From the Guidelines
For an 80-year-old female with dementia experiencing persistent paranoia, repetitive questioning, and afternoon agitation despite current medications, I recommend reducing the Zyprexa (olanzapine) dose gradually while adding Seroquel (quetiapine) 25mg twice daily, titrating up to 50-100mg twice daily as tolerated, as suggested by the most recent study 1. The current Zyprexa dose of 25mg daily is quite high for an elderly patient and may be contributing to side effects without additional benefit. Seroquel often works better for sundowning symptoms and has a more favorable side effect profile for elderly patients. Additionally, consider adding Depakote (divalproex sodium) starting at 125mg twice daily and gradually increasing to 250mg twice daily, which can help with agitation and mood stabilization, as seen in previous studies 1. Morning doses of antipsychotics could be reduced while maintaining or increasing the afternoon/evening doses to target the time when symptoms worsen. Continue the memantine, but consider reducing Remeron to 15mg as higher doses don't provide additional benefit and may increase side effects. Throughout any medication changes, implement a slow, sequential approach, changing one medication at a time while monitoring for improvement in target symptoms and potential side effects, particularly sedation, falls, and extrapyramidal symptoms, as recommended by recent guidelines 1. It's also important to note that antipsychotic medications should be used with caution in elderly patients with dementia, due to the increased risk of adverse effects, including falls, stroke, and death, as highlighted in a recent study 1. Therefore, it's crucial to weigh the potential benefits and risks of medication changes and to prioritize non-pharmacological interventions, such as behavioral modifications and psychosocial interventions, whenever possible.
From the FDA Drug Label
2.3 Dose Modifications in Elderly Patients Consideration should be given to a slower rate of dose titration and a lower target dose in the elderly and in patients who are debilitated or who have a predisposition to hypotensive reactions [see Clinical Pharmacology (12.3)] . When indicated, dose escalation should be performed with caution in these patients. Elderly patients should be started on quetiapine fumarate tablets 50 mg/day and the dose can be increased in increments of 50 mg/day depending on the clinical response and tolerability of the individual patient.
The patient is currently on Zyprexa (olanzapine), not quetiapine, so the provided drug label does not directly apply to the patient's current medication regimen. However, considering the patient's age and the fact that she is on a high dose of Zyprexa, caution should be exercised when making any medication changes. Given the patient's symptoms and current medication regimen, it may be beneficial to consider a reduction in dose or a switch to a different medication. However, without more information about the patient's response to current treatments and potential side effects, it is difficult to make a specific recommendation. It is also important to note that behavioral modifications should continue to be a part of the patient's treatment plan. Consultation with a geriatric psychiatrist or other qualified healthcare professional is recommended to determine the best course of treatment for this patient 2.
From the Research
Medication Changes for Dementia Patient
The patient is currently experiencing fixed beliefs of paranoia, increased question asking, and verbal agitation in the afternoons, despite multiple behavioral modifications. The patient's current medication regimen includes Zyprexa, Remeron, memantine, and melatonin.
Current Medications
- Zyprexa (olanzapine) 10mg in the morning, 10mg in the afternoon, and 5mg QHS
- Remeron (mirtazapine) 30mg QHS
- Memantine 10mg BID
- Melatonin 9mg
Potential Medication Changes
Based on the studies, the following medication changes could be considered:
- Adjusting the dosage of Zyprexa, as the current dosage may be too high, especially considering the patient's age and potential sensitivity to the medication 3
- Switching to a different atypical antipsychotic, such as risperidone or quetiapine, which have been shown to be effective in treating behavioral and psychological symptoms in patients with Alzheimer's disease 4, 5, 6
- Adding or adjusting other medications, such as selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs), to help manage depressive symptoms 5
Considerations
When making medication changes, it is essential to consider the patient's individual needs, medical history, and potential interactions with other medications. The patient's response to treatment should be closely monitored, and adjustments made as needed.
Relevant Studies
The following studies provide evidence for the potential medication changes:
- 4: Compared the effectiveness of olanzapine, risperidone, and quetiapine in treating psychotic agitation
- 5: Compared the effectiveness of risperidone, quetiapine, and olanzapine as adjunctive treatments in major depression with psychotic features
- 6: Examined the effects of risperidone, olanzapine, and quetiapine on behavioral disturbances in patients with Alzheimer's disease
- 7: Compared the efficacy and tolerability of olanzapine, quetiapine, and risperidone in the treatment of early psychosis