What are the considerations for using Rexulti (brexpiprazole) in a 75-year-old female with dementia, anxiety, and behavioral concerns, already taking sertraline (selective serotonin reuptake inhibitor)?

Rexulti (Brexpiprazole) Use in Elderly Patient with Dementia, Anxiety, and Behavioral Concerns

Rexulti (brexpiprazole) is contraindicated in this 75-year-old female with dementia due to increased risk of cerebrovascular adverse events and mortality, and non-pharmacological interventions should be prioritized first, followed by optimization of sertraline therapy if needed.

Safety Concerns with Brexpiprazole in Dementia

Brexpiprazole carries a black box warning specifically for elderly patients with dementia-related psychosis:

• Increased risk of cerebrovascular adverse reactions including stroke in elderly patients with dementia 1
• Higher mortality rates compared to placebo when used in dementia patients 2
• Not FDA-approved for the treatment of patients with dementia-related psychosis 1

While recent research suggests brexpiprazole may be generally well-tolerated for agitation in Alzheimer's disease 3, the mortality risk cannot be ignored when considering overall morbidity and mortality outcomes.

Management Algorithm for Behavioral Concerns in Dementia

Step 1: Optimize Non-Pharmacological Approaches

Non-pharmacological interventions should be exhausted before considering additional medications:

• Implement the "three R's" approach: repeat, reassure, and redirect 4
• Establish predictable routines to avert behavioral problems 4
• Consider enrollment in day care programs for patients with dementia 4
• Register the patient in the Alzheimer's Association Safe Return Program if wandering is a concern 4
• Ensure appropriate environmental modifications (locked doors/gates as needed) 4

Step 2: Optimize Current Sertraline Therapy

Sertraline is already an appropriate choice for this patient:

• SSRIs like sertraline are preferred for depression in elderly patients with dementia due to minimal anticholinergic effects 4
• Sertraline has a favorable safety profile in elderly patients and requires no age-based dosage adjustments 5, 6
• Typical effective dose range is 50-200 mg/day 7
• Ensure adequate trial duration (8-12 weeks) before evaluating efficacy 8

Step 3: Consider Alternative Approaches if Needed

If behavioral symptoms persist despite optimized sertraline therapy and non-pharmacological interventions:

• Assess for depression using a simple, short assessment tool 4
• Consider vortioxetine or mirtazapine as safer alternatives for older adults with dementia and frailty 4
• Avoid tricyclic antidepressants due to anticholinergic burden 4

Special Considerations

Monitoring

• Regular assessment of behavioral symptoms using standardized tools
• Monitor for side effects of sertraline (most common: dry mouth, headache, diarrhea, nausea, insomnia)
• Assess for suicidal ideation, especially during medication adjustments 8

Caregiver Support

• Provide comprehensive psychoeducational training for caregivers 4
• Connect with support groups and community resources 4
• Establish a close working relationship between physician, patient, and caregiver 4

Common Pitfalls to Avoid

1. Adding antipsychotics without exhausting non-pharmacological approaches - This increases mortality risk without addressing underlying causes
2. Ignoring the black box warning - Brexpiprazole and other antipsychotics significantly increase stroke and mortality risk in elderly dementia patients
3. Inadequate sertraline trial - Ensure proper dosing and duration before adding other medications
4. Overlooking caregiver education - Proper caregiver training can significantly reduce the need for additional medications
5. Missing treatable causes of behavioral symptoms - Pain, constipation, infection, and sleep disturbances can all manifest as behavioral issues in dementia

By prioritizing non-pharmacological approaches and optimizing sertraline therapy, many behavioral symptoms can be managed without exposing this vulnerable patient to the significant risks associated with antipsychotic medications like brexpiprazole.