A 76-year-old man with a 5-year history of Alzheimer's disease is brought to the office by his wife. Over the past 6 months, he has developed increasing agitation and verbal aggression, particularly in the evenings. He has no delusions or hallucinations. He is currently taking donepezil 10 mg daily and memantine 10 mg twice daily. His wife is asking for medication to help manage his behavior as it is becoming difficult for her to care for him at home. Physical examination is unchanged from his previous visit.
In addition to non-pharmacologic interventions, which of the following is the most appropriate next step in the pharmacologic management of this patient's agitation?
- Initiate a low dose of lorazepam as needed for agitation.
- Increase the dose of donepezil to 23 mg daily.
- Initiate a low dose of risperidone daily.
- Initiate a low dose of citalopram daily. (correct answer)
Explanation: The patient is experiencing behavioral and psychological symptoms of dementia (BPSD), specifically agitation. First-line management is always non-pharmacologic interventions. When pharmacotherapy is required for agitation in the absence of psychosis, selective serotonin reuptake inhibitors (SSRIs) such as citalopram or sertraline have the best evidence for efficacy and safety. Atypical antipsychotics have a black box warning for increased mortality in elderly patients with dementia and are typically reserved for severe symptoms, particularly psychosis. Benzodiazepines should be avoided due to risks of paradoxical agitation, falls, and worsening confusion. Increasing the donepezil dose is unlikely to improve agitation.