Can a 94-year-old patient with dementia and behavioral disturbances on Seroquel (quetiapine), Memantine (memantine), and Mirtazapine (mirtazapine) be given Lorazepam (lorazepam) at night for sundowning?

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

Lorazepam should be avoided in this 94-year-old patient with dementia and behavioral disturbances who is already on quetiapine, memantine, and mirtazapine due to the high risk of worsening cognitive impairment and increased adverse effects.

Understanding Sundowning in Dementia

Sundowning syndrome refers to the emergence or worsening of neuropsychiatric symptoms in the late afternoon or evening in patients with dementia. It is characterized by:

• Increased agitation, confusion, anxiety, and aggressiveness in the evening or at night 1
• Prevalence ranging from 1.6% to 66% of patients with dementia 2
• Association with impaired circadian rhythmicity, environmental factors, and cognitive impairment 1

Medication Considerations for This Patient

Current Medication Analysis

The patient is already on:

• Quetiapine (Seroquel) - an antipsychotic medication used for behavioral disturbances
• Memantine - an NMDA receptor antagonist for cognitive symptoms
• Mirtazapine - a sedating antidepressant that may help with sleep and appetite 3

Risks of Adding Lorazepam

• Benzodiazepines should be avoided in older patients and in patients with cognitive impairment due to their potential to cause decreased cognitive performance 3
• The combination of benzodiazepines with antipsychotics (quetiapine) increases the risk of excessive sedation and falls 3
• Lorazepam may worsen confusion and increase the risk of paradoxical excitation in elderly patients with dementia 3

Recommended Approach for Managing Sundowning

Non-Pharmacological Interventions (First Line)

• Implement sleep hygiene measures and structured evening activities 3
• Provide environmental modifications (adequate lighting, familiar surroundings) 4
• Ensure caregiver education and support for managing sundowning behaviors 1

Pharmacological Options (If Non-Pharmacological Approaches Fail)

1. Optimize current medications:

   • Ensure mirtazapine is given at bedtime (7.5-30 mg) as it promotes sleep and may help with sundowning 3
   • Consider adjusting quetiapine timing or dosage for evening coverage of symptoms 3

2. Alternative pharmacological options if needed:

   • Consider trazodone (25-100 mg at bedtime) which has a better safety profile than benzodiazepines in elderly patients with dementia 3
   • Low-dose olanzapine (2.5-5 mg at bedtime) may be considered with caution in elderly patients 3

Monitoring and Follow-up

• Regularly assess effectiveness of interventions on sundowning symptoms 4
• Monitor for adverse effects including excessive sedation, falls, and worsening cognitive function 3
• Evaluate for drug interactions among the multiple CNS-active medications 3

Cautions and Contraindications

• Benzodiazepines like lorazepam should not be used as initial treatment for behavioral disturbances in elderly patients with dementia 3
• The FDA has issued warnings about increased mortality risk with antipsychotic use in elderly patients with dementia-related psychosis 3
• The combination of multiple sedating medications increases the risk of falls, fractures, and respiratory depression 3

Special Considerations

• If agitation is severe and refractory to other interventions, a benzodiazepine may be considered only after consultation with a specialist and with close monitoring 3
• Any medication trial should be time-limited with regular reassessment of risks and benefits 3
• Consider investigating for underlying causes of worsening evening symptoms (pain, constipation, urinary retention) 4