What are the effects of Quetiapine (Seroquel) on patients with dementia?

From the Guidelines

Seroquel (quetiapine) should not be used as a first-line treatment for patients with dementia due to the increased risk of mortality and other serious side effects. According to the American Psychiatric Association practice guideline on the use of antipsychotics to treat agitation or psychosis in patients with dementia 1, the benefits of antipsychotic medications, including Seroquel, are small, and they are associated with clinically significant adverse effects.

Key Considerations

• The FDA has issued a black box warning against using antipsychotics like Seroquel in elderly patients with dementia-related psychosis.
• If behavioral symptoms in dementia are severe and non-drug approaches have failed, Seroquel might be considered at very low doses (typically starting at 12.5-25mg), with careful monitoring for side effects like sedation, orthostatic hypotension, falls, and worsening confusion.
• Treatment should be time-limited and regularly reassessed.
• Before considering Seroquel, it's essential to try non-pharmacological approaches first, such as maintaining routines, providing a calm environment, addressing underlying causes of agitation (pain, infection, constipation), and using behavioral management techniques.

Alternative Treatments

• Other atypical antipsychotic agents, such as risperidone (Risperdal) and olanzapine (Zyprexa), may be considered as alternatives to Seroquel, with careful monitoring of side effects and regular reassessment of treatment 1.
• Mood-stabilizing drugs, such as trazodone (Desyrel) and divalproex sodium (Depakote), may also be useful in managing agitation and aggression in patients with dementia.
• Anxiolytic drugs, such as lorazepam (Ativan) and buspirone (BuSpar), may be used to manage insomnia, anxiety, and agitation, but with caution due to the risk of tolerance, addiction, and cognitive impairment.

Informed Consent

Any use of Seroquel or other antipsychotic medications in patients with dementia should involve informed consent discussions with the patient (if capable) and family members about the significant risks versus potential benefits 1.

From the FDA Drug Label

WARNINGS AND PRECAUTIONS SECTION 5. 1 Increased Mortality in Elderly Patients with Dementia-Related Psychosis 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 [see BOXED WARNING].

The use of Seroquel (quetiapine) in patients with dementia is associated with an increased risk of death. Quetiapine is not approved for the treatment of patients with dementia-related psychosis.

• Key points:
  • Increased mortality risk in elderly patients with dementia-related psychosis
  • Quetiapine is not approved for dementia-related psychosis treatment
  • Use with caution and consider alternative treatments 2

From the Research

Seroquel (Quetiapine) and Dementia

• Seroquel is an atypical antipsychotic that has been studied for its efficacy in treating agitation and psychosis in patients with dementia 3, 4, 5.
• A study published in 2004 found that quetiapine was a high second-line option for treating agitated dementia with delusions, with a recommended dose of 50-150 mg/day 3.
• Another study published in 2007 found that quetiapine was well-tolerated and did not worsen parkinsonism in patients with dementia and parkinsonism, but did not show demonstrable benefit for treating agitation or psychosis 4.
• A study published in 2006 found that quetiapine was effective in reducing behavioral symptoms, deliria, and hallucinations in patients with dementia and concomitant psychotic disorders 5.
• A review published in 2019 noted that low doses of atypical antipsychotics such as quetiapine can be effective for treating agitation in dementia, but emphasized the importance of considering potential adverse effects 6.

Efficacy and Tolerability

• Quetiapine has been shown to be effective in reducing behavioral symptoms and psychosis in patients with dementia 5.
• The drug has been found to be well-tolerated, with a low incidence of extrapyramidal effects and other adverse events 4, 5.
• However, quetiapine can cause orthostatic hypotension, which can be partially preventable by slower drug titration 5.

Comparison to Other Treatments

• Quetiapine has been compared to other atypical antipsychotics, such as risperidone, and has been found to be similarly effective 3.
• A study published in 2011 found that selective serotonin reuptake inhibitors (SSRIs) such as citalopram may be effective for treating agitation in dementia, and may be a viable alternative to atypical antipsychotics 7.