Levetiracetam & ansious/aggressive state

[dampex]

Hi, I'm an Italian Psychiatrist interested in cognitive impairment, delirium and dementia. I'm treating an old patient (79 yrs) with organic and vascular dementia, ansious state, aggressiveness, and walking deficits. I've started a therapy with levetiracetam (Keppra), because patient's family doesn't find a way to manage his behaviour, but something is going bad...
At 500-750 mg dose, the drug is apparently ineffective, but at 1000 mg/die the patient shows a pronounced confusional state, though aggressiveness vanishes. This effect isn't due to interaction with other drugs. Is there something that has experienced this collateral effect with his patients? I need help to best manage clinical trend... I'm thinking to switch to gabapentin or valproic acid, but I'm not sure this is the right thing to do (especially because I have only a little amount of time before discharge).
Thank you all,
damiano

[Suvash]

Dear Mr Damiano,
Its so nice to hear from you again. and thank you so much for sharing your experiences with us. you are always welcome.

i also talked about your case with my teacher and he says that the details you have given here are just not sufficient to comment anything about the treatment. we have to see the case in more detailed fashion which, ofcourse, i am sure you must have done.

The treatment should be guided and aimed at the underlying cause usually hypertension, diabetes, atherosclerosis, strokes, coronary arterial disease- in case of vascular dementia. You have not mentioned anything about these things. so, if you could possibly post more about the symtoms, signs and history of your patient, then it will be lot more easier for anyone to comment on it.
however, in cases of vascular dementia, the recovery of the lost cognitive functions is not likely to occur, isn't that so?

at the same time, comfort and support to the patient can also be very valuable and helpful. In fact, non drug therapy has an important place in the management of dementia. the primary goal is to make the dementiated patients life comfortable, uncomplicated and safe. Memory aids such as notebooks, lists and posted daily reminders are frequently helpful.

In such cases, anti cholinesterases like DONEPEZIL and RIVASTIGMINE may also be considered as suitable alternatives. what do you think about that, mr damiano?

Levetiracetam may have various side effects like drowsiness, asthenia, dizziness, anorexia, diarrhoea, amnesia, ataxia, depression, emotional lability, aggression, insomnia, nervousness, tremors, headache.. so these might have manifested while going for higher doses.

so, i hope you will consider these things and go for the most suitable option for your patient. We all wish you all the best.

[dampex]

First of all, thak you very much Suvash for your pondered intervention.

You’re right when you say I gave insufficient information about patient’s history. I was so interested about collateral effects of levetiracetam and the possibility that these were noted by other clinicians, so I haven’t explained previous pharmacological and psychosocial treatments interesting A. (Privacy Law!), 79 years, male.
History: recurrent bronchitis (last episode 10/2005), no other significant pathologies untill 2004, when A. shows an Aphasic T.I.A. and parents told this event like starting point of cognitive impairment. In 2005, after neurologic evaluation (clinical, brain CT, laboratory examinations,...), there was a mixed dementia diagnosis (MMSE 12/30). Therapy was based about aceticholinesterase inhibitors (donepezil), ambiental therapy (functional recovery in everyday duties,...) and educational support for the family. But things, progressively, goes bad... Cognitive impairment (MMSE 8/30) was followed by sensory-motor impairment and BPSD (high aggressiveness, depression, ansious state, presence of opposition). Donepezil was stopped because without benefical effects and for arousal effect evidencied on behaviour. Now A. shows aphasia, significative psychomotor slowing, full functional dependence, double incontinence, adequate nutrition, renal and hepatic functions are good. A. is currently in Alzheimer Unit, where I follow him with other clinicians, and his family went in our hospital specifically to manage exacerbated aggressiveness (because they want to treat A. at home at discharge).
Current pharmacological therapy is very simple and based about cardioaspirin, an SSRI, zolpidem for the night, and prior levetiracetam, but this has caused chronic lowering of vigilance, despite lowering of aggressiveness. You must know that quetiapine, olanzapine were ineffective in adequate treating A. BPSD. I was thinking about others AED, like gabapentin, lamotrigine or valproic acid, because their behaviour stabilizing effects... also i was interested if anybody has experimented this kind of effect with low dosages of levetiracetam (before never seen in our hospital...).

I thank you again for your precious advices, damiano.

P.S. I beg your pardon for my bad English, I think writing to xenomed forums is a good exercise to improve...

[Suvash]

hello dampex,
its so nice to hear from you...
and i beg your pardon i could not follow up for so long...although i was so interested in your case...

and i appreciate your dedication and your willingness to do good for your patient very much.. you are really doing a great job... but i feel sorry that we havenot seen much of the case as yours....

anyway how is your patient doing.. i wish you all the best.... i am sure your patient must be doing good...

and we always love to hear from you....
with regards,
suvash.