Can quetiapine (Seroquel) be used to treat acute psychosis in a 72‑year‑old hospitalized female?

Can Quetiapine Be Used for Hospital Psychosis in a 72-Year-Old Female?

Quetiapine can be used for acute psychosis in a hospitalized 72-year-old female, but only after non-pharmacological interventions have failed or are impossible, and only if she is severely agitated or threatening substantial harm to herself or others. However, patients over 75 years respond less well to antipsychotics, particularly olanzapine, and quetiapine carries significant risks including increased mortality, falls, and metabolic effects in elderly patients. 1, 2

Critical Prerequisites Before Prescribing Quetiapine

Before initiating any antipsychotic, you must systematically investigate and treat reversible medical causes that commonly drive psychosis and agitation in hospitalized elderly patients:

• Pain assessment and management is mandatory, as untreated pain is a major contributor to behavioral disturbances in patients who cannot verbally communicate discomfort 1, 2
• Check for infections, particularly urinary tract infections and pneumonia, which are disproportionately common triggers of acute psychosis in elderly hospitalized patients 1, 2
• Evaluate for metabolic disturbances including hypoxia, dehydration, electrolyte abnormalities, constipation, and urinary retention 1, 2
• Review all medications for anticholinergic properties and drug interactions that worsen confusion and agitation 2

When Quetiapine Is Appropriate

Quetiapine should only be used when:

• The patient is severely agitated, distressed, or threatening substantial harm to self or others 1
• Behavioral interventions have been attempted and documented as failed or are not possible 1, 2
• You have discussed with the patient (if feasible) and surrogate decision maker the increased mortality risk (1.6-1.7 times higher than placebo), cardiovascular effects, falls risk, and expected benefits 2

Quetiapine-Specific Advantages in This Population

Quetiapine has several characteristics that may make it preferable to other antipsychotics in certain hospitalized elderly patients:

• Placebo-level incidence of extrapyramidal symptoms across all doses, allowing confident dose escalation without increasing EPS risk 3, 4
• Sedating properties can be advantageous in hyperactive delirium or severe agitation 1, 3
• Does not elevate prolactin levels, unlike risperidone and haloperidol 4
• May offer benefit in symptomatic management of delirium-associated psychosis, though evidence level is lower than for primary psychotic disorders 3

Dosing Strategy for Elderly Hospitalized Patients

Start low and titrate slowly:

• Initial dose: 12.5 mg twice daily 2
• Target therapeutic range: 25-100 mg twice daily for most elderly patients with psychosis 2
• Maximum dose: 200 mg twice daily, though most elderly patients respond to lower doses 2
• Allow 4-6 weeks at therapeutic dose to assess efficacy 3, 5

Critical Safety Warnings

All antipsychotics, including quetiapine, carry serious risks in elderly patients:

• Increased mortality risk of 1.6-1.7 times higher than placebo in elderly patients with dementia 1, 2
• Cardiovascular risks including QT prolongation, dysrhythmias, sudden death, and hypotension 1, 2
• Falls risk due to orthostatic hypotension and sedation, particularly during initial titration 2, 6
• Metabolic effects including weight gain, though quetiapine causes less metabolic dysfunction than olanzapine 3

Monitoring Requirements

Daily in-person examination is required to evaluate ongoing need and assess for adverse effects 1, 2:

• Monitor for extrapyramidal symptoms, though risk is low with quetiapine 3, 4
• Assess for falls, sedation, and orthostatic hypotension 2, 6
• Check for metabolic changes including weight gain 2
• Consider ECG monitoring for QTc prolongation 2

Duration of Treatment

Use the lowest effective dose for the shortest possible duration:

• Evaluate response within 4 weeks of initiating treatment 2, 3
• Attempt taper within 3-6 months to determine if still needed 2
• Approximately 47% of patients continue receiving antipsychotics after discharge without clear indication—avoid this pitfall 2

What NOT to Use

• Avoid benzodiazepines as first-line treatment for psychosis or agitated delirium in elderly patients (except for alcohol or benzodiazepine withdrawal), as they increase delirium incidence and duration and cause paradoxical agitation in approximately 10% of elderly patients 1, 2
• Avoid typical antipsychotics (haloperidol, fluphenazine, thiothixene) as first-line therapy due to 50% risk of tardive dyskinesia after 2 years of continuous use in elderly patients 2

Alternative First-Line Options

If the psychosis is part of chronic agitation rather than acute psychosis, SSRIs (citalopram 10-40 mg/day or sertraline 25-200 mg/day) are preferred as first-line pharmacological treatment for chronic agitation in elderly patients, with quetiapine reserved for severe, dangerous symptoms that fail SSRI therapy 2

Common Pitfalls to Avoid

• Do not continue quetiapine indefinitely—review need at every visit and taper if no longer indicated 2
• Do not use quetiapine for mild agitation or behaviors like unfriendliness, poor self-care, repetitive questioning, or wandering, as these are unlikely to respond to antipsychotics 2
• Do not add quetiapine without first treating reversible medical causes such as pain, infection, and metabolic disturbances 1, 2