From the Guidelines
For behavioral disturbances in elderly dementia patients taking amiodarone, I strongly recommend starting with non-pharmacological approaches first, such as maintaining a consistent routine, providing a calm environment, and identifying triggers for agitation, as suggested by the most recent guidelines 1. If medication becomes necessary, quetiapine at low doses (12.5-25mg once or twice daily) is often preferred due to its lower risk of QT prolongation compared to other antipsychotics, which is important for patients on amiodarone, as noted in earlier guidelines 1. Some key points to consider when managing behavioral disturbances in elderly dementia patients include:
- Non-pharmacological strategies should be considered as first-line management, including cognitive behavioral, interpersonal, and/or problem-solving deficits, psychotherapeutic strategies, and structured and tailored activities that are individualized and aligned to current capabilities and take into account previous roles and interests 1.
- If pharmacological treatment of behavior is required, most evidence comes from the treatment of behavioral symptoms in dementia in general rather than VCI specifically, and the Canadian Coalition for Seniors’ Mental Health has issued detailed guidelines for managing behavioral symptoms of dementia 1.
- Risperidone (0.25-0.5mg daily) is an alternative but carries a slightly higher risk of QT prolongation, and haloperidol, ziprasidone, and thioridazine should be avoided due to significant QT prolongation risks.
- For patients with depression or anxiety contributing to behaviors, consider citalopram (10mg daily) or sertraline (25-50mg daily), though citalopram requires careful ECG monitoring with amiodarone, and trazodone (25-50mg at bedtime) may help with sleep disturbances.
- All medications should be started at the lowest possible dose with the principle of "start low, go slow," and regular ECG monitoring is essential to watch for QT prolongation, as antipsychotics carry black box warnings for increased mortality in elderly dementia patients.
- Additionally, a systematic, comprehensive review of medications is encouraged for all individuals with dementia and frailty, and deprescribing unnecessary or inappropriate medication as per published criteria is recommended, to minimize polypharmacy and potential drug—drug or drug—disease interactions 1.
From the Research
Medication Options for Behavioral Disturbances in Elderly Dementia Patients with Amiodarone
- There is no direct evidence regarding the use of specific medications for behavioral disturbances in elderly dementia patients taking amiodarone 2, 3, 4, 5, 6.
Non-Pharmacologic Approaches
- Non-pharmacologic measures can help ameliorate behavioral problems and assist in the overall care of elderly patients with dementia 2.
- Assessing the environmental, medical, and psychiatric causes of problematic behaviors and implementing a plan of behavioral, medical, and psychiatric management can reduce difficult target behaviors 5.
Pharmacologic Options
- Atypical antipsychotics, such as quetiapine and risperidone, have been shown to be effective in treating behavioral and psychological symptoms of dementia (BPSD) in elderly patients 3.
- Selective serotonin reuptake inhibitors, such as citalopram, have demonstrated efficacy in improving dementia-related behavioral symptoms 4.
- Antidepressants may be used to treat behavioral disturbances in dementia, with a focus on their safety profile in the elderly 4.