Is it advisable to increase the midazolam dosage for a dementia patient with increased calling out, who is already on quetiapine?

Managing Calling Out Behavior in a Dementia Patient on Quetiapine

Increasing midazolam dosage is not recommended for a dementia patient with increased calling out behavior who is already on quetiapine, as this combination increases risk of respiratory depression, excessive sedation, and may worsen cognitive function.

Assessment of Current Situation

• The patient is currently on quetiapine 25mg and PRN midazolam for behavioral symptoms 1
• Staff are requesting to increase midazolam to twice daily spray TDS PRN (three times daily as needed) 1
• Increased calling out behavior may indicate:
  • Unmet needs (pain, hunger, toileting needs)
  • Progression of dementia
  • Possible delirium
  • Medication side effects 1

Risks of Increasing Midazolam

• Midazolam is a short-acting benzodiazepine with significant risks in elderly and dementia patients:

  • Respiratory depression, which can be severe and potentially fatal 1, 2
  • Increased risk of falls 1
  • Paradoxical agitation and worsening of behavioral symptoms 1
  • May cause or worsen delirium 3, 4
  • Accumulation with repeated dosing, especially in patients with renal impairment 4

• Concomitant use of benzodiazepines with antipsychotics like quetiapine significantly increases risk of:

  • Profound sedation and respiratory depression 2
  • Oversedation and potential coma 1, 2
  • Increased mortality 2, 5

Alternative Management Approaches

Non-pharmacological Interventions (First Line)

• Identify and address potential triggers for calling out behavior:

  • Physical discomfort or pain
  • Environmental factors (noise, temperature)
  • Unmet needs (thirst, hunger, toileting)
  • Boredom or lack of meaningful activity 1

• Implement structured activities, reassurance, and socialization 1

Pharmacological Alternatives (If Non-pharmacological Approaches Fail)

1. Optimize current quetiapine dose:

   • Consider whether current dose is appropriate
   • Low-dose quetiapine (12.5-50mg) may be sufficient for behavioral symptoms 6
   • Monitor for side effects including sedation, orthostatic hypotension 1, 5

2. Consider alternative medications if needed:

   • If symptoms suggest depression: Consider mirtazapine 7.5mg at bedtime (promotes sleep, appetite) 1
   • If anxiety predominates: Consider low-dose lorazepam 0.25-0.5mg PRN (safer than midazolam for intermittent use) 1
   • For severe agitation: Haloperidol 0.25-0.5mg may be considered with careful monitoring 1

Monitoring and Follow-up

• Regular assessment of behavioral symptoms using standardized tools 1
• Monitor for medication side effects, particularly:
  • Excessive sedation
  • Respiratory depression
  • Falls
  • Worsening cognition 2, 3
• Reassess need for medications regularly with aim to use lowest effective dose for shortest duration 1

Common Pitfalls to Avoid

• Treating behavioral symptoms with sedation without identifying underlying causes 1
• Using benzodiazepines as first-line treatment for behavioral symptoms in dementia 1
• Combining multiple sedating medications without careful monitoring 2
• Prolonged use of benzodiazepines leading to tolerance and dependence 4
• Failing to recognize that medications themselves can worsen behavioral symptoms 3, 5

Conclusion

Increasing midazolam dosage in this dementia patient already on quetiapine presents significant risks with limited benefit. A more appropriate approach would be to identify and address underlying causes of the calling out behavior, optimize non-pharmacological interventions, and consider safer pharmacological alternatives if absolutely necessary.