What are the considerations for using Rexulti (brexpiprazole) in an elderly patient with dementia, experiencing panic, agitation, and worsening memory?

Brexpiprazole (Rexulti) Use in Elderly Patients with Dementia

Brexpiprazole should NOT be used for this elderly dementia patient experiencing agitation, panic, and worsening memory due to its FDA black box warning for increased mortality in elderly patients with dementia-related psychosis. 1

Risks and Warnings

• Brexpiprazole carries a black box warning specifically stating: "Antipsychotic drugs increase the risk of death in elderly patients with dementia-related psychosis. Brexpiprazole is not approved for the treatment of patients with dementia-related psychosis." 1

• All antipsychotics, including brexpiprazole, are associated with increased mortality in elderly patients with dementia 2

• The American Psychiatric Association recommends that antipsychotic medications should only be used for dementia-related agitation or psychosis when:

  • Symptoms are severe, dangerous, or cause significant distress
  • Non-pharmacological interventions have been tried first
  • A thorough risk/benefit assessment has been conducted 3

First-Line Approach: Non-Pharmacological Interventions

The American Academy of Family Physicians and American Psychiatric Association recommend exhausting non-pharmacological approaches before considering medications 3:

• Provide a predictable routine (exercise, meals, bedtime should be punctual)
• Allow the patient to wear their own clothing and keep possessions
• Explain all procedures in simple language
• Break complex tasks into simple steps
• Use distraction and redirection techniques
• Ensure proper lighting to reduce confusion at night
• Reduce environmental stimuli that may cause agitation
• Consider day care programs for patients with Alzheimer's disease 3

When Medication Is Necessary

If non-pharmacological interventions fail and medication becomes necessary:

1. Assess for underlying causes of agitation (pain, infection, medication side effects)
2. Consider cholinesterase inhibitors for mild-moderate dementia (donepezil, rivastigmine, galantamine) 4
3. If antipsychotics must be used (for severe, dangerous symptoms):
   • Start with the lowest possible dose
   • Use for the shortest duration possible (attempt to taper within 3-6 months)
   • Monitor closely for side effects
   • Reassess regularly for continued need 3, 2

Important Considerations for the Family

When discussing medication options with the family:

• Be transparent about the FDA black box warning for increased mortality with antipsychotics in dementia patients 1
• Explain that brexpiprazole, despite recent FDA approval for agitation in Alzheimer's dementia 5, still carries mortality risks similar to other antipsychotics
• Emphasize that non-drug approaches should be tried first and are often effective
• If medication becomes necessary, explain the importance of:
  • Starting with the lowest possible dose
  • Regular monitoring for side effects
  • Time-limited use with planned reassessment 3

Common Pitfalls to Avoid

• Using benzodiazepines (like lorazepam) as first-line therapy, which significantly increases fall risk and cognitive impairment 2
• Failing to rule out reversible causes of agitation before starting medication
• Inadequate monitoring for medication side effects
• Not implementing comprehensive non-pharmacological approaches
• Using excessive doses of medication
• Not reassessing the need for continued medication therapy 2

By following these guidelines, you can help manage this patient's symptoms while minimizing risks associated with antipsychotic use in elderly patients with dementia.