Improvement in Delusional Jealousy and Caregiver Distress After Switching From Oral Galantamine to a Donepezil Transdermal Patch in Alzheimer's Disease: A Case Report.

BACKGROUND: Neuropsychiatric symptoms (NPS) in Alzheimer's disease (AD) are common and strongly associated with caregiver distress. Switching cholinesterase inhibitors (ChEIs) may be considered when NPS remain clinically problematic. Although switching ChEIs may improve NPS in some patients, published reports describing improvement in delusional jealousy after switching to a donepezil transdermal patch remain limited. CASE PRESENTATION: We report a woman in her 60s with probable AD who developed caregiver-reported delusional jealousy and near-daily marital conflicts during oral galantamine therapy. NPS were assessed using the caregiver-rated Neuropsychiatric Inventory Questionnaire (NPI-Q) at three time points: prior to initiating galantamine (baseline symptoms were predominantly non-psychotic), immediately prior to switching and 6 months after switching. Total NPI-Q severity increased from 4 to 20 and then decreased to 11; total caregiver distress increased from 3 to 31 and then decreased to 13. After switching from oral galantamine, 16 mg/day, to a donepezil transdermal patch, 27.5 mg/day, improvements in domain-level severity were observed in the delusions domain, driven mainly by reduced caregiver-rated delusional jealousy, as well as in agitation/aggression, disinhibition and irritability/lability. Clinically, the conviction of delusional jealousy gradually diminished with a reduction in conflict frequency; at 6 months, delusional jealousy had almost completely resolved, whereas caregiver-attributed negative self-appraisals (e.g., a persistent belief that she was useless, perceived by the caregiver as delusional) persisted. No psychotropic medications were initiated or dose-adjusted from immediately prior to switching through the 6-month follow-up. Subsequently, the patient became able to attend day care services. CONCLUSION: This case suggests that switching from oral galantamine to a donepezil transdermal patch may be associated with improvement in delusional jealousy, selected caregiver-rated NPS domains and caregiver distress in some patients, although causal inference is not possible in a single case and responses may vary.