Pharmacological Management of Aggression in Dementia: Investigating the Role and Risks of Antipsychotics

Abstract

Dementia is a progressive neurodegenerative disorder characterized not only by cognitive decline but also by a range of behavioural and psychological symptoms, among which aggression poses a significant clinical challenge. Aggression in dementia is associated with increased caregiver stress, patient morbidity, early institutionalization, and elevated healthcare costs. While non-pharmacological interventions are considered the first-line approach for managing behavioural disturbances, pharmacological treatments, particularly antipsychotics, are often employed when symptoms become severe or pose a risk to the patient or others.

This literature review aims to explore the current pharmacological strategies for managing aggression in dementia, with a central focus on the use of antipsychotic medications. It delves into the neurobiological underpinnings of aggression, including alterations in neurotransmitter systems such as dopamine, serotonin, and acetylcholine, as well as structural and functional changes in specific brain regions. Both typical and atypical antipsychotics are examined in terms of their mechanisms of action, clinical efficacy, and safety profiles. Among these, risperidone and olanzapine have demonstrated modest benefits in reducing aggression, although their use is frequently accompanied by adverse effects such as extrapyramidal symptoms, sedation, metabolic disturbances, and increased risk of cerebrovascular events and mortality, particularly in elderly patients.

Regulatory agencies, including the FDA and EMA, have issued warnings concerning the use of antipsychotics in dementia, urging clinicians to weigh the risks and benefits carefully. The review further evaluates current clinical guidelines, discusses alternative pharmacologic options including antidepressants and mood stabilizers, and briefly outlines non-pharmacological strategies as adjuncts or alternatives. Additionally, the paper highlights emerging therapeutic directions, including novel drug targets and personalized medicine approaches.

Given the delicate balance between symptom control and patient safety, a cautious, individualized, and ethically sound prescribing approach is imperative. Future research should focus on safer, more effective treatments and strategies that integrate pharmacologic and holistic care for individuals with dementia experiencing aggression.

Keywords: Dementia, Cognitive impairment, Psychiatric symptom, Hospital care, Inpatient, Older people, Systematic review, Alzheimer’s disease (AD)