How to manage agitation in an elderly female with a history of dementia and seizure disorder?

From the Guidelines

For an elderly female with a history of dementia and seizure disorder experiencing agitation, I strongly recommend starting with non-pharmacological interventions as the first line of treatment, as supported by the American Psychiatric Association practice guideline 1. This approach should include identifying and addressing potential triggers such as pain, infection, constipation, or environmental factors. Creating a calm environment with familiar objects, consistent routines, and gentle redirection is also crucial, as suggested by guidelines for managing Alzheimer's disease 1. Some key non-pharmacological strategies include:

• Providing a predictable routine for exercise, meals, and bedtime
• Allowing the patient to dress in their own clothing and keep possessions
• Explaining procedures and activities in simple language before performing them
• Simplifying tasks and providing instructions for each step
• Using distraction and redirection of activities to divert the patient from problematic situations
• Ensuring that comorbid conditions are optimally treated
• Providing a safe environment by removing hazards and installing safety locks and grab bars If pharmacological management is necessary, consider starting with a low dose of an atypical antipsychotic like quetiapine 12.5-25mg at bedtime, titrating slowly while monitoring for side effects, as recommended by guidelines for managing Alzheimer's disease 1. Risperidone 0.25-0.5mg daily is another option. These medications should be used at the lowest effective dose for the shortest duration possible due to increased mortality risk in elderly patients with dementia, as highlighted by the American Psychiatric Association practice guideline 1. Avoid benzodiazepines as they may worsen confusion and increase fall risk. Antiepileptic medications like valproate or carbamazepine might serve dual purposes for both seizure control and behavior management, but require careful monitoring, as noted in guidelines for managing Alzheimer's disease 1. Any medication choice must consider potential interactions with her seizure medications and should be regularly reassessed. The goal is to improve quality of life while minimizing medication burden and side effects, recognizing that behavioral symptoms in dementia often fluctuate over time.

From the FDA Drug Label

5.13 Seizures During clinical trials, seizures occurred in 0.5% (20/3490) of patients treated with quetiapine compared to 0.2% (2/954) on placebo and 0. 7% (4/527) on active control drugs. As with other antipsychotics, quetiapine should be used cautiously in patients with a history of seizures or with conditions that potentially lower the seizure threshold, e.g., Alzheimer’s dementia. BOXED WARNING SECTION WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS; AND SUICIDAL THOUGHTS AND BEHAVIORS Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death [see Warnings and Precautions (5. 1)]. Quetiapine is not approved for the treatment of patients with dementia-related psychosis [see Warnings and Precautions (5. 1)].

The treatment of agitation in an old female with a history of dementia and seizures disorder should be approached with caution.

• Quetiapine should be used cautiously in patients with a history of seizures or with conditions that potentially lower the seizure threshold, such as Alzheimer’s dementia.
• Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death.
• Quetiapine is not approved for the treatment of patients with dementia-related psychosis 2 2. Given the potential risks, alternative treatments for agitation should be considered.

From the Research

Treatment Options for Agitation in Dementia

• The treatment of agitation in older adults with dementia can be challenging, and several studies have investigated the use of various medications to manage this condition 3, 4, 5, 6.
• Risperidone, an atypical antipsychotic, has been shown to be effective in reducing agitation in patients with dementia, although its use is associated with an increased risk of cerebrovascular adverse events and death 3.
• Selective serotonin reuptake inhibitors (SSRIs), such as citalopram, have also been found to be effective in reducing symptoms of agitation in patients with dementia, with a relatively favorable safety profile 4, 6.
• Quetiapine, another atypical antipsychotic, has been shown to be effective in treating agitation in dementia at a dose of 200mg/day, although its use should be approached with caution due to the potential for increased mortality 5.

Considerations for Patients with Seizure Disorders

• In patients with dementia and a history of seizure disorders, the treatment of agitation should take into account the potential for drug-drug interactions and the risk of exacerbating seizure activity 7.
• Second-generation antiseizure medications may be preferred in this population due to their more favorable pharmacokinetic profiles, although their use should be carefully monitored to minimize the risk of adverse effects 7.

Non-Pharmacological Interventions

• Non-pharmacological interventions, such as identifying and addressing medical and environmental precipitants of agitation, should be prioritized in the management of agitation in dementia 6.
• Acetylcholinesterase inhibitors and memantine may be initiated to enhance cognition, and trazodone may be used to manage insomnia or sundowning 6.