Primary care and mental health providers are the frontline for managing the complex interplay between physical health and neuropsychiatric symptoms (NPS). Whether it is the subtle onset of depression in an older adult or the disruptive agitation of a patient with advancing dementia, the burden on the patient, their caregivers, and the healthcare system is profound. This article provides a concise guide to non-pharmacologic strategies, medication safety, and recent therapeutic updates to help streamline your psychiatric consultations for the care of those with dementia.
1. The Foundation: Non-Pharmacologic Management
Before reaching for the prescription pad, non-pharmacologic interventions should be the first-line approach, particularly for depression, anxiety, and agitation. These strategies are not only evidence-based but also avoid the polypharmacy risks inherent in psychiatric medications.
For Depression: Focus on Behavioral Activation. Encourage patients and caregivers to schedule small, manageable activities that once brought them joy. Even a 10-minute daily walk can significantly impact mood. Walking outside in the morning can also provide light exposure which can help with circadian rythms which can help promote regular sleep-wake cycles. Where and when available, engaging in adult day programs or senior centers that provide dementia support groups or programming can be helpful for structure. Socialization is one of the main pillars of care for those with dementia.
For Anxiety: Implement Structured Relaxation. Teach simple diaphragmatic breathing or “box breathing” during the visit and provide written instructions/online resources to practice/review. Caregivers may need to cue them to do the breathing or suggest “let’s do some breathing together.” Referral to Cognitive Behavioral Therapy (CBT) remains the gold standard for long-term anxiety management but may need to be modified for those with cognitive impairment and also may not be readily available to all patients. Where cognitive impairment is still mild, this can still be effective with modifications. Identify other calming environmental changes (check temperature, use of white noise or calming music, or distracting with a conversation or activity can be helpful). What is calming should be individualized to that specific person.
For Agitation/Aggression: Use Environmental Modification. Identify triggers—such as loud noises, poor lighting, or “sundowning” patterns. Use nightlights to help with sundowning. Maintain a consistent daily routine. Using “validation therapy” (acknowledging the patient’s feelings rather than correcting their reality) can de-escalate aggressive outbursts. Avoid confrontation. Avoid overscheduling and allow adequate rest between activities. Acknowledge and respond to requests. Educate caregivers about dementia by providing resources for education and support. Identify sources of pain, constipation, need to use the bathroom, hunger, or thirst. Urinary retention and constipation from medications and dental issues are common underrecognized contributors to behavior.
2. Medication Review: Protecting Cognition
Polypharmacy is a quiet thief of cognitive function. Many common medications possess anticholinergic properties that can induce or worsen “pseudo-dementia.” A partial list of common contributors:
| Drug Class | Examples to Review | Impact on Cognition |
| Antihistamines | diphenhydramine, hydroxyzine | Confusion, sedation, increased fall risk. |
| TCAs | amitriptyline, nortriptyline | High anticholinergic burden; worsens memory. |
| Benzodiazepines And “Z drugs: | lorazepam, alprazolam, zolpidem, zaleplon, eszopiclone | Paradoxical agitation, amnesia, and gait instability. |
| GI Agents | hyoscyamine, dicyclomine | May cause acute delirium in the elderly. |
The American Geriatrics Society’s has a list of medications (the Beers list) that can impact cognition and contribute to things like falls. These medications are recommended not to be used in geriatric patients. Remember that it’s not always a single agent causing the issue but rather the synergy of multiple agents with cognitive side effects. Never abruptly stop medications; provide instructions for taper and discontinuation. Regularly review and encourage patients and families to keep an updated list of all medications they take, who prescribes them, and include supplements and over the counter medications. It is especially important to carefully review lists during transitions like a move or discharge from a hospitalization. For those in facilities, regularly review the Medication Administration Record (MAR) not just the orders list; the MAR documents scheduled medications but also how often as needed medications are being given and efficacy, which is especially important if as needed psychotropic medications are being prescribed. Assessing from documentation whether a specific target symptom is improved with as needed medication administration is paramount so that ineffective medications are not given indefinitely.
3. Updates in Pharmacotherapy: Brexpiprazole and Pimavanserin
In 2026, the landscape for managing agitation associated with dementia shifted toward more targeted agents with improved safety profiles compared to traditional antipsychotics.
- Brexpiprazole: Originally an adjunct for MDD and schizophrenia, brexpiprazole is now FDA-approved for agitation associated with Alzheimer’s dementia. It acts as a partial agonist at D2 and 5-HT1A receptors. Unlike older agents, it has lower intrinsic activity at dopamine receptors, which may reduce the risk of extrapyramidal symptoms (EPS).
- Pimavanserin: This is a selective serotonin inverse agonist (SSIA) targeting 5-HT2A receptors. It is notably the only medication FDA-approved for Parkinson’s disease psychosis. Its lack of dopamine D2 blockade is critical because it treats hallucinations and delusions without worsening motor function.
