What medication is used to calm aggressive dementia patients?

October 11, 2025 •

5 min read

Behavioral and psychological symptoms of dementia, including aggression and agitation, affect up to 90% of people living with the condition. When managing these challenging behaviors, understanding what medication is used to calm aggressive dementia patients is crucial, but non-drug interventions are considered the first-line approach.

Quick Summary

Brexpiprazole (Rexulti) is the sole FDA-approved medication for agitation associated with Alzheimer's dementia. Other medications, like atypical antipsychotics and antidepressants, are used off-label but carry significant risks, including black box warnings. The priority is to exhaust non-pharmacological strategies before considering drug intervention, using the lowest effective dose for the shortest duration when necessary.

Key Points

First-line treatment: Non-pharmacological interventions, such as addressing unmet needs, adjusting the environment, and employing calming strategies, are the primary approach for managing aggression in dementia.
FDA-approved medication: Brexpiprazole (Rexulti) is the only drug with FDA approval specifically for agitation associated with Alzheimer's dementia.
Off-label antipsychotics: Other atypical antipsychotics like risperidone are used off-label but carry serious black box warnings due to risks of stroke, cardiovascular events, and increased mortality in elderly dementia patients.
Cautions for medication: When pharmacological intervention is necessary, guidelines stress using the lowest effective dose for the shortest possible duration, with regular reassessment of its necessity and impact.
Alternative medications: Some antidepressants, like SSRIs, may be considered if depression or anxiety is a contributing factor to aggression, though evidence is mixed and risks must be weighed.
Personalized care: Effective management relies on a personalized approach that addresses the individual's specific triggers and needs, often requiring a collaborative effort between caregivers and medical specialists.

Understanding Aggression in Dementia

Aggressive behavior in individuals with dementia is a complex and distressing symptom for both the patient and their caregivers. This behavior is often a form of communication, stemming from unmet needs, pain, environmental overstimulation, or frustration related to cognitive decline. Medication is one tool in a broader treatment plan, which prioritizes non-pharmacological interventions first. A medical evaluation is necessary to rule out underlying causes such as infection, pain, or medication side effects before starting any new treatment for aggressive behavior.

The First-Line Approach: Non-Pharmacological Interventions

Healthcare guidelines and recent research strongly recommend exhausting non-drug therapies before resorting to medication for managing aggressive behaviors in dementia. These strategies focus on identifying and addressing triggers, creating a calm environment, and providing person-centered care. Effective non-pharmacological interventions include:

Environmental adjustments: Reducing noise, glare, and clutter can help prevent overstimulation. A quiet, predictable environment is less likely to trigger aggression.
Routine and structure: Establishing a consistent daily routine can provide a sense of security and reduce confusion.
Communication strategies: Speaking calmly and slowly, maintaining friendly eye contact, and validating the person's feelings can de-escalate a tense situation. Avoid arguing or correcting the person.
Engaging activities: Providing meaningful, enjoyable activities can help redirect energy and attention. This can include music therapy, simple hobbies, or physical activity like walking.
Sensory interventions: Gentle massage, aromatherapy (e.g., lavender), and multisensory stimulation can have a calming effect.
Pain management: Undetected pain is a common trigger for aggression. Regular assessment and management of pain can reduce challenging behaviors.

Medication Options: FDA-Approved and Off-Label Use

When non-pharmacological strategies fail to manage severe, dangerous, or highly distressing behaviors, a healthcare professional may consider medication. It's crucial to understand the risks and benefits associated with each option.

FDA-Approved Medication for Alzheimer's Agitation

Brexpiprazole (Rexulti) is the only medication specifically approved by the U.S. Food and Drug Administration (FDA) to treat agitation associated with dementia due to Alzheimer's disease. It is an atypical antipsychotic, but unlike many others, it has FDA approval for this specific use. Its approval was based on clinical trial evidence showing a dose-dependent benefit for some patients. However, like all atypical antipsychotics, brexpiprazole carries a black box warning about the increased risk of death in older patients with dementia-related psychosis.

Other Pharmacological Options (Off-Label Use)

Many medications used to manage aggressive dementia patients are used off-label, meaning they are prescribed for a condition other than their original FDA-approved purpose. This is a common practice in medicine, but it requires a careful risk-benefit analysis by a physician.

