๐ง Antipsychotics in the Elderly: Special Considerations, Risks & Best Practices
Prescribing antipsychotics in older adults is never straightforward. Aging changes the way drugs are absorbed, metabolised, and tolerated โ making this population more sensitive to both therapeutic effects and adverse reactions.
While antipsychotics may be necessary in conditions like psychosis, bipolar disorder, delirium, agitation in dementia, or severe behavioural disturbances, they must be used cautiously, with clear indication and close monitoring.
๐ด Why Are Elderly More Vulnerable to Antipsychotic Side Effects?
Physiological changes with age affect pharmacokinetics and pharmacodynamics:
| Age-Related Change | Result |
|---|---|
| โ Liver function (CYP450 activity) | Slower drug metabolism |
| โ Kidney function | Prolonged drug clearance |
| โ Body fat, โ muscle mass | Higher fat-soluble drug accumulation |
| โ Dopamine receptors | Greater sensitivity to EPS (Parkinsonism) |
| โ Blood pressure regulation | Orthostatic hypotension risk |
| Polypharmacy | Drugโdrug interactions |
๐ Indications for Antipsychotic Use in Elderly
โ
Schizophrenia or late-onset psychosis
โ
Bipolar disorder (acute mania)
โ
Psychosis in Parkinson’s disease or dementia (with caution)
โ
Severe agitation or aggression in dementia only after non-drug methods fail
โ
Delirium with severe agitation (short-term only)
โ Not indicated for insomnia, mild irritability, or caregiver convenience.
โ ๏ธ Major Risks & Side Effects in Elderly
| Side Effect | Mechanism | Clinical Impact |
|---|---|---|
| Extrapyramidal Symptoms (EPS) | Dopamine blockade | Parkinsonism, rigidity, tremor, falls |
| Tardive Dyskinesia | Long-term D2 blockade | Irreversible facial/limb movements |
| Sedation & Cognitive Decline | Antihistamine, anticholinergic effects | Confusion, delirium |
| Orthostatic Hypotension | ฮฑ-adrenergic blockade | Falls, fractures, syncope |
| Cardiac Risks | QT prolongation | Arrhythmias, sudden cardiac death |
| Metabolic Syndrome (Atypicals) | 5-HT2C blockade | Weight gain, diabetes, dyslipidemia |
| Stroke & Mortality in Dementia | Black Box Warning | โ Stroke & death risk with both typical & atypical antipsychotics |
๐ FDA & EMA Warning: Antipsychotics increase mortality in elderly dementia patients โ mainly due to cardiovascular and infectious causes.
๐งช Typical vs Atypical Antipsychotics in Elderly
| Feature | Typical (Haloperidol, Chlorpromazine) | Atypical (Risperidone, Olanzapine, Quetiapine, Clozapine) |
|---|---|---|
| EPS Risk | High | Lower (except Risperidone at high doses) |
| Anticholinergic Effect | ModerateโHigh (especially chlorpromazine) | Low except clozapine |
| Cardiovascular Risk | Moderate | QT prolongation with ziprasidone, โ stroke risk |
| Sedation | High in low-potency agents | High in quetiapine, olanzapine |
| Preferred in Dementia | โ Avoid if possible | โ Risperidone (short-term), Quetiapine (Parkinsonโs disease psychosis) |
โ Best Practices for Prescribing Antipsychotics in Elderly
โ Start Low, Go Slow:
Start at 1/3 โ 1/2 of adult dose, titrate cautiously.
โ Choose the Right Drug:
-
Dementia psychosis: Risperidone (โค1 mg), Quetiapine, Pimavanserin
-
Parkinsonโs psychosis: Quetiapine or Clozapine (low dose)
-
Agitation in delirium: Haloperidol low IV/IM in acute setting
โ Regular Monitoring:
-
Blood pressure (orthostatic)
-
ECG (QTc interval)
-
Blood sugar, lipids, weight
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EPS / Tardive Dyskinesia (AIMS score)
-
Liver and kidney function tests
โ Use Time-Limited Trials:
Re-evaluate every 4โ12 weeks; taper if no improvement.
โ Non-pharmacological Approaches First:
Orientation therapy, sleep hygiene, caregiver education, behavioural modifications should always be first-line in dementia.
๐ Deprescribing Antipsychotics โ When and How?
-
If symptoms have been stable for 3โ6 months
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Gradually taper by 25% every 2โ4 weeks
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Watch for return of agitation or psychosis
-
Support with psychosocial & environmental strategies
๐ Key Takeaways
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Antipsychotics can be life-saving in elderly, but high-risk if used casually
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Always weigh risk vs benefit, especially in dementia
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Combine medication with structured routines, caregiver training, sleep regulation, environmental changes
-
Start low, go slow, review often, stop if unnecessary
๐จโโ๏ธ Author & Clinical Services
Dr. Srinivas Rajkumar T
MD (AIIMS, New Delhi), DNB Psychiatry
Consultant Psychiatrist | Geriatric Mental Health Specialist
Mind & Memory Clinic โ Apollo Clinic (Opp. Phoenix MarketCity), Velachery, Chennai
๐ +91-8595155808 | ๐ www.srinivasaiims.com