- Both medications are new and therefore can be quite expensive, often necessitating prior authorization/review of prior failed medications or justification for use.
The Role of Medications for the Treatment of Dementia
While not primary treatments for agitation, Acetylcholinesterase Inhibitors (AChEIs) like donepezil and NMDA receptor antagonists like memantine should be optimized. AChEIs can subtly improve apathy and anxiety, while memantine may help reduce the “overflow” of glutamate that contributes to irritability and aggression in moderate-to-severe cases.
4. Other antipsychotics: Considerations for Use and the “Black Box”
Antipsychotics (e.g., quetiapine, risperidone, haloperidol, aripiprazole) are frequently used off-label in primary care and in psychiatry for management of neuropsychiatric symptoms in dementia. Common reasons for use include:
- Acute Safety: When a patient is a danger to themselves or others.
- Severe Psychosis: Distressing hallucinations or paranoid delusions.
- Refractory Agitation, Inconsolable or persistent distress, or difficulty receiving care: When non-pharmacologic and first-line agents fail
FDA Black Box Warning: All antipsychotics (both typical and atypical) carry a “Black Box” warning regarding an increased risk of death in elderly patients with dementia-related psychosis. Most deaths are cardiovascular (heart failure, sudden death) or infectious (pneumonia) in nature. Informed consent with family and caregivers is mandatory before initiation.
Be aware of the particular risks of using many antipsychotic medications in those with dementia with Lewy bodies or dementia due to Parkinson’s disease as they can be exquisitely sensitive to extrapyramidal side effects. Quetiapine, pimsvanserin, or sometimes clozapine are first line agents where antipsychotic medications are needed. Brexpiprazole may be another option given its potentially lower propensity for EPS.
5. Supporting the “Invisible Patient”: The Caregiver
Caregiver stress is often an underrecognized contributor to symptoms in patients with dementia. When a caregiver’s mental health fails, the patient’s institutionalization can become imminent and crisis-driven so it’s important to check in regularly.
- Screening: Use the Zarit Burden Interview or simply ask: “How are you holding up?”
- Depression in Caregivers: Caregivers have significantly higher rates of clinical depression than the general population. PCPs should treat the caregiver as an essential component of the patient’s “care ecosystem.”
- Resources: Emphasize respite care. Encourage them to utilize local Area Agency on Aging resources to prevent burnout.
Managing psychiatric symptoms in dementia requires a delicate balance between behavioral interventions and careful medication management. Prioritizing non-pharmacologic strategies, reviewing cognitive-impairing drugs, and staying updated on new developments in pharmacotherapy are central management strategies for individualized dementia care.
Resources:
UW Medicine Project ECHO Dementia (virtual)
Free case-based learning for primary care providers hosted by dementia specialists at the UW; meets every other Friday; CME/CNE credit available.
Dementia Road Map
The DSHS Health Care Providers and Community Organizations page hosts clinical tools from the Dementia Action Collaborative, including the Dementia Road Map, a free guide for newly diagnosed patients and families.
Washington Association of Area Agencies on Aging
Connects adults with dementia and their families with local long-term care, community resources, and specialized caregiver support.
The Memory Hub, UW Medicine Memory and Brain Wellness Center
Offers education, support groups, and resources for patients and their care partners, including virtual or phone appointments with a Memory Navigator.
Alzheimer’s Association Washington State Chapter, Education and Resources
Free on-demand webinars and live programs on Alzheimer’s and dementia and a 24/7 Helpline for patients and families.
American Geriatrics Society Beers Criteria® Alternatives Panel, & Steinman, M. A. (2025). Alternative treatments to selected medications in the 2023 American Geriatrics Society Beers Criteria®. Journal of the American Geriatrics Society, 73(9), 2657–2677. https://doi.org/10.1111/jgs.19500
Brody, H., & Heath, A. (2023, July). Nonpharmacologic approaches to adverse behaviors associated with dementia. Practical Neurology. https://practicalneurology.com/diseases-diagnoses/alzheimer-disease-dementias/nonpharmacologic-approaches-to-adverse-behaviors-associated-with-dementia/32015/
Imbimbo, C., Cotta Ramusino, M., Leone, S., et al. (2025). Emerging pharmacological approaches for psychosis and agitation in Alzheimer’s disease. CNS Drugs, 39(2), 143–160. https://doi.org/10.1007/s40263-024-01133-9
Dr. Carlson is a board-certified psychiatrist and geriatric psychiatrist in the UW Medicine Department of Psychiatry and Behavioral Sciences. She graduated from the University of Iowa College of Medicine, completed her Psychiatry Residency at the University of Michigan and a Geriatric Psychiatry Fellowship at the University of Washington. Dr. Carlson is the medical director of the Geriatric Psychiatry Services Clinic at Harborview Medical Center and is one of the primary faculty on the Psychiatry Consultation Line (PCL). Her clinical interests include aging in chronic mental illness, mood disorders, nursing home psychiatry/consult liaison psychiatry, ethics, and palliative care.