Atypical Antipsychotics: This class of drugs, including risperidone (Risperdal) and olanzapine (Zyprexa), can be used cautiously for severe symptoms but carry significant risks. Clinical trials have shown modest effectiveness, but also increased risks of serious side effects, such as stroke, blood clots, heart failure, and death, particularly in the elderly population. This has led to the FDA requiring black box warnings on all atypical antipsychotics.
Antidepressants (SSRIs): Selective serotonin reuptake inhibitors (SSRIs) such as citalopram (Celexa) and sertraline (Zoloft) may be used if aggression is linked to depression or anxiety. While some studies show benefit, results are mixed, and potential side effects like cardiac issues (e.g., QT prolongation with citalopram) must be considered.
Dextromethorphan/Quinidine (Nuedexta): This combination therapy is approved for pseudobulbar affect but has been used off-label for agitation in dementia, with some trials suggesting a benefit. It requires careful monitoring for side effects, including QT prolongation.
Memantine (Namenda): An NMDA receptor antagonist used for moderate to severe Alzheimer's, memantine is sometimes used to help reduce aggression and psychosis with fewer side effects than antipsychotics, though its impact on aggression specifically can be inconsistent.

Comparison of Treatment Approaches for Aggressive Dementia


Feature	Non-Pharmacological Interventions	FDA-Approved Medication (Brexpiprazole)	Off-Label Antipsychotics (e.g., Risperidone)
Risks	Very low risk of side effects; can reduce aggression without medication risks.	Carries FDA black box warning for increased risk of death in elderly dementia patients.	High risk of severe side effects like stroke, heart issues, and death; also carries black box warning.
Effectiveness	Highly effective as first-line treatment, especially for aggression from unmet needs.	Shown to be effective for some patients with Alzheimer's-related agitation.	Modest effectiveness, but serious adverse events may offset benefits.
Application	Universal first step; tailored to individual needs and triggers.	Reserved for severe agitation when non-drug methods fail; specific to Alzheimer's dementia.	Used as a last resort for severe and dangerous behaviors; wide range of potential side effects.
Duration	Ongoing strategy as part of holistic care.	Lowest effective dose for shortest duration possible, with regular reassessment.	Lowest effective dose for shortest duration; regular review and tapering attempts are standard.
Intervention	Caregiver training, environmental changes, music therapy, exercise.	Oral tablet prescribed by a physician.	Oral tablets prescribed and monitored by a specialist physician.

The Critical Importance of a Low-Dose, Short-Duration Strategy

When medication is deemed necessary, the American Psychiatric Association and other guidelines recommend starting with the lowest possible dose and using it for the shortest duration. This minimizes the risk of adverse effects while attempting to control symptoms. Regular reassessment is essential, with efforts to taper and discontinue the medication once behavioral control is achieved. The decision to use any medication, particularly antipsychotics, must be made with extreme caution and in consultation with a specialist, such as a geriatric psychiatrist.

Conclusion

While brexpiprazole is the only FDA-approved medication for agitation in Alzheimer's dementia, it is not the first or only answer for managing aggression in dementia patients. An aggressive or agitated behavior is a signal that something is wrong, and the initial and preferred course of action involves identifying and addressing non-medical triggers through person-centered care. Pharmacological treatments, including brexpiprazole, other atypical antipsychotics used off-label, and some antidepressants, are considered secondary options for severe and distressing symptoms. Given the significant safety concerns, especially the black box warnings associated with antipsychotics, any decision to use medication must be carefully weighed against potential risks, with the lowest dose for the shortest duration being the standard protocol. The most effective approach combines patient-tailored non-pharmacological strategies with cautious, evidence-based use of medication when absolutely necessary. For more detailed information on managing behavioral symptoms, caregivers should consult resources from the Alzheimer's Association.

Frequently Asked Questions

The primary treatment approach for aggressive dementia is non-pharmacological, focusing on identifying triggers, adjusting the environment, and using person-centered care techniques like music therapy or reassurance.

Brexpiprazole (Rexulti) is the only medication specifically approved by the FDA for the treatment of agitation associated with dementia due to Alzheimer's disease. It is not approved for aggression in other types of dementia.

Antipsychotics carry serious risks for elderly dementia patients, including an increased risk of stroke, heart attack, falls, and death. The FDA has issued a black box warning about these dangers.

Yes, some antidepressants (like certain SSRIs), dextromethorphan/quinidine, and memantine are sometimes used off-label for aggression in dementia. However, they also have risks and varying levels of evidence for effectiveness.

During an aggressive episode, ensure safety first by calmly stepping back to give the person space. Try to identify and address any immediate trigger, offer reassurance, and use distraction techniques if possible. Avoid arguing or sudden movements.

The decision to use medication is made by a specialist physician after non-pharmacological methods have been exhausted and for symptoms that are severe, dangerous, or causing significant distress. A careful risk-benefit analysis is performed for each individual.

Medication should be used at the lowest effective dose for the shortest possible duration. Regular reviews are required, with attempts to taper and discontinue the medication once symptoms are controlled to minimize long-term risks.

Effective non-drug therapies include music therapy, sensory stimulation, massage and touch therapy, and individualized activities. Tailoring interventions to the individual's history and preferences is key.