In an 83‑year‑old patient with dementia on quetiapine (Seroquel) 25 mg daily who is now experiencing worsening nightmares or visual hallucinations, how should I manage the medication?

Discontinue Quetiapine and Switch to an Alternative Agent

In an 83-year-old patient with dementia experiencing worsening nightmares and hallucinations on quetiapine 25 mg, you should discontinue the quetiapine and switch to low-dose risperidone (starting at 0.25 mg at bedtime) if psychotic symptoms are severe and dangerous, or to an SSRI (citalopram 10 mg daily or sertraline 25–50 mg daily) if agitation without prominent psychosis is the primary concern. 1

Why Quetiapine Is Likely Causing the Problem

• Quetiapine at low doses paradoxically worsens nightmares and hallucinations in a subset of elderly dementia patients because its primary mechanism at 25 mg is sedation via histamine blockade rather than dopamine antagonism, and it can cause vivid dreams and sleep fragmentation. 2, 1
• A 2025 study demonstrated that low-dose quetiapine (used for insomnia in older adults) is associated with significantly higher rates of mortality (HR 3.1), dementia progression (HR 8.1), and falls (HR 2.8) compared to trazodone, and higher dementia rates (HR 7.1) compared to mirtazapine. 3
• The American Academy of Family Physicians notes that quetiapine is more sedating and carries a risk of transient orthostasis, which can contribute to confusion and perceptual disturbances in frail elderly patients. 1

Step 1: Rule Out Reversible Medical Causes First

Before switching medications, systematically investigate and treat:

• Urinary tract infections, pneumonia, and other infections, which are major drivers of hallucinations and behavioral disturbances in non-communicative dementia patients. 1
• Pain assessment and management, as untreated pain is a major contributor to behavioral symptoms. 1
• Constipation and urinary retention, which significantly contribute to restlessness and confusion. 1
• Metabolic disturbances (dehydration, electrolyte abnormalities, hypoxia). 1
• Review all medications for anticholinergic properties (diphenhydramine, oxybutynin, cyclobenzaprine), which worsen confusion and hallucinations. 1

Step 2: Determine the Predominant Symptom Profile

If Severe Psychotic Features (Delusions, Dangerous Hallucinations, Aggression):

Switch to low-dose risperidone:

• Start risperidone 0.25 mg once daily at bedtime, titrating to a target dose of 0.5–1.25 mg daily as tolerated. 1, 4
• The American Academy of Family Physicians designates risperidone as first-line for severe agitation with psychotic features in dementia, with quetiapine and olanzapine as high second-line options. 1
• Do not exceed 2 mg/day, as doses above this threshold significantly increase extrapyramidal symptoms. 1, 4
• Expert consensus from a 2004 survey of 48 geriatric specialists ranked risperidone (0.5–2.0 mg/day) as first-line, followed by quetiapine (50–150 mg/day) and olanzapine (5.0–7.5 mg/day) as high second-line for agitated dementia with delusions. 5

If Chronic Agitation Without Prominent Psychosis:

Switch to an SSRI:

• Citalopram 10 mg/day (maximum 40 mg/day) or sertraline 25–50 mg/day (maximum 200 mg/day) are preferred first-line pharmacological options for chronic agitation in dementia. 1
• The American Psychiatric Association recommends initiating SSRIs at low dose and titrating to the minimum effective dose, with reassessment after 4 weeks of adequate dosing. 1
• SSRIs significantly reduce overall neuropsychiatric symptoms, agitation, and depression in patients with vascular cognitive impairment and dementia. 1

Step 3: Taper Quetiapine Safely

• Taper quetiapine gradually over 1–2 weeks (e.g., reduce to 12.5 mg for 3–7 days, then discontinue) to avoid rebound insomnia or withdrawal symptoms. 1
• Do not abruptly discontinue, as this can precipitate acute worsening of behavioral symptoms. 1

Step 4: Implement Non-Pharmacological Interventions Concurrently

• Ensure adequate lighting during the day and especially during late afternoon/evening to reduce sundowning-related hallucinations. 1
• Increase daytime bright light exposure (2 hours of morning bright light at 3,000–5,000 lux) to consolidate the sleep-wake cycle and reduce nighttime perceptual disturbances. 1
• Use calm tones, simple one-step commands, and gentle touch for reassurance rather than complex multi-step instructions. 1
• Establish predictable daily routines and structured bedtime routines to regulate circadian rhythm. 1

Step 5: Monitor Response and Safety

• Assess response within 4 weeks using a quantitative measure (Cohen-Mansfield Agitation Inventory or NPI-Q). 1
• If switching to risperidone, monitor daily for extrapyramidal symptoms (tremor, rigidity, bradykinesia), falls, sedation, and orthostatic hypotension. 1, 4
• If switching to an SSRI, monitor for nausea, sleep disturbances, and hyponatremia (especially with citalopram in elderly patients). 1
• Attempt taper within 3–6 months to determine the lowest effective maintenance dose or whether continued treatment is necessary. 1

Critical Safety Discussion Required

• All antipsychotics increase mortality risk 1.6–1.7 times higher than placebo in elderly patients with dementia. 1
• Before initiating risperidone, discuss with the patient (if feasible) and surrogate decision maker the increased mortality risk, cerebrovascular adverse events (three-fold increase in stroke risk with risperidone), cardiovascular effects, falls risk, and metabolic changes. 1, 4
• Document this discussion and the decision-making process in the medical record. 1

Common Pitfalls to Avoid

• Do not increase the quetiapine dose in response to worsening hallucinations, as higher doses may paradoxically worsen confusion and sedation without adequately treating psychosis at doses below 100–150 mg/day. 1, 5
• Do not add a benzodiazepine for nightmares or agitation, as benzodiazepines increase delirium incidence and duration, cause paradoxical agitation in ~10% of elderly patients, and worsen cognitive function. 1
• Do not continue antipsychotics indefinitely without regular reassessment; approximately 47% of patients continue receiving antipsychotics after discharge without clear indication. 1
• Do not use typical antipsychotics (haloperidol, fluphenazine) as alternatives, as they carry a 50% risk of tardive dyskinesia after 2 years of continuous use in elderly patients. 1