What medication options can be safely added to a regimen for a patient with behavioral dementia currently on Aricept (donepezil) and trazodone?

Medication Options for Behavioral Dementia in a 78-Year-Old on Aricept and Trazodone

For a 78-year-old gentleman with behavioral dementia currently on Aricept (donepezil) and trazodone, atypical antipsychotics at low doses are the most appropriate medication to add for managing problematic behaviors, with risperidone being the preferred option due to its established efficacy and safety profile at low doses.

Current Medication Assessment

• The patient is currently on Aricept (donepezil), a cholinesterase inhibitor that provides modest improvement of cognitive symptoms in Alzheimer's disease 1
• Trazodone is already being used, which is a mood-stabilizing (antiagitation) drug that can help control severe agitated behaviors 1
• Current trazodone dosing can range from 25 mg initially to 200-400 mg per day in divided doses; ensure the current dose is optimized before adding additional medications 1

Medication Options to Consider

Atypical Antipsychotics (First-Line Options)

Atypical antipsychotics are recommended for controlling problematic delusions, hallucinations, severe psychomotor agitation, and combativeness in dementia:

• Risperidone (Risperdal):

  • Initial dosage: 0.25 mg per day at bedtime
  • Maximum: 2-3 mg per day in divided doses
  • Current research supports use of low dosages; extrapyramidal symptoms may occur at doses of 2 mg per day or higher 1

• Olanzapine (Zyprexa):

  • Initial dosage: 2.5 mg per day at bedtime
  • Maximum: 10 mg per day in divided doses
  • Generally well tolerated 1

• Quetiapine (Seroquel):

  • Initial dosage: 12.5 mg twice daily
  • Maximum: 200 mg twice daily
  • More sedating; beware of transient orthostasis 1

Mood Stabilizers (Alternative Options)

• Divalproex sodium (Depakote):

  • Initial dosage: 125 mg twice daily
  • Titrate to therapeutic blood level (40-90 mcg/mL)
  • Generally better tolerated than other mood stabilizers
  • Requires monitoring of liver enzymes, platelets, prothrombin time, and partial thromboplastin time 1

• Carbamazepine (Tegretol):

  • Initial dosage: 100 mg twice daily
  • Titrate to therapeutic blood level (4-8 mcg/mL)
  • Requires regular monitoring of complete blood count and liver enzymes
  • Has more problematic side effects than divalproex 1

Important Considerations and Cautions

Atypical Antipsychotics

• Use with caution due to FDA black box warning regarding increased risk of mortality when used in elderly patients with dementia 1, 2
• Should be used at the lowest effective dose for the shortest duration necessary 2
• Have diminished risk of extrapyramidal symptoms and tardive dyskinesia compared to typical antipsychotics 1
• Regular monitoring for metabolic effects, extrapyramidal symptoms, falls, cognitive worsening, cardiac arrhythmia, and pneumonia is essential 2

Typical Antipsychotics (Not Recommended)

• Should be avoided if possible due to significant side effects involving cholinergic, cardiovascular, and extrapyramidal systems 1
• Risk of irreversible tardive dyskinesia can develop in 50% of elderly patients after continuous use for 2 years 1

Benzodiazepines (Use with Caution)

• Can lead to tolerance, addiction, depression, and cognitive impairment 1
• Paradoxical agitation occurs in about 10% of patients 1
• If needed, use infrequent, low doses of agents with short half-lives (lorazepam, oxazepam) 1

Evidence for Trazodone (Current Medication)

• Trazodone has shown modest efficacy for behavioral symptoms in dementia 3, 4
• In a comparative study, trazodone was as effective as haloperidol for treating agitated behaviors but with fewer adverse effects 4
• Particularly effective for repetitive, verbally aggressive, and oppositional behaviors 4
• However, a Cochrane review found insufficient evidence to strongly recommend trazodone for behavioral symptoms in dementia 5

Recommended Approach

1. First, optimize current trazodone dosage if not already at therapeutic levels (up to 200-400 mg/day in divided doses) 1

2. If additional medication is needed, add low-dose risperidone:

   • Start at 0.25 mg at bedtime
   • Titrate slowly based on response and tolerability
   • Monitor closely for side effects
   • Keep dose below 2 mg daily to minimize risk of extrapyramidal symptoms 1

3. If risperidone is not tolerated or ineffective:

   • Consider quetiapine starting at 12.5 mg twice daily, especially if sedation is desired 1
   • OR olanzapine starting at 2.5 mg at bedtime if less sedation is preferred 1

4. For patients who cannot tolerate antipsychotics:

   • Consider divalproex sodium starting at 125 mg twice daily 1
   • Monitor liver function and blood counts regularly 1

Monitoring Recommendations

• Assess response to medication after 2-4 weeks
• Monitor for extrapyramidal symptoms, sedation, orthostatic hypotension
• Regular follow-up visits to evaluate continued need for medication
• Consider medication discontinuation if symptoms have been in remission for 3-6 months 2

Remember that all pharmacological interventions should be accompanied by appropriate non-pharmacological approaches and environmental modifications to manage behavioral symptoms in dementia 1.