Choosing Between Augmentation and Switching for Agitation Therapy

In "Choosing Between Augmentation and Switching for Agitation Therapy," the panel examines how clinicians decide between augmenting and switching therapy, and where neurology fits into that decision.

The panel discusses how to choose between augmenting and switching therapy when a patient's response to first-line treatment is inadequate. That choice is driven largely by comorbidities and risk profile, such as starting with the non-antipsychotic combination when a patient already has hyperlipidemia, along with the degree of any partial response and whether the patient is already at the maximum dose. Augmentation is generally reserved for patients on the non-antipsychotic combination who develop concurrent psychotic symptoms, typically by adding a low dose of an antipsychotic. Citalopram at 30 milligrams, the only other agent with proven positive effect in agitation, has not been added by panelists given serotonin syndrome risk, since SSRIs were excluded from the combination's pivotal trial, though continuing an existing mirtazapine for appetite or trazodone for sleep is considered acceptable.

Long-term care facilities sometimes push clinicians to cross-titrate patients off a clinically stable antipsychotic regimen purely to protect five-star quality ratings once the non-antipsychotic option became available, rather than for any clinical reason. The panel debates what counts as "adequate control" of agitation, agreeing that the caregiver should ultimately define it, generally through remaining distress and disruption to caregiving rather than a fixed numeric target, while acknowledging the field still lacks a well-defined, shared threshold.

The conversation turns to neurology's role, noting that neurologists, especially behavioral and cognitive specialists, are often a first point of contact but have inconsistent access to psychiatry; some psychiatrists are reluctant to manage these patients, letting severe cases escalate all the way to geropsychiatric units before finally reaching memory care. The panel argues neurology should build its own comfort managing these symptoms rather than reflexively referring them elsewhere.

The next episode in this series, "Follow-Up Care and the Caregiver's Role in Managing Agitation," features the panel closing out with a look at follow-up ownership and the caregiver's role.