The efficacy and safety of quetiapine for treatment of geriatric psychosis

Quetiapine Oral Solution in Alzheimer's Disease: Efficacy and Dosage Insights from a Real-World Retrospective Study

BACKGROUND

Neuropsychiatric symptoms (NPS) are distressing for patients with dementia, often accelerating functional decline and nursing home placement. Medications such as quetiapine are used to alleviate NPS, but their side effects require cautious use. Liquid formulations such as quetiapine oral suspension suit specific populations; however, real-world data on their use in patients with dementia are limited.

OBJECTIVE

The purpose of this retrospective, naturalistic study was to provide preliminary data on the effects of treatment with quetiapine oral suspension on behavioral and psychiatric disturbances in Alzheimer's disease (AD) outpatients in Taiwan.

METHODS

Between January 2022 and June 2023, data were collected from outpatients with a diagnosis of probable AD who received treatment with Qting® (quetiapine oral solution 25 mg/ml). Primary outcome measures were changes in Neuropsychiatric Inventory (NPI) total score and its sub-items from baseline to the endpoint.

RESULTS

We recruited 66 AD patients with a mean age of 72.1±7.6 years, most of whom were female (69.7%). Twenty-three patients had data on neuropsychological test and NPI scores before and after quetiapine treatment. There was no significant change in global cognitive function from baseline to the endpoint. A significant reduction in NPI total score after quetiapine treatment was noted, while the effect on NPI sub-items was limited. The average maintenance dose was 1.5±0.6 ml.

CONCLUSIONS

We demonstrated our clinical experience of the use of quetiapine oral solution in AD patients with NPS. Our results showed that quetiapine oral solution treatment significantly improved these symptoms at a relatively low dose.

Bipolar Disorder and Manic-Like Symptoms in Alzheimer's, Vascular and Frontotemporal Dementia: A Systematic Review

BACKGROUND

An increased risk of manic episodes has been reported in patients with neurodegenerative disorders, but the clinical features of bipolar disorder (BD) in different subtypes of dementia have not been thoroughly investigated.

OBJECTIVES

The main aim of this study is to systematically review clinical and therapeutic evidence about manic syndromes in patients with Alzheimer's disease (AD), vascular dementia (VaD), and frontotemporal dementia (FTD). Since manic-mixed episodes have been associated to negative outcomes in patients with dementia and often require medical intervention, we also critically summarized selected studies with relevance for the treatment of mania in patients with cognitive decline.

METHODS

A systematic review of the literature was conducted according to PRISMA guidelines. PubMed, Scopus, and Web of Science databases were searched up to February 2022. Sixty-one articles on patients with AD, VaD, or FTD and BD or (hypo) mania have been included.

RESULTS

Manic symptoms seem to be associated to disease progression in AD, have a greatly variable temporal relationship with cognitive decline in VaD, and frequently coincide with or precede cognitive impairment in FTD. Overall, mood stabilizers, and electroconvulsive therapy may be the most effective treatments, while the benefits of short-term treatment with antipsychotic agents must be balanced with the associated risks. Importantly, low-dose lithium salts may exert neuroprotective activity in patients with AD.

CONCLUSION

Prevalence, course, and characteristics of manic syndromes in patients with dementia may be differentially affected by the nature of the underlying neurodegenerative conditions.

[Antipsychotics: features of undesirable adverse reactions in elderly and senile age]

This review summarizes and systematizes currently available literature on antipsychotics as one of the most frequently prescribed group of psychotropic drugs. Based on published data from clinical studies and meta-analyzes, the authors consider unwanted adverse reactions in patients taking antipsychotic medications. Mechanisms of development of undesirable drug reactions are discussed. Special attention is paid to those adverse reactions of antipsychotics that most often occur in old and very old age (increased risk of adverse cardiovascular and cerebrovascular events, sudden death, prolonged QTc interval, falls, fractures, orthostatic hypotension, extrapyramidal disorders, pneumonia, urinary tract infections, etc.).

Metabolic side effects of atypical antipsychotics in older adults

ABSTRACTBackground:The atypical antipsychotics (AAPs) are associated with a recognized class effect of glucose and lipid dysregulation. The use of these medications is rapidly increasing in elderly patients with, and without, dementia. However, the metabolic risks specific to elderly remain poorly studied.

METHODS

Design: A case-control study.

SETTING

Psychogeriatric service in Auckland, New Zealand.

PARTICIPANTS

Elderly patients either receiving AAP treatment (cases) or not (controls) between 1 Jan 2008 and 1 Jan 2014.

