From the Guidelines
For a 92-year-old female with Charles Bonnet syndrome, dementia with psychosis, and visual hallucinations affecting her safety, I recommend adding a low-dose atypical antipsychotic such as quetiapine 12.5-25mg at bedtime, with careful titration based on response and tolerability, as suggested by the American Psychiatric Association practice guideline for the treatment of patients with schizophrenia 1. This approach is supported by the guideline's recommendation for the use of antipsychotic medication in patients with schizophrenia, which can be applied to patients with dementia with psychosis, given the similar symptom profiles. The choice of quetiapine is based on its lower risk of extrapyramidal symptoms compared to other antipsychotics, as noted in the guidelines for managing Alzheimer's disease 1. Alternatively, risperidone 0.25-0.5mg daily could be considered, as it is also recommended for the control of problematic delusions, hallucinations, severe psychomotor agitation, and combativeness in patients with dementia 1. These medications can help reduce the hallucinations that are causing falls and bed refusal. It's essential to start at the lowest possible dose and monitor closely for side effects, including sedation, orthostatic hypotension, and metabolic changes, as well as regular assessment of QTc interval. Additionally, non-pharmacological approaches should be continued, including ensuring adequate lighting, removing triggers like reflective surfaces, and maintaining a consistent routine. The goal is to use the minimum effective dose for the shortest duration necessary to manage symptoms that pose safety risks, while regularly reassessing the need for continued treatment. Key considerations in the management of this patient include:
- Monitoring for side effects and adjusting the medication regimen as needed
- Regular assessment of the patient's safety and well-being
- Collaboration with the patient's caregivers and healthcare team to ensure a comprehensive treatment plan
- Consideration of non-pharmacological interventions, such as cognitive-behavioral therapy and psychoeducation, as recommended by the American Psychiatric Association practice guideline 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Medication Recommendations for Charles Bonnet Syndrome and Dementia with Psychosis
The patient is currently experiencing visual hallucinations and is on clonazepam, Remeron, Namenda, and melatonin. Considering the addition of an antipsychotic medication to manage the psychosis, the following points should be taken into account:
- Risperidone is an antipsychotic drug that has been studied for its efficacy in managing psychotic symptoms, but it may cause extrapyramidal side effects (EPS) 2, 3, 4, 5, 6.
- The risk of EPS with risperidone is dose-dependent, and higher doses are associated with a higher risk of EPS 3, 4, 5.
- Compared to conventional antipsychotics, risperidone may cause fewer EPS, but more than clozapine 6.
- The patient's current medication regimen and the potential for drug interactions should be considered when adding an antipsychotic medication.
Potential Antipsychotic Medication Options
Some potential antipsychotic medication options to consider are:
- Risperidone, but with careful monitoring for EPS and dose adjustment as needed 2, 3, 4, 5, 6.
- Other atypical antipsychotics, such as paliperidone or aripiprazole, which may have a lower risk of EPS compared to risperidone 5.
- Clozapine, which has a lower risk of EPS, but may have other side effects and requires regular monitoring 6.
Important Considerations
When selecting an antipsychotic medication, it is essential to consider the following:
- The patient's medical history, current medications, and potential drug interactions.
- The risk of EPS and other side effects associated with each medication.
- The need for regular monitoring and dose adjustments to minimize the risk of side effects.
- The patient's response to the medication and any changes in their condition.