzodiazepine, M. Philip Luber, MD, said at the annual meeting of the American College of Physicians.
If this combination doesn’t provide satisfactory improvement after adequate dosing for sufficient duration, only then is it time to turn to an atypical antipsychotic agent as a higher-risk/higher-reward third-line therapy, added Dr. Luber, professor of psychiatry and associate dean for graduate medical education at the University of Texas, San Antonio.
He emphasized, however, that medications are not the first-line therapy for agitation in outpatients with dementia. That distinction belongs to psychosocial interventions.
“Utilize a social worker to assist the family in modifying the environment: family settings and people, regular routines, consistently orienting the patient, keeping stimulation at a low to moderate level. When that’s done right, it can really dampen down a lot of agitation,” he said.
Dr. Luber noted that the formal randomized trial evidence base for SSRIs as first-line pharmacotherapy and benzodiazepines as second-line is quite limited. But in conversations with geriatric psychiatrists and other health care professionals around the country who are working in this area, he has found broad agreement that this is a good strategy.
“A lot of folks don’t realize that [SSRIs] are actually very useful in the treatment of agitation in dementia. But you want to choose one with fewer side effects and drug-drug interactions,” Dr. Luber said.
Two SSRIs that fit the bill are escitalopram (Lexapro) and sertraline (Zoloft). Start low and increase the dose slowly, provided circumstances allow. Expect a therapeutic response to emerge in weeks, not days. And, in this elderly population, be sure to monitor for hyponatremia.
When considering augmentation, remember that “using benzodiazepines in the elderly is controversial, particularly with agitation in dementia. There is very little randomized clinical trial data on benzodiazepines in dementia. Actually, though, there are lots of clinical trials of benzodiazepines in dementia that feature benzodiazepines as rescue medication. So, clinically, there’s an awareness that the drugs work, but they haven’t been studied except as rescue medication,” he explained.
The phenomenon of paradoxical agitation occurring in elderly patients on benzodiazepines “is something to be careful about, but in fact it’s pretty uncommon. Just watch for it,” he added.
Dr. Luber is among many geriatric psychiatrists who preferentially turn to clonazepam (Klonopin) because its relatively long half-life allows for twice-daily administration.
“Think about using it regularly rather than PRN. You want to stay ahead of the agitation rather than behind it,” he advised.
Patients with liver disease are better served by a shorter-acting benzodiazepine such as lorazepam (Ativan), which is not oxidized in the liver.
Also controversial is use of atypical antipsychotics as third-line pharmacotherapy, “but many geriatric psychiatrists would agree with me that the next step if the patient is still agitated despite an SSRI augmented with a benzodiazepine is to consider a trial of an atypical antipsychotic,” Dr. Luber said.
He pointed to risperidone (Risperdal) and aripiprazole (Abilify) as agents with a good track record for treatment of agitation in dementia. He urged primary care physicians to be familiar with the risk of serious and even potentially fatal side effects as described in the black box warning.
“There are tough choices involved in treating patients with this disorder. Use shared decision making with the patient or family,” Dr. Luber said.
He reported having no financial conflicts of interest regarding his presentation.
REPORTING FROM ACP INTERNAL MEDICINE