A 68-year-old woman with probable Alzheimer's dementia develops severe agitation at night ('sundowning'). Her family asks about medication. Which class of medication has a BLACK BOX WARNING for increased mortality in elderly patients with dementia-related psychosis?

• A Atypical antipsychotics ✓
• B Cholinesterase inhibitors
• C Memantine
• D SSRIs

Explanation

The FDA issued a black box warning in 2005 for all atypical antipsychotics (and later extended to conventional antipsychotics) stating that their use in elderly patients with dementia-related psychosis is associated with a 1.6–1.7 fold increased risk of death (primarily cardiovascular and infectious causes). Despite this, they are sometimes used cautiously for severe behavioral disturbances when non-pharmacological measures fail. Cholinesterase inhibitors (donepezil, rivastigmine, galantamine) and memantine are the approved cognitive-enhancing agents for AD without this mortality warning.

Reference: Kaplan & Sadock's Synopsis of Psychiatry, 11th ed.

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Written and medically reviewed by the StethoPrep medical team.