Is quetiapine (Seroquel) effective for treating globus sensation in patients with dementia?

Quetiapine is Not Effective for Globus Sensation in Dementia and May Worsen Outcomes

Quetiapine is not recommended for treating globus sensation in patients with dementia due to significant risks of mortality, cognitive decline, and falls, with no evidence supporting its efficacy for this specific symptom.

Understanding Globus Sensation in Dementia

Globus pharyngeus (sensation of a lump in the throat) is a functional disorder characterized by:

• Recurrent, non-painful but uncomfortable sensation in the throat
• Feeling of a foreign body, tightening, or choking sensation
• Often more noticeable between meals and improves with eating
• Commonly associated with throat clearing, mucus sensation, and repeated swallowing 1

In patients with dementia, this symptom can be particularly distressing and may contribute to:

• Avoidance behaviors around eating
• Reduced food intake
• Social withdrawal
• Anxiety and fear of choking 1

Evidence Against Using Quetiapine for Globus Sensation

Safety Concerns in Dementia Patients

1. Mortality Risk:

   • Antipsychotics including quetiapine carry an FDA black box warning for increased mortality in elderly patients with dementia 1
   • Recent evidence shows low-dose quetiapine is associated with 3.1 times higher mortality risk compared to alternative medications 2

2. Cognitive Deterioration:

   • Quetiapine is associated with significant cognitive decline in dementia patients
   • Research shows quetiapine treatment resulted in worse cognitive performance on the Severe Impairment Battery compared to placebo (14.6 points lower at 6 weeks, 15.4 points lower at 26 weeks) 3

3. Increased Risk of Falls and Dementia:

   • Even at low doses, quetiapine is associated with 2.8 times higher risk of falls 2
   • Significantly higher rates of new-onset dementia (7.1-8.1 times higher risk) compared to alternative medications 2

Lack of Efficacy for Globus Sensation

The 2021 consensus recommendations for speech and language therapy explicitly state:

• No randomized controlled trials exist for treatments specifically targeted at functional dysphagia or globus sensation 1
• While antidepressants are sometimes used for overlapping disorders causing esophageal discomfort, there is no evidence supporting antipsychotics like quetiapine for globus sensation 1

Management Recommendations for Globus Sensation in Dementia

First-Line Approaches

1. Speech and Language Therapy Assessment:

   • Comprehensive evaluation to rule out physical causes of dysphagia
   • Assessment of swallowing function and safety

2. Behavioral Management:

   • Address anxiety and stress factors that may exacerbate globus sensation
   • Implement swallowing techniques and posture modifications

3. Environmental Modifications:

   • Food texture modifications if appropriate
   • Creating a calm, unhurried eating environment

Medication Considerations

If pharmacological intervention is deemed necessary for associated symptoms:

1. For Anxiety/Depression Components:

   • Consider antidepressants with evidence for esophageal discomfort 1
   • Avoid medications with strong anticholinergic properties which can worsen cognition 1

2. For Cognitive Support:

   • Cholinesterase inhibitors may be considered for overall dementia management, though they have not shown specific benefit for globus sensation 1

Important Cautions

1. Avoid Antipsychotics for Non-Psychotic Symptoms:

   • The American Psychiatric Association practice guideline emphasizes that antipsychotics should only be considered for dangerous agitation or psychosis in dementia, not for other symptoms 1

2. Deprescribing Priority:

   • Antipsychotics like quetiapine are specifically identified as medications to target for deprescribing in older adults 1
   • The Mayo Clinic polypharmacy management guidelines list quetiapine among medications to avoid or taper in elderly patients 1

3. Monitor for Adverse Effects:

   • If an antipsychotic is used for severe behavioral symptoms (not recommended for globus), close monitoring for cognitive decline, sedation, falls, and cardiovascular effects is essential 1

In conclusion, there is no evidence supporting quetiapine use for globus sensation in dementia, while substantial evidence shows potential harm. Management should focus on non-pharmacological approaches with speech therapy assessment and behavioral interventions.