What is the best intervention for managing sundowning symptoms in a dementia patient on Seroquel (quetiapine) and Mirtazapine?

Management of Sundowning in a 94-Year-Old Female with Dementia

For this 94-year-old female with dementia and sundowning symptoms who is currently on quetiapine 25mg twice daily and mirtazapine 7.5mg at night, the best intervention is to discontinue quetiapine and optimize the mirtazapine dose to 15-30mg at bedtime, while implementing structured non-pharmacological interventions.

Current Medication Assessment

The patient is currently on:

• Quetiapine (Seroquel) 25mg at 3pm and 8pm for sundowning
• Mirtazapine 7.5mg at night (with a meantime of 10mg)

Issues with Current Regimen

1. Quetiapine (Seroquel):

   • Antipsychotics should be avoided if possible in elderly dementia patients due to significant risks 1
   • Associated with greater cognitive decline compared to placebo 2
   • The American Geriatrics Society recommends avoiding antipsychotics due to increased mortality risk 3

2. Mirtazapine:

   • Currently underdosed at 7.5mg (therapeutic dose typically 15-30mg) 1
   • Mirtazapine is well-tolerated and promotes sleep, appetite, and weight gain 1

Recommended Intervention Plan

1. Optimize Mirtazapine

• Increase mirtazapine to 15mg at bedtime 1
• Mirtazapine is potent, well-tolerated, and promotes sleep which can help with sundowning symptoms
• May further titrate up to 30mg at bedtime if needed after 2-4 weeks

2. Discontinue Quetiapine

• Gradually taper quetiapine to minimize withdrawal effects
• Replace with non-pharmacological interventions

3. Implement Non-Pharmacological Interventions

• Establish predictable daily routine with consistent meal, exercise, and bedtime schedules 1, 3
• Reduce environmental stimulation in the evening (minimize noise, dim lights) 3
• Ensure adequate lighting during daytime to regulate circadian rhythm 3
• Simplify tasks and break complex activities into simple steps 1
• Use distraction and redirection techniques when agitation begins 1

Monitoring and Follow-up

• Reassess sundowning symptoms weekly during medication changes
• Monitor for:
  • Improvement in sundowning behaviors
  • Sleep quality and duration
  • Potential side effects of mirtazapine (sedation, dry mouth, increased appetite)
  • Withdrawal symptoms from quetiapine

Rationale for Recommendation

1. Safety concerns with quetiapine:

   • Quetiapine and other antipsychotics have been shown to accelerate cognitive decline in dementia patients 2
   • Limited efficacy for agitation in dementia based on controlled trials 2
   • Risk of orthostatic hypotension, sedation, and falls especially concerning in a 94-year-old 4

2. Benefits of optimized mirtazapine:

   • Mirtazapine is specifically noted in guidelines as "potent and well tolerated; promotes sleep, appetite, and weight gain" 1
   • The therapeutic dose range is 15-30mg at bedtime 1
   • May help with both sleep disturbances and mood symptoms that contribute to sundowning

3. Importance of non-pharmacological approaches:

   • The American Geriatrics Society recommends exhausting non-pharmacological interventions before using medications 1
   • Environmental modifications and structured routines can significantly reduce sundowning behaviors 3

Common Pitfalls to Avoid

1. Overreliance on antipsychotics - Despite their common use, antipsychotics should be avoided when possible due to increased mortality risk and cognitive decline
2. Inadequate trial of non-pharmacological interventions - These should be implemented consistently before and during medication adjustments
3. Underdosing effective medications - The current mirtazapine dose (7.5mg) is below the recommended therapeutic range (15-30mg)
4. Polypharmacy - Using multiple sedating medications increases risk of falls and cognitive impairment in elderly patients

By optimizing mirtazapine dosing and implementing structured non-pharmacological interventions while discontinuing quetiapine, we can better manage this patient's sundowning symptoms while minimizing risks associated with antipsychotic use in elderly dementia patients.