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Managing Agitation and Psychosis in Dementia

A Hierarchical, Evidence-Based Approach

Psychiatric Nurse Practitioner Clinical Guide

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Learning Objectives

🎯 Assessment

Apply DICE framework
Identify medical causes
Characterize behaviors

💊 Pharmacology

Navigate black box warnings
Select appropriate agents
Monitor safely

🛡️ Safety

Non-pharmacologic first-line
De-escalation techniques
Environmental management

📉 De-prescribing

Know when to taper
Implement algorithms
Manage relapse

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The Scope of BPSD

90%+

of dementia patients experience BPSD during their disease course

Behavioral Symptoms

Agitation
Aggression
Wandering
Resistance to care

Psychological Symptoms

Delusions
Hallucinations
Depression
Anxiety

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Case Presentation

Patient: 78-year-old female with Alzheimer's disease, MMSE 18/30

Presentation: Increasing agitation during evening hours for past 2 weeks. Pacing, yelling, hitting caregivers. Family considering nursing home placement.

Current Meds: Donepezil 10mg, memantine 10mg, trazodone 50mg PRN

Key Teaching:

Sundowning pattern suggests environmental/circadian factors
Rule out UTI, pain, medication side effects before starting antipsychotic
Trazodone may contribute to confusion in elderly
Consider non-pharmacologic interventions first

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The DICE Framework

Describe
Document thoroughly

→

Investigate
Medical, caregiver, environment

→

Create
Individualized plan

→

Evaluate
Assess outcomes

Document the Behavior:

Frequency: How often?
Intensity: Mild, moderate, severe?
Duration: How long?
Triggers: Time, activities, caregivers?
Context: What precedes/follows?

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Medical Causes Checklist

Before attributing to BPSD, rule out:

🔴 Infections

UTI, pneumonia, skin infections

🔴 Pain

Arthritis, fractures, dental, constipation

🔴 Metabolic

Dehydration, electrolytes, hypoglycemia

🔴 Medications

Anticholinergics, benzos, new drugs

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Non-Pharmacologic Interventions

Category	Interventions
Environmental	Lighting optimization, noise reduction, clear pathways
Communication	Validation therapy, BANGS de-escalation
Activity-Based	Music therapy, reminiscence, structured activities
Caregiver Training	"Bathing Without a Battle," CPI training

BANGS Framework: Breathe, Agree, Never argue, Go with flow, Say sorry

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⚠️ Black Box Warning

Increased Mortality Risk

Antipsychotics carry a 1.6-1.7x increased risk of death in elderly patients with dementia-related psychosis

Primary causes: Cardiovascular events (heart failure, sudden death) and infections (pneumonia)

Stroke risk: 2-fold increased risk of cerebrovascular events

Informed Consent Essentials:

Explain specific risks (stroke, death)
Discuss risks of untreated agitation
Emphasize lowest dose, shortest duration
Document discussion

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Antipsychotic Selection

Drug	Evidence	Starting → Target	Monitoring
Risperidone	Strongest	0.25-0.5 → 0.5-1.5 mg	EPS, BP, prolactin
Olanzapine	Moderate	2.5-5 → 5-10 mg	Weight, glucose, lipids
Aripiprazole	Moderate	2.5-5 → 7.5-12.5 mg	Akathisia, insomnia
Quetiapine	Limited	12.5-25 → 50-200 mg	Sedation, hypotension

Avoid: Benzodiazepines (falls, confusion), Valproate (NICE recommends against), Anticholinergics

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Monitoring Protocol

Timeframe	Assessment
Week 2	Acute side effects, sedation, falls
Monthly	Weight, BP, EPS assessment
Q3-6 months	Metabolic panel, lipids, HbA1c (olanzapine)
Q3-6 months	AIMS Scale for tardive dyskinesia

🎯 Reassess at 4 weeks: Discontinue if no benefit

📉 Efficacy duration: 6-12 weeks maximum

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De-prescribing Algorithm

Stable 3-6 months
No incidents

→

Reduce 25-50%
Every 1-2 weeks

→

Monitor weekly
During taper

Risperidone Taper Example:

Weeks 1-2: 1mg → 0.75mg
Weeks 3-4: 0.75mg → 0.5mg
Weeks 5-6: 0.5mg → 0.25mg
Weeks 7-8: 0.25mg → 0.125mg
Weeks 9-10: Discontinue

If relapse: Resume previous effective dose

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Key Takeaways

1. Always Assess First

Rule out medical causes (UTI, pain, delirium) before starting medications

2. Start Non-Pharmacologic

Use DICE framework, environmental modifications, caregiver training

3. Use Lowest Effective Dose

Inform of black box risks, monitor regularly, plan to de-prescribe

4. Time-Limited Treatment

Evidence supports 6-12 weeks; reassess and taper when stable