MAIN OUTCOME MEASURES

metabolic data of glucose, HbA1c, lipids, and cardiovascular events and death. The data were analyzed using t-tests and linear regression models for each metabolic outcome.

RESULTS

There were 330 eligible cases and 301 controls from a total study population of 5,307. There was a statistically significant change in the HbA1c over time, within the cases group of -1.14 mmol/mol (p = 0.018, 95% CI -0.19 to -2.09). Also statistically significant was the reduction in total cholesterol of -0.13 mmol/L (p = 0.036, 95% CI -0.008 to -0.245). The only significant difference found between cases and controls was in the change in cholesterol ratio of 0.16 mmol/L between groups (95%CI 0.01-0.31, p = 0.036).

CONCLUSIONS

AAP use was not associated with any clinically significant change in metabolic outcomes in this study population.

Antipsychotic medication and oropharyngeal dysphagia: systematic review

The association between antipsychotics (also known as neuroleptics) and oropharyngeal dysphagia (OD) has been suggested in several case reports. The purpose of this systematic review was to examine the effect of antipsychotic medication on OD. A systematic literature search was carried out according to PRISMA guidelines using the electronic databases Pubmed and Embase. In Pubmed, we used the MeSH terms 'antipsychotic agents' OR 'tranquilizing agents' combined with 'deglutition disorders' OR 'deglutition'. In Embase, we used the Emtree terms 'neuroleptic agents' combined with 'swallowing' OR 'dysphagia'. Two reviewers assessed the eligibility of each report independently. The level of evidence of the included studies was also assessed according to pre-established criteria. Case reports were excluded. We found 18 clinical studies of dysphagia related to antipsychotics: 12 were related both to typical and atypical antipsychotics, four to atypical antipsychotics and two to typical antipsychotics. According to the clinical studies included, prevalence of patients with swallowing problems taking antipsychotics ranged from 21.9 to 69.5% whereas prevalence of patients without swallowing problems taking antipsychotics ranged from 5 to 30.5%. The available evidence suggests considering an etiology of dysphagia in patients with swallowing problems who are taking antipsychotics, even if no other symptoms are present. Although few general conclusions can be drawn from current evidence, both typical and atypical antipsychotics can be associated with OD.

Atypical antipsychotic-induced metabolic disturbances in the elderly

The metabolic side effects of atypical antipsychotics (AAPs) have been widely studied in younger populations, but research investigating these sequelae in the elderly is lacking. This article reviews the available literature examining the use of AAPs in the elderly, evaluating their association with weight gain and changes in blood glucose and lipid parameters. We find a relative paucity of studies in this area; while some data highlight significant, collective changes in metabolic parameters, the majority suggests an apparent low vulnerability to these side effects. We conclude that the risk and clinical implications of unfavorable metabolic changes in the elderly being treated with AAP medications remain largely undetermined, and we caution against drawing firm conclusions based on the available data. The conflicting evidence leaves us recommending that metabolic monitoring be implemented, with regular follow-up as advocated in other populations.

Management of schizophrenia in late life with antipsychotic medications: a qualitative review

Although patients with schizophrenia are reported to have excess mortality compared with the general population, many affected patients will nonetheless survive and continue to have the disorder in later life. Consequently, geriatric schizophrenia will be a significant public health concern in the years to come, and evidence-based treatment of schizophrenia in older patients is becoming an urgent issue. However, there has been a paucity of comparative data to guide selection of antipsychotics for schizophrenia in late life. The primary aim of this review was to synthesize the available evidence on management of late-life schizophrenia with antipsychotic medications; a secondary aim was to evaluate treatment resistance in this population. Accordingly, PubMed and EMBASE were searched using the keywords 'antipsychotics', 'age' and 'schizophrenia' to identify psychopharmacological studies of antipsychotics in late-life schizophrenia (last search 30 April 2011). The literature search identified 23 prospective studies of use of antipsychotics for schizophrenia in older patients (generally age ≥65 years), including eight double-blind trials. The sample size was smaller than 40 patients for 52% of the studies. Two of the double-blind studies were post hoc analyses and one was a placebo-controlled trial. In the largest double-blind study, olanzapine (n = 88, median dose 10 mg/day) and risperidone (n = 87, median dose 2 mg/day) were compared in patients not resistant to these therapies, with similar effects. There have also been several open-label trials of these two agents that have shown efficacy and tolerability in non-resistant patients. Evidence on other antipsychotics has been scarce and less robust. The gold standard for treatment-resistant schizophrenia is clozapine. However, almost all of the studies of clozapine to date have effectively excluded older patients with schizophrenia. Only one small study has evaluated clozapine (n = 24, mean dose 300 mg/day) in comparison with chlorpromazine (n = 18, mean dose 600 mg/day) in a difficult-to-treat older population; the investigators reported that both treatments were similarly efficacious. Furthermore, there has been little compelling evidence in favour of or against augmentation of antipsychotics with other psychotropic medications in the older age group. Treatment of non-resistant, late-life schizophrenia with olanzapine and risperidone appears to be supported by the available evidence. However, data on geriatric patients with schizophrenia are generally scarce, particularly for treatment-resistant subpopulations, underscoring the need for more research in this important area.

