Aggression in Dementia With Lamotrigine Treatment

Ms. A was a 65-year-old woman with a 12-year history of chronic recurrent episodes of major depression. Before that she had excellent premorbid functioning and worked in accounting. After her husband’s suicide when she was 40 years old, she managed to bring up her two sons alone. Treatment of her depression included a variety of antidepressants, which resulted in some improvement that was not sustained. Her last admission was after a 3-month history of repeatedly asking the same questions, picking her nose until it bled, and being verbally and physically aggressive. The episodes of aggression were characterized by hitting, punching, biting, tearing clothes, grunting, barking, screaming, and grimacing—all of which appeared to come on suddenly and involuntarily and were puzzling to her. She had been treated with fluvoxamine, buspirone, lorazepam, vitamin E, thiamine, loxapine, risperidone, and divalproex sodium with little or no improvement.

On admission, in addition to the ongoing problems just listed, Ms. A appeared extremely aggressive and disinhibited, with moderate deterioration in concentration and cognition. Her medications at admission included 1500 mg/day of divalproex sodium (in therapeutic blood concentrations), 2 mg/day of risperidone, and 2–4 mg/day of lorazepam. Preventive measures for aggressive behaviors were applied. However, she convinced the psychiatric trainees and other members of the staff that she would not harm them. The staff believed her, but when approached within an arm’s length, she hit two psychiatric residents, a psychiatrist, and a neurologist and left some with facial bruises and black eyes. After neurological examinations, brain scans (computerized tomography and single photon emission computed tomography), and neuropsychological testing, Ms. A was diagnosed with frontal lobe dementia.

Therefore, Ms. A was initially treated with a dose of 12.5 mg/day of lamotrigine, which was gradually increased to 100 mg/day over 4 weeks, according to clinical response. All of her symptoms dramatically improved, and she was back to her pleasant premorbid mood. She was maintained with this dose of lamotrigine over 6 months with no relapse. No dermatologic or other side effects were reported.