Case report: levetiracetam associated psychosis in dementia

Introduction Existing studies provide evidence that epilepsy and seizure history are risk factors for cognitive impairment and dementia in older adults. Prompt diagnosis and intervention following seizure episodes are imperative as additional seizures can perpetuate further cognitive and functional decline in older adults with pre-existing cognitive impairment or dementia. Various antiepileptic drugs have been studied in Alzheimer's disease with lamotrigine and levetiracetam commonly used. Levetiracetam is frequently used broad spectrum antiepileptic medications among other antiepileptics and considered to have more benign side effects most commonly somnolence and dizziness. However, levetiracetam is commonly associated with psychiatric and behavioral side effects including mood and psychotic symptoms, anxiety, suicidal thoughts, and agitation. Despite the high prevalence of behavioral symptoms in dementia, it is poorly understood whether psychiatric and behavioral side effects of levetiracetam are more common among older adults with cognitive impairment. Here, we present a case of levetiracetam associated psychosis in an older adult with moderate-severe dementia. Methods The objectives of this project are as follows: 1. To discuss a case of levetiracetam associated psychosis in older adults with cognitive difficulties. 2. To discuss different treatment options in managing psychosis associated with levetiracetam. 3. To discuss patient-related risk factors for neuropsychiatric side effects among patients treated with levetiracetam. Results The patient is a 89-year-old woman with prior history of anxiety, depression, dementia along with other medical problems including seizure disorder, cerebrovascular accident, atrial fibrillation, hypertension, diabetes, and gait instability, who later developed new-onset psychotic symptoms following initiation of levetiracetam. She was started on levetiracetam when she presented in emergency department with non-convulsive status epilepticus. Her seizures were controlled on levetiracetam while in-patient. Subsequently she developed psychosis with symptoms of persecutory delusions that somebody is following her, intermittent agitation, and was found to be internally preoccupied. The patient had previously been tried on valproic acid with intolerable side effect of somnolence. During her treatment course, neurology team continued her on levetiracetam for seizure control due to its good response and exhibits lesser drug to drug interactions and side effects as compared to other AEDs including Lamictal. Her psychotic symptoms and agitation improved on low-dose quetiapine(12.5 mg). Conclusions This case highlights potential risks of levetiracetam in a patient with dementia at high risk for behavioral and psychiatric problems. We may need to monitor closely for any developing neuropsychiatric signs and symptoms following initiation of levetiracetam in patients with neurocognitive difficulties. Existing studies provide evidence that epilepsy and seizure history are risk factors for cognitive impairment and dementia in older adults. Prompt diagnosis and intervention following seizure episodes are imperative as additional seizures can perpetuate further cognitive and functional decline in older adults with pre-existing cognitive impairment or dementia. Various antiepileptic drugs have been studied in Alzheimer's disease with lamotrigine and levetiracetam commonly used. Levetiracetam is frequently used broad spectrum antiepileptic medications among other antiepileptics and considered to have more benign side effects most commonly somnolence and dizziness. However, levetiracetam is commonly associated with psychiatric and behavioral side effects including mood and psychotic symptoms, anxiety, suicidal thoughts, and agitation. Despite the high prevalence of behavioral symptoms in dementia, it is poorly understood whether psychiatric and behavioral side effects of levetiracetam are more common among older adults with cognitive impairment. Here, we present a case of levetiracetam associated psychosis in an older adult with moderate-severe dementia. The objectives of this project are as follows: 1. To discuss a case of levetiracetam associated psychosis in older adults with cognitive difficulties. 2. To discuss different treatment options in managing psychosis associated with levetiracetam. 3. To discuss patient-related risk factors for neuropsychiatric side effects among patients treated with levetiracetam. The patient is a 89-year-old woman with prior history of anxiety, depression, dementia along with other medical problems including seizure disorder, cerebrovascular accident, atrial fibrillation, hypertension, diabetes, and gait instability, who later developed new-onset psychotic symptoms following initiation of levetiracetam. She was started on levetiracetam when she presented in emergency department with non-convulsive status epilepticus. Her seizures were controlled on levetiracetam while in-patient. Subsequently she developed psychosis with symptoms of persecutory delusions that somebody is following her, intermittent agitation, and was found to be internally preoccupied. The patient had previously been tried on valproic acid with intolerable side effect of somnolence. During her treatment course, neurology team continued her on levetiracetam for seizure control due to its good response and exhibits lesser drug to drug interactions and side effects as compared to other AEDs including Lamictal. Her psychotic symptoms and agitation improved on low-dose quetiapine(12.5 mg). This case highlights potential risks of levetiracetam in a patient with dementia at high risk for behavioral and psychiatric problems. We may need to monitor closely for any developing neuropsychiatric signs and symptoms following initiation of levetiracetam in patients with neurocognitive difficulties.