What is the appropriate workup for an 87-year-old male with dementia and epilepsy, on quetiapine, lamotrigine, trazodone, and citalopram, presenting with upper extremity bruising secondary to self-gripping?

Workup for Upper Extremity Bruising in an Elderly Patient with Dementia and Epilepsy

The most appropriate workup for this 87-year-old male with dementia and epilepsy presenting with upper extremity bruising secondary to self-gripping should include a medication review with focus on potential drug interactions and side effects, coagulation studies, and evaluation for delirium.

Medication Review and Evaluation

Current Medication Assessment

• Evaluate the patient's current regimen:
  • Quetiapine: Associated with increased risk of falls, mortality, and cognitive decline in elderly patients with dementia 1
  • Lamotrigine: Generally well-tolerated but may interact with other medications 2
  • Trazodone: Often used off-label for sleep in elderly but can contribute to falls 3
  • Citalopram: May contribute to QT prolongation, especially in combination with other medications 4

Drug Interactions and Side Effects

• Check for drug-drug interactions between:
  • Lamotrigine and quetiapine: Potential for increased seizure risk 5
  • Multiple psychotropic medications: Increased risk of falls and cognitive impairment 3
  • Citalopram and quetiapine: Potential for QT prolongation 4

Laboratory and Diagnostic Workup

Coagulation Studies

• Complete blood count with platelets
• Prothrombin time (PT)/International Normalized Ratio (INR)
• Activated partial thromboplastin time (aPTT)
• Liver function tests (may affect coagulation and medication metabolism)
• Renal function tests (may affect medication clearance)

Medication Levels

• Check lamotrigine levels to ensure therapeutic range without toxicity 6
• Consider checking levels of other medications if clinically indicated

Clinical Evaluation

Delirium Assessment

• Evaluate for signs of delirium which may contribute to self-gripping behavior 6
• Use standardized delirium assessment tools
• Look for potential causes:
  • Medication side effects or interactions
  • Infection
  • Metabolic abnormalities
  • Pain
  • Constipation or urinary retention 7

Neurological Assessment

• Assess for changes in seizure frequency or pattern 6
• Evaluate for new neurological deficits
• Consider EEG if clinical suspicion for subclinical seizures or status epilepticus 6

Management Considerations

Medication Adjustments

• Consider reducing or discontinuing quetiapine due to:

  • Increased risk of mortality (HR 3.1,95% CI 1.2-8.1) 1
  • Increased risk of dementia (HR 8.1,95% CI 4.1-15.8) 1
  • Increased risk of falls (HR 2.8,95% CI 1.4-5.3) 1
  • Potential to lower seizure threshold 5

• For epilepsy management:

  • Consider levetiracetam or lamotrigine as preferred agents in elderly patients with epilepsy 2
  • Ensure monotherapy when possible to minimize drug interactions 6

• For anxiety/agitation management:

  • Consider non-pharmacological approaches first 7
  • If medication needed, consider starting with lowest possible dose of an SSRI 7
  • Avoid benzodiazepines except for very short-term use 7

Behavioral Interventions

• Implement non-pharmacological approaches for agitation:
  • Physical exercise (50-60 minutes daily distributed throughout the day) 7
  • Environmental modifications to create a calming environment 7
  • Verbal de-escalation techniques 7

Pitfalls and Caveats

1. Don't assume bruising is solely due to self-gripping behavior

   • Always rule out coagulopathy, elder abuse, or other causes of bruising

2. Avoid adding more medications without reviewing current regimen

   • This patient is already on multiple psychotropic medications with potential interactions

3. Don't overlook the contribution of polypharmacy

   • The combination of four CNS-active medications increases risk of adverse effects

4. Avoid high-dose antipsychotics in elderly patients with dementia

   • Associated with increased mortality, falls, and cognitive decline 1

5. Don't miss the opportunity to simplify medication regimen

   • Consider discontinuing medications that may be contributing to the problem rather than adding new ones