Antipsychotics in the elderly

Guidance for the management of behavioural and psychiatric symptoms in dementia and the treatment of psychosis in people with history of stroke/TIA.

Working group for the Faculty of Old Age Psychiatry RCPsych, RCGP, BGS, and Alzheimer’s Society, following CSM restriction on risperidone and olanzapine

1. Assessment
   • Any changes in environment, relationships or physical health?
   • To whom is the symptom a problem and why?
   • Do family carers and care staff need additional training to improve therapeutic interactions?
2. Non-pharmacological management: have these approaches been tried?
   • Psychosocial, behavioural and environmental interventions
   • Aromatherapy
3. Withdrawal of risperidone and olanzapine in existing patients
   Try gradual withdrawal over 2-4 weeks, or seek specialist advice in the following circumstances:
   • People with diagnosis of schizophrenia and a history of CVA I TIA
   • People with continuing moderate to severe behavioural / psychiatric symptoms despite medication
   • People with a history of serious risk to self or others
4. Treatment of new cases, or if severe symptoms arise on withdrawal of medication
   Considering postponing treatment for a few days or using “as required” medication initially, particularly if carers report symptoms on withdrawal of existing medication.

Depression: Commonly missed. Assess for this and consider a therapeutic trial of SSRI.

Dementia with Lewy Bodies (DLB): Beware traditional antipsychotics. Cholinesterase inhibitors are often used first line by specialists. Newer antipsychotics are also used but with increasing evidence of risk.

Any drug used should be commenced at the lowest possible dose, monitored and titrated carefully with regular reviews, aimed at short-term use only, for the treatment of severe psychosis, severe emotional distress or behaviour that is dangerous to the individual or others.

Choice of medication

• Cholinesterase inhibitors are licensed for mild to moderate severity AD, with some evidence of benefit in behavioural and psychiatric symptoms and in other dementias.
• Memantine is licensed for moderate to severe AD, though evidence of benefit in behavioural disturbance and psychiatric symptoms is very limited.
• Newer antipsychotics are felt to have a favourable side effect profile compared to older antipsychotics, though may still cause cerebrovascular events, sedation, extrapyramidal side effects (EPSE), and agitation. Total daily dose quetiapine 25-150mg, sulpiride 100-1200mg and amisulpride 50-400mg.
• Other medications (Limited evidence of benefit and all prescribing is off licence)
  Traditional antipsychotics and other commonly used sedatives have potentially serious adverse effects which include sedation, confusion, accelerated cognitive decline, falls, urinary symptoms, hypotension, cardiac side effects, EPSE and tardive dyskinesia (TD). Consult the BNF for use in individual patients.