Is it safe to discontinue trazodone (an antidepressant) and start gabapentin (an anticonvulsant) at 300 mg at night, 100 mg in the morning, and 20 mg in the afternoon for anxiety in an elderly patient with dementia, Alzheimer's disease, and a history of urinary tract infections (UTIs)?

Discontinuing Trazodone and Starting Gabapentin for Anxiety in Elderly Dementia Patients

Direct Recommendation

Do not discontinue trazodone and switch to gabapentin for anxiety management in this elderly patient with dementia, Alzheimer's disease, and recurrent UTIs. This proposed regimen contradicts evidence-based guidelines and introduces significant risks without established benefit for the target symptoms.

Why This Switch Is Not Recommended

Gabapentin Lacks Evidence for Anxiety in Dementia

• Gabapentin has no controlled trial evidence supporting its use for behavioral and psychological symptoms of dementia (BPSD), with only limited case reports and case series available, and no FDA approval for this indication 1
• Two case reports specifically questioned the appropriateness of gabapentin for dementia-related agitation, particularly in Lewy body dementia 1
• The dearth of available data limits support for off-label use of gabapentin for BPSD treatment 1

Trazodone Has Established Efficacy

• Trazodone demonstrated 65.7% effectiveness for sleep disorders in elderly dementia patients in observational studies, making it the most commonly used medication for this population 2
• The American Academy of Family Physicians recommends trazodone (starting 25 mg/day, maximum 200-400 mg/day) as a safer alternative to antipsychotics for agitation in dementia, with better tolerability than typical antipsychotics 3
• Trazodone is specifically listed as a guideline-supported option for chronic agitation without psychotic features in dementia patients 3

The Proposed Gabapentin Dosing Is Problematic

• The suggested regimen (300 mg at night, 100 mg AM, 20 mg afternoon) totals 420 mg daily, which is not a standard titration schedule for any approved indication 4
• Gabapentin requires careful dose adjustment in elderly patients and those with renal insufficiency, with recommended starting doses of 100-300 mg at bedtime 4
• The 20 mg afternoon dose is unusually low and not aligned with standard gabapentin dosing increments of 100-300 mg 4

Safety Concerns in This Population

• Gabapentin causes dose-dependent dizziness and sedation, which can be reduced by starting with lower dosages and titrating cautiously 4
• In elderly patients and those with renal dysfunction, gabapentin should be used with further caution and dose adjustment 4
• This patient's history of recurrent UTIs may indicate underlying renal issues requiring dose modification 4

What Should Be Done Instead

Address Underlying Medical Causes First

• Treat the documented UTI immediately with appropriate antibiotics, as UTIs are a major driver of behavioral disturbances in dementia patients who cannot verbally communicate discomfort 3
• Urinary incontinence and lower urinary tract symptoms are highly prevalent in Alzheimer's patients and correlate with disease severity 5, 6
• Assess and treat pain systematically, check for constipation and urinary retention, and evaluate metabolic disturbances before adjusting psychotropics 3

Optimize Current Trazodone Therapy

• If trazodone is providing benefit for sleep or agitation, continue it rather than discontinuing 3
• The typical trazodone dosing range is 25-400 mg/day in divided doses, allowing room for optimization if needed 3
• Use caution in patients with premature ventricular contractions due to orthostatic hypotension risk 3

Consider SSRIs as First-Line for Anxiety

• For chronic anxiety and agitation in dementia, SSRIs are the preferred first-line pharmacological option 3
• Sertraline (starting 25-50 mg/day, maximum 200 mg/day) or citalopram (starting 10 mg/day, maximum 40 mg/day) have established efficacy for neuropsychiatric symptoms in dementia 3
• SSRIs require 4-8 weeks for full therapeutic effect at adequate dosing 3

Implement Non-Pharmacological Interventions

• Use calm tones, simple one-step commands, and gentle touch for reassurance 3
• Ensure adequate lighting and reduce excessive noise 3
• Provide predictable daily routines and use ABC charting to identify specific triggers 3

Critical Pitfalls to Avoid

• Do not add multiple psychotropics simultaneously without first treating reversible medical causes like UTIs 3
• Avoid discontinuing medications that are providing benefit without clear rationale 3
• Do not use gabapentin for BPSD based solely on case reports when guideline-supported alternatives exist 1
• Review all medications for anticholinergic properties that worsen confusion and agitation 3