Several types of medications are used to manage agitation, aggression, and other distressing behaviors in people with dementia. Atypical antipsychotics are the most widely prescribed class for this purpose, though antidepressants, mood stabilizers, and a few other options play a role depending on how severe the symptoms are. Importantly, clinical guidelines recommend trying non-drug approaches first, and every medication in this space carries real risks for older adults.
Why Non-Drug Approaches Come First
Current clinical guidance from organizations including the Agency for Healthcare Research and Quality recommends nonpharmacologic interventions as the first choice for agitation and aggression in dementia. These aren’t soft suggestions. Medications for calming behavioral symptoms carry side effects that are especially dangerous in elderly patients, so the goal is always to try other strategies before reaching for a prescription.
The range of non-drug options is broader than most people realize. Music therapy, aromatherapy, bright light therapy, structured activities like exercise or art, massage, and even changes to the physical environment (reducing noise, improving lighting, creating dedicated wandering areas) all have evidence behind them. For family caregivers at home, education programs that teach communication techniques and behavior management skills can make a significant difference. These approaches aim to prevent episodes, reduce their severity when they happen, and lower caregiver distress.
When these strategies aren’t enough, medications become part of the conversation.
Atypical Antipsychotics
Atypical antipsychotics are the most widely used class of medication for behavioral and psychological symptoms of dementia, particularly when symptoms are severe or involve psychosis (delusions, hallucinations). The most commonly prescribed options include risperidone, quetiapine, olanzapine, and aripiprazole.
Risperidone is the best-studied of these drugs for dementia-related behaviors, and its effectiveness is well established. Quetiapine is often chosen for patients who also have Parkinson’s-like symptoms because it’s less likely to cause stiffness and movement problems. Olanzapine reduces psychosis and behavioral symptoms but comes with notable side effects including sedation, weight gain, and metabolic changes. Aripiprazole has shown modest improvements in both psychosis and agitation.
Doses used in dementia are much lower than those used for conditions like schizophrenia. Typical target ranges are 0.25 to 1 mg for risperidone, 12.5 to 150 mg for quetiapine, 2.5 to 7.5 mg for olanzapine, and 5 to 10 mg for aripiprazole. Clinicians start at the lowest possible dose and increase slowly, because side effects like sedation, unsteady gait, and movement problems are common even at low doses.
A major clinical trial known as CATIE-AD found no significant difference between risperidone, olanzapine, quetiapine, and placebo in how long patients stayed on the drug overall. However, risperidone and olanzapine did outperform placebo when researchers looked specifically at patients who stopped treatment because the drug wasn’t working. In plain terms: these medications help some people, but many patients discontinue them because of side effects.
The FDA Black Box Warning
Every antipsychotic carries a black box warning, the most serious type of safety alert the FDA issues. Seventeen controlled studies found that elderly dementia patients treated with antipsychotics were 1.6 to 1.7 times more likely to die than those given a placebo. Deaths were linked to heart failure, sudden cardiac events, and infections like pneumonia. The labels explicitly state that these drugs are not approved for behavioral symptoms in elderly dementia patients.
There is one exception. In May 2023, the FDA approved brexpiprazole (brand name Rexulti) specifically for agitation associated with Alzheimer’s dementia. It is the first and currently only drug with this specific approval. This doesn’t mean it’s free of risk, but it does mean it went through clinical trials designed specifically for this patient population.
Antidepressants
For mild to moderate behavioral symptoms, antidepressants are a common alternative to antipsychotics. The SSRIs citalopram and sertraline have the most attention in research. A meta-analysis found that both showed some reduction in agitation and psychosis compared to placebo. However, a more recent systematic review of four randomized trials involving 502 patients found that citalopram and escitalopram did not significantly reduce agitation severity overall, though they were generally well tolerated. One consistent finding: SSRI use was associated with a 1.78 times higher risk of falls, which is a serious concern in frail older adults.
Trazodone, an older antidepressant with sedating properties, is used with partial success for agitation. It has particular evidence in frontotemporal dementia, a type of dementia that often causes prominent behavioral changes. Doses are typically low, often in the range of 25 to 75 mg, sometimes given primarily at bedtime to help with sleep disruption alongside daytime agitation. Mirtazapine, another sedating antidepressant, showed significant reductions in agitation scores in a small study of 16 patients over 12 weeks.
Medications Originally Designed for Other Conditions
Several drugs developed for other purposes are used off-label when first-line options fail or aren’t tolerable.
Memantine, a medication approved for moderate to severe Alzheimer’s disease, primarily targets memory and thinking. But in a major trial published in the New England Journal of Medicine, patients taking memantine also scored an average of 4 points lower on a behavioral symptom scale compared to placebo. That’s a modest but meaningful reduction in symptoms like agitation, irritability, and sleep disturbance. Cholinesterase inhibitors (the other main class of Alzheimer’s drugs) may offer similar secondary benefits for milder behavioral symptoms.
Gabapentin, an anti-seizure and nerve pain medication, is sometimes tried when antipsychotics and antidepressants haven’t worked or can’t be used safely. The idea is that it quiets overactive brain signaling, which may reduce agitation. Doses in published cases range widely, from 200 mg to 3,600 mg per day. Its side effect profile is relatively mild compared to antipsychotics, and it works faster than SSRIs. But the evidence comes mostly from case reports rather than large trials, so it’s considered a later option when drugs with stronger evidence aren’t effective or are too risky.
Buspirone, an anti-anxiety medication, has shown some benefit for agitation and aggression in open-label studies, though the evidence base is limited.
Medications to Use With Caution or Avoid
Benzodiazepines (drugs like lorazepam and diazepam commonly prescribed for anxiety) are listed by the American Geriatrics Society’s Beers Criteria as potentially inappropriate for older adults. They cause drowsiness, delayed reaction time, impaired balance, and nighttime confusion, all of which lead to falls and fractures. The Beers Criteria, updated in 2023, serves as a widely used reference for medications that are typically best avoided in adults 65 and older.
Similarly, “Z-drug” sleeping pills have been linked to a 1.6-fold increase in fractures in older adults. The underlying problem with any sedating medication in this population is the same: drug-induced sleepiness, slower reflexes, and impaired balance create a dangerous combination in someone who may already be unsteady on their feet and confused.
What This Means for Caregivers
If you’re caring for someone with dementia who is agitated or aggressive, the realistic picture is this: no medication works dramatically well, every option involves trade-offs, and the best approach usually combines environmental and behavioral strategies with cautious, low-dose medication when needed. Mild to moderate symptoms are typically addressed with antidepressants or standard Alzheimer’s medications. Severe symptoms, especially those involving psychosis, are where atypical antipsychotics come in, despite their risks.
Whatever medication is tried, the process involves starting low, increasing slowly, and watching closely for side effects like excessive drowsiness, unsteady walking, or falls. Many patients go through more than one medication before finding something that helps without causing unacceptable problems. Regular reassessment matters, because behavioral symptoms in dementia often change over time, and a medication that was necessary six months ago may no longer be needed.