Can Rexalti (vortioxetine) be used in patients with dementia and head trauma?

Use of Brexpiprazole (Rexulti) in Patients with Dementia and Head Trauma

Brexpiprazole (Rexulti) should not be used in patients with dementia and head trauma due to increased mortality risk, worsening cognitive function, and significant safety concerns.

Safety Concerns in Dementia Patients

Brexpiprazole (Rexulti) is an antipsychotic medication that carries significant risks when used in patients with dementia. The evidence strongly indicates several important safety concerns:

• Antipsychotics like Rexulti carry an FDA black box warning regarding increased mortality risk in dementia patients 1
• Antipsychotics are associated with cognitive decline in dementia patients, which would further compromise cognitive function 1
• The American Geriatrics Society recommends against antipsychotics as first-line treatment for behavioral symptoms in dementia due to these risks 1

Head Trauma Considerations

For patients with head trauma history, additional concerns exist:

• Neuroimaging is often necessary in patients with head trauma to assess for intracranial pathology before considering any psychotropic medications 2
• Patients with head trauma are at increased risk for seizures, and certain medications may lower the seizure threshold 2
• Cognitive impairment following head trauma may be worsened by medications with anticholinergic or sedating properties 1

Alternative Treatment Approaches

Non-Pharmacological Interventions (First-Line)

1. Environmental modifications to decrease sensory stimulation 1
2. Verbal de-escalation techniques including calm communication and establishing rapport 1
3. Physical exercise (50-60 minutes daily) for anxiety and agitation management 1
4. Cognitive therapy for cognitive impairment, which has shown mild to modest benefits in improving overall cognitive function 2

Safer Pharmacological Alternatives

If medication is absolutely necessary for severe symptoms:

1. For cognitive symptoms:

   • Cholinesterase inhibitors for mild to moderate dementia 2
   • Memantine for moderate to severe dementia 2

2. For depression/anxiety:

   • Vortioxetine has shown benefits in patients with early-stage dementia and depression 3
   • Recent research indicates vortioxetine improved cognitive function and depressive symptoms in patients with early-stage dementia 3
   • Vortioxetine has demonstrated effectiveness in improving depressive symptoms, cognitive performance, daily functioning, and quality of life in patients with MDD and comorbid early-stage dementia 3

Monitoring Recommendations

If any psychotropic medication is used despite risks:

• Schedule follow-up within 2 weeks to assess response to medication changes 1
• Monitor for changes in agitation/anxiety levels, fall frequency, cognitive function, and vital signs 1
• Regular reassessment every 2-4 weeks initially to monitor for medication side effects 1
• Use validated assessment tools to track cognitive function and behavioral symptoms 1

Important Cautions

• Patients with dementia and head trauma are at significantly higher risk for falls, which can be exacerbated by psychotropic medications 1
• Antipsychotics should be avoided or used only as a last resort at the lowest effective dose for the shortest duration possible 1
• SSRIs should be used with caution as they may increase the risk of intracerebral hemorrhage, especially in patients with prior head trauma 2

In conclusion, the risks of using Brexpiprazole (Rexulti) in patients with dementia and head trauma outweigh potential benefits. Non-pharmacological approaches should be exhausted first, and if medication is necessary, safer alternatives with better evidence for this specific population should be considered.