Letter to the Editor: Levetiracetam as an Alternative for Refractory Confusional Syndromes: A Case Series

Abstract

In palliative care, the number of patients, both oncological and non-oncological, has significantly increased. This growth has led to a rise in the complexity and duration of care, particularly concerning neuropsychiatric symptoms such as acute confusional syndrome.¹ Delirium affects up to 80% of patients nearing the end of life.^2,3 Standard treatment for delirium includes addressing reversible causes, non-pharmacological interventions, and antipsychotics like Haloperidol, Quetiapine, Risperidone, and Levomepromazine. In refractory cases, palliative sedation may be necessary.

Levetiracetam, an antiepileptic drug, is frequently used in patients at risk of seizures. This case series presents five patients with refractory delirium who responded positively to Levetiracetam, suggesting its potential as a treatment option in such cases.⁴

Patient 1: An 80-year-old woman with a history of strokes developed agitation and hallucinations. Quetiapine was ineffective, so she was started on Levetiracetam (500 mg twice daily). Within 24 hours, her symptoms were controlled, and agitation did not recur for over three months.

Patient 2: A 73-year-old man with COPD and frequent falls developed new-onset confusion and agitation. Haloperidol caused severe side effects, so Levetiracetam (500 mg twice daily) was initiated. Symptoms improved within 48 hours, and agitation did not return for more than three months. Haloperidol was discontinued.

Patient 3: A 72-year-old man with stage IV breast cancer developed delirium with aggression and agitation. Due to poor tolerance to antipsychotics, Levetiracetam (500 mg twice daily) was prescribed. His symptoms improved within 48 hours, and no further agitation occurred before his death 15 days later.

Patient 4: An 82-year-old man with ischemic heart disease developed fluctuating confusion and agitation. Risperidone provided partial relief, but Levetiracetam (500 mg twice daily) controlled his symptoms within 48 hours. Agitation did not recur for four months, and Risperidone was discontinued.

Patient 5: A 90-year-old woman with cognitive impairment and leukemia developed delirium with myoclonic movements. Risperidone was ineffective, so Levetiracetam (500 mg twice daily) was started. Her agitation and myoclonus improved, and she remained stable for at least four months.

Levetiracetam showed efficacy in reducing agitation in these patients with refractory delirium. Its rapid improvement of symptoms justifies further investigation into its role in severe delirium cases. The drug’s oral, subcutaneous, and intravenous forms make it versatile for palliative care settings. While Levetiracetam is typically used for seizures, its potential to treat agitation could be linked to underlying seizure activity in delirium patients. Other antiepileptics, such as Carbamazepine and Valproic acid, have also shown benefits in treating agitation and delirium.⁵

Levetiracetam’s sedative effect is minimal, as patients remained alert but calm, unlike traditional sedatives. Despite its potential to cause delirium in certain conditions, careful monitoring in these cases showed no worsening of symptoms.⁵

Levetiracetam demonstrated efficacy in managing refractory agitation in patients with delirium, suggesting it could be a valuable alternative for future clinical trials. Further research using validated tools like MDAS and RASS is recommended to explore its full potential.

Footnotes

Author Disclosure Statement

The authors declare that they have no conflicts of interest and have the authorization of the institution’s bioethics committee.

Funding Information

No funding was received for this article.

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