What is the best medication for an alert and oriented elderly female with chronic obstructive pulmonary disease (COPD), seizure disorder on Keppra (levetiracetam), buspar (buspirone), amlodipine, rosuvastatin, and celecoxib, presenting with verbal aggression, excessive talking, and yelling?

Management of Verbal Aggression and Excessive Talking in an Alert, Oriented Elderly Female with COPD

Before adding any psychotropic medication, first evaluate whether Keppra (levetiracetam) is causing or exacerbating the behavioral symptoms, as this is a well-documented adverse effect that may resolve with dose adjustment or discontinuation.

Critical First Step: Assess Keppra as the Culprit

Levetiracetam is strongly associated with behavioral disturbances including aggression, irritability, and mood disorders in up to 11-13% of patients. 1 The FDA label specifically warns that:

• Non-psychotic behavioral disorders (aggression, irritability) occur in 5-11.4% of Keppra-treated patients versus 0-3.6% on placebo 1
• These symptoms can manifest as increased verbal aggression and behavioral changes 1
• Dose reduction or discontinuation resolves these symptoms in many cases 1

Action: Consult with the prescribing neurologist about potentially reducing the Keppra dose or switching to an alternative antiseizure medication before adding another psychotropic agent. 1

If Keppra Adjustment is Not Feasible or Symptoms Persist

Recommended Pharmacologic Approach

Low-dose atypical antipsychotics represent the most evidence-based pharmacologic option for severe, persistent verbal aggression in elderly patients when behavioral interventions have failed, though they carry significant risks that must be discussed with the patient and family. 2

Specific Considerations for This Patient:

Respiratory Safety with COPD:

• Avoid traditional sedating medications that could suppress respiratory drive 3
• Avoid adding systemic anticholinergic medications (which would compound effects with any anticholinergic bronchodilators she may be using for COPD) 4
• Beta-blocking agents should be avoided in COPD patients 3

Atypical Antipsychotic Selection:

• Start with the lowest possible dose of risperidone (0.25-0.5 mg daily) or quetiapine (12.5-25 mg daily) 5, 2
• These have the most evidence for managing agitation in elderly patients, though primarily studied in dementia populations 2
• Critical caveat: FDA black box warning exists for increased mortality risk in elderly patients with dementia-related psychosis 2
• Document informed consent discussion with patient/family about risks versus benefits 2

Alternative Consideration - Antidepressants:

• If aggression appears related to underlying mood/anxiety disorder, consider SSRI antidepressants (sertraline 25-50 mg or citalopram 10-20 mg) 6
• Aggression in elderly patients often represents an anxiety-depressive state rather than primary behavioral disorder 6
• SSRIs have better safety profile than antipsychotics in elderly patients with medical comorbidities 6

Important Drug Interaction Considerations

Current medication review reveals:

• Buspirone is already prescribed (anxiolytic) - assess if this is being taken as prescribed and at adequate dose
• Celecoxib and rosuvastatin have no significant interactions with recommended agents
• Amlodipine may have additive hypotensive effects with antipsychotics - monitor blood pressure 5

Treatment Algorithm

1. First: Evaluate and potentially adjust Keppra with neurology 1
2. Second: Optimize buspirone dosing if subtherapeutic
3. Third: If symptoms suggest depression/anxiety, trial SSRI antidepressant 6
4. Fourth: Only if above fail and symptoms are severe/dangerous, consider low-dose atypical antipsychotic with documented informed consent 2
5. Throughout: Implement behavioral interventions and environmental modifications 2, 7

Critical Pitfalls to Avoid

• Do not use benzodiazepines - high risk of respiratory depression in COPD, paradoxical agitation, and falls in elderly 7
• Do not use typical antipsychotics (haloperidol) - higher extrapyramidal side effects and similar mortality risk as atypicals 2
• Do not use propranolol or other beta-blockers - contraindicated in COPD 3
• Avoid polypharmacy - she is already on multiple medications; adding more increases fall risk and confusion 5

Monitoring Requirements

• Reassess need for any psychotropic medication every 2-3 months with attempts at dose reduction or discontinuation 7
• Monitor for oversedation, falls, worsening respiratory status, and extrapyramidal symptoms 5, 2
• Document ongoing clinical necessity if continuing treatment beyond initial trial period 2, 7