From the Guidelines
Seroquel (quetiapine) is not a safe first-line option for patients with dementia and aggression due to the increased risk of mortality and adverse effects. The American Psychiatric Association practice guideline on the use of antipsychotics to treat agitation or psychosis in patients with dementia 1 emphasizes the need for careful consideration of the benefits and harms of antipsychotic medications, including quetiapine, in this population.
Key points to consider when evaluating the use of quetiapine in patients with dementia and aggression include:
- The potential benefits of antipsychotic medications, including quetiapine, are small, and the risks of adverse effects, such as mortality, are significant 1
- Non-pharmacological approaches, such as identifying and addressing triggers, maintaining routine, creating a calm environment, and using behavioral interventions, should be tried first
- If medication is necessary, it should be used at the lowest effective dose for the shortest possible time with close monitoring
- Alternative medications, such as citalopram or trazodone, may be considered for some patients with less risk
In specific cases where the benefits of quetiapine might outweigh the risks, a low dose (25-50mg) may be considered, but only after careful assessment, discussion of risks with family members, and with regular monitoring for side effects 1. Regular reassessment of the medication approach is necessary, with attempts to reduce or discontinue the medication when possible.
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].
Quetiapine is not a safe option for a patient with dementia and aggression, as it may increase the risk of death in elderly patients with dementia-related psychosis 2.
From the Research
Safety of Quetiapine for Dementia and Aggression
- There are limited data available on the use of quetiapine for treating aggression in patients with dementia 3, 4, 5, 6.
- Atypical antipsychotics, including quetiapine, have been used to treat behavioral and psychological symptoms of dementia, such as aggression and psychosis 3, 4, 5.
- However, the use of atypical antipsychotics in elderly patients with dementia has been associated with an increased risk of cerebrovascular adverse events, including stroke, and mortality 4, 6.
- The FDA has issued black box warnings for several atypical antipsychotics, including quetiapine, regarding the increased risk of cerebrovascular adverse events and mortality in elderly patients with dementia 6.
Alternative Treatment Options
- Nonpharmacological approaches, such as caregiver education, supportive therapy, and behavioral interventions, should be considered before initiating pharmacological treatment for aggression in patients with dementia 3, 6.
- Other atypical antipsychotics, such as risperidone and olanzapine, have been shown to be effective in reducing aggression and psychosis in patients with dementia, but are also associated with increased risks of adverse events 4, 5, 7.
Clinical Considerations
- The use of quetiapine or other atypical antipsychotics for treating aggression in patients with dementia should be carefully considered, weighing the potential benefits against the risks of adverse events 4, 6.
- Patients and their families should be fully informed of the potential risks and benefits of treatment, and alternative treatment options should be explored before initiating pharmacological therapy 6.