Efficacy and safety of quetiapine treatment for delusional parasitosis: experience in an elderly patient

Delusional parasitosis is an unusual psychiatric disorder characterized by the false and persistent belief of being infested by parasites. Treatments include haloperidol, pimozide, and at present, olanzapine and risperidone. We report a case of delusional parasitosis in an elderly man, in which the treatment with low doses of quetiapine induced the complete remission of the syndrome, without any considerable side effects. No such report has been described before.

Chinese demented inpatients admitted following a suicide attempt: a case series

OBJECTIVE

Suicide attempt is rarely reported in dementia. This study explores the clinical and phenomenological aspects as well as the treatment of Chinese demented patients who have attempted suicide.

METHODS

During a 1-year period, demented patients admitted to a geropsychiatric unit as a result of suicide attempt were investigated for factors related to suicide attempt, such as motives and method.

RESULTS

In this 1-year survey, seven demented patients (11.7% of all demented patients) were admitted immediately following a suicide attempt. All seven patients had mild or moderate dementia. Three had significant clinical depression symptoms on admission. In all patients, delusions were the primary cause of suicide attempt. Their suicidal ideations were improved with antipsychotic and antidepressant treatment.

CONCLUSION

These cases, taken together, suggest that suicide attempt can occur in patients with dementia. It is important for clinicians to be aware of the risk of suicide in patients with dementia, especially those associated with delusions, even if they have no major depression or suicide attempt history. Antidepressants and antipsychotics may play a critical role in the treatment of suicide attempt in dementia.

Quetiapine for the treatment of borderline personality disorder; an open-label study

PURPOSE

Only a few studies have commented on the use of atypical antipsychotics for the treatment of Borderline Personality Disorder (BPD) features, including affective dysregulation and aggression. We aimed at evaluating both efficacy and safety of quetiapine in a sample of consecutive BPD patients.

GENERAL METHODS

29 BPD outpatients entered, and 23 completed, a 12 week, open-label, regime of quetiapine at an average daily dosage of 540 mg (range: 400-800 mg). Efficacy assessment psychometric instruments included: Hamilton Rating Scales for Depression (HAM-D); Brief Psychiatric Rating Scale (BPRS); Global Assessment of Functioning (GAF); Clinical Global Impression Scale (CGI); and Aggression Questionnaire (AQ).

FINDINGS

Both completer and intent-to-treat analysis showed that most psychometric scales' scores exhibited a highly significant (HAM-D: p=.003; BPRS Hostility and Suspiciousness subscales; CGI; GAF; AQ: all at p=.000) improvement over time. Six patients dropped out early from treatment due to side effects; quetiapine was associated with two cases of transient thrombocytopenia.

CONCLUSIONS

Present findings would suggest that quetiapine may be effective for the treatment of a number of BPD features, including low mood and aggression. However, monitoring blood counts in patients receiving quetiapine seems to be justified.

Pharmacotherapy for behavioral and psychological symptoms of dementia in the elderly

PURPOSE

The use of atypical antipsychotics for maximizing clinical efficacy and overall health in patients with neuropsychiatric symptoms of dementia is discussed.

SUMMARY

Psychotic and behavioral symptoms are common among older patients with dementia, and an accurate diagnosis can be obscured by complex presentation of symptoms and comorbidities. When initiating pharmacotherapy in this patient population, it is important to consider the increased presence of comorbidities and the additive pharmacologic effects of concomitantly administered drugs. Atypical antipsychotics are among the most well-studied therapeutic classes of psychoactive medications and are frequently utilized for treating psychotic symptoms and agitation in the elderly. These medications have distinct pharmacologic profiles with different liabilities for adverse effects such as sedation, metabolic disturbances, and anticholinergic effects. Recent findings from the Clinical Antipsychotic Trials of Intervention Effectiveness-Alzheimer's Disease (CATIE-AD) study demonstrate that although these agents have some efficacy, their adverse effects may limit their utility in patients.

CONCLUSION

The adverse effect profile should be an important consideration for clinicians selecting an atypical antipsychotic for use in this population.