Should I add a morning dose of quetiapine (Seroquel) 25 mg to the current regimen for a patient with Alzheimer's disease and persistent daytime agitation, who is already taking quetiapine (Seroquel) 50 mg at bedtime?

Management of Daytime Agitation in Alzheimer's Disease Patient on Quetiapine

Yes, adding a morning dose of quetiapine 25 mg is appropriate for your patient with Alzheimer's disease who has persistent daytime agitation despite the 50 mg bedtime dose. 1

Rationale for Adding Morning Dose

• Quetiapine is an atypical antipsychotic that can effectively manage agitation and aggression in Alzheimer's disease patients, with initial recommended dosing of 12.5 mg twice daily and maximum dosing of 200 mg twice daily 1
• The FDA-approved dosing for quetiapine allows for divided dosing throughout the day, with gradual titration to achieve symptom control 2
• Since your patient is already responding to the nighttime dose but experiencing breakthrough daytime symptoms, adding a morning dose follows the recommended approach for managing persistent symptoms 1

Dosing Considerations

• Starting with a low morning dose of 25 mg is appropriate, as it follows the principle of "start low, go slow" in elderly patients with dementia 2
• The recommended initial dosing for quetiapine in elderly patients is 50 mg/day with increases in increments of 50 mg/day depending on clinical response and tolerability 2
• Divided dosing (BID) has been shown to be as effective as three-times-daily (TID) dosing in clinical studies 3
• Total daily dose after adding the morning 25 mg will be 75 mg, which is well within the safe range for elderly patients 1

Monitoring and Safety Considerations

• Monitor for common side effects including:

  • Sedation and orthostatic hypotension, particularly with the morning dose 1
  • Cognitive decline, as quetiapine has been associated with greater cognitive decline compared to placebo in some studies 4
  • Extrapyramidal symptoms, though these are less common with quetiapine than with typical antipsychotics 1

• Assess response to the added morning dose after 2-4 weeks to determine efficacy 1

• If partial response is observed, consider further dose adjustments or combining with environmental interventions 1

Important Caveats

• Atypical antipsychotics like quetiapine carry an FDA black box warning regarding increased mortality risk in elderly patients with dementia-related psychosis 1
• Consider non-pharmacological approaches alongside medication management:
  • Structured activities, reassurance, socialization, and caregiver education 1
  • Environmental safety measures and supervision 1
• If no improvement is seen after adding the morning dose, consider switching to an alternative medication rather than continuing to increase the quetiapine dose 1
• Periodically reassess the need for continued treatment and consider dose reduction after 9 months to determine if medication is still required 1

Alternative Approaches if Quetiapine is Ineffective

• Consider mood stabilizers like trazodone (initial dose 25 mg/day, maximum 200-400 mg/day in divided doses) or divalproex sodium (initial dose 125 mg twice daily) 1
• For mild to moderate agitation, buspirone may be considered (initial dose 5 mg twice daily) 1
• Avoid benzodiazepines when possible due to risk of tolerance, addiction, cognitive impairment, and paradoxical agitation in about 10% of elderly patients 1