● All atypical anti-psychotic drugs have morbidity/mortality risk.

● Discuss risks w/ caregiver vs quality of life

● If you don't need something urgently, then do SSRI FIRST, regardless of whether there are OVERT symptoms of depression. Depression hard to screen/catch in someone with advanced dementia

● First line SSRI: lexapro or zoloft.

○ If you need something activating, and makes you more alert during the day, then use prozac in the morning.

○ If you need something that causes sleepiness at night, trial paxil at night time.

● Note that citalapram 20mg study showed decreased agitation, but increase in QT.

● If you need something urgently: best and most data on efficacy is with risperidone (risperdal). Also can consider aripriprazole (abilify) as 1st/2nd line

● Give atypical antipsychotics as standing unless a safety risk, then prn. DON’T do them as PRN

● Reassess on the atypical antipsychotic and discontinue/taper @ 12 weeks

● 1st month of tapering an antipsychotic is critical period where staff raise issues

● Add on donepezil and namenda (sequentially) - helps decrease incidence of behavior change. BOTH functional & cognitive: increase dependence, delay decline, decrease in behavioral issues like agitation) & benefit seen both short term and long term: 6-12 mo and longer. Don’t take off this med, even in those with advanced dementia if they are tolerating w/o side effects

● No benefit from mirtazapine

● Don’t use depakote/valproic acid - accelerates decline across a number of trials

● Primavanserin for LBD/PD psychosis

● Brexipraxole shows significant benefit in agitation & aggression (2-3mg). Safer but increased mortality risk. Also as it is a new drug, brand name only = $$$

● Don’t use depakote/valproic acid - accelerates decline across a # of trials.

● Don't forget about adding the non-medication interventions as well

Version: YT 1/2025