Is it appropriate to start Abilify (aripiprazole) in an elderly female patient in her 80s with a history of regular delusions, on hospice care, and currently taking Lexapro (escitalopram) 20 mg and Seroquel (quetiapine) 25 mg?

Aripiprazole is NOT Appropriate in This Clinical Context

I strongly recommend AGAINST adding Abilify (aripiprazole) to this hospice patient's regimen. Instead, optimize the existing Seroquel dose or consider alternative antipsychotics with better safety profiles in elderly hospice patients. 1

Critical Safety Concerns with Aripiprazole

Black Box Warning for Elderly Patients with Dementia

• Aripiprazole carries an FDA black box warning for increased mortality in elderly patients with dementia-related psychosis and is explicitly NOT approved for this indication 1
• In clinical trials, elderly patients with dementia-related psychosis treated with aripiprazole experienced increased cerebrovascular adverse events (stroke, TIA) with a statistically significant dose-response relationship 1
• Common adverse effects in this population include lethargy (5%), somnolence/sedation (8%), urinary incontinence (5%), excessive salivation (4%), and lightheadedness (4%) 1

Drug Interaction Concerns

• Your patient is already on Lexapro (escitalopram), an SSRI that can interact with antipsychotics through CYP450 enzyme inhibition, requiring extra caution and monitoring 2
• The combination of multiple psychotropic medications increases risk of adverse effects in elderly hospice patients 3

Recommended Alternative Approach

First: Optimize Current Seroquel Regimen

• The current Seroquel dose of 25 mg is subtherapeutic for treating delusions 4, 2
• The American Academy of Family Physicians recommends Quetiapine (Seroquel) as the preferred antipsychotic for geriatric patients due to its lowest risk of extrapyramidal symptoms (EPS) among commonly used antipsychotics 4
• Increase Seroquel to 50-150 mg/day in divided doses (starting at 25 mg twice daily, titrating upward) for agitated dementia with delusions 2
• Quetiapine was rated as first-line or high second-line by expert consensus for delusions in elderly patients 2

Second-Line Options if Seroquel Optimization Fails

• Risperidone 0.5-2.0 mg/day was the first-line recommendation by expert consensus for agitated dementia with delusions 2
• Olanzapine 5.0-7.5 mg/day was rated as high second-line for this indication 2
• Both have better evidence for efficacy in treating delusions compared to aripiprazole in this population 5

Palliative Care Context Considerations

Medication Selection in Hospice

• In hospice/palliative care settings, haloperidol remains the drug of choice for delirium and severe agitation when rapid control is needed 6
• Starting dose: 0.5-2 mg IV/SC, with careful monitoring for QT prolongation and extrapyramidal effects 6
• Alternative neuroleptics for hospice include levomepromazine (12.5-25 mg) or chlorpromazine (12.5 mg every 4-12 hours) 6

Duration of Treatment

• For agitated dementia in hospice, attempt to taper to the lowest effective maintenance dose within 3-6 months to minimize cumulative toxicity 2
• Regular face-to-face assessments are essential to monitor response, tolerance, and continued need for treatment 3

Critical Monitoring Parameters

Before Starting or Adjusting Any Antipsychotic

• Rule out reversible causes of delirium: medications (especially anticholinergics, benzodiazepines), metabolic disturbances, infection, pain, constipation, urinary retention 6, 3
• Assess baseline metabolic parameters, though in hospice this may be less relevant given goals of care 3
• Monitor for orthostatic hypotension, especially during dose titration of Quetiapine 4

Common Pitfalls to Avoid

• Do not combine Quetiapine with benzodiazepines when possible, as this significantly increases sedation risk 4
• Avoid typical/conventional antipsychotics in elderly patients due to severe side effects and up to 50% risk of irreversible tardive dyskinesia after 2 years 4, 7, 8
• Never use antipsychotics for non-psychotic anxiety, depression, or simple sleep disturbance 2

Risk Hierarchy of Antipsychotics in Elderly

From lowest to highest EPS risk: Quetiapine < Aripiprazole < Olanzapine < Risperidone < Typical antipsychotics 4

However, for efficacy in treating delusions specifically: Risperidone and Quetiapine have the strongest evidence, with aripiprazole having limited data in elderly dementia patients 2, 5

Bottom Line Algorithm

1. Optimize Seroquel first: Increase to 50-150 mg/day in divided doses 4, 2
2. If inadequate response after 1-2 weeks: Consider adding or switching to risperidone 0.5-2.0 mg/day 2
3. If severe acute agitation: Use haloperidol 0.5-2 mg as needed, with careful monitoring 6
4. Avoid aripiprazole entirely in this elderly hospice patient with dementia-related delusions due to black box warnings and lack of efficacy data 1