In fact, elderly patients are at increased risk of adverse events due to atypical antipsychotic drugs because of age-related changes in pharmacokinetics and pharmacodynamics and current medical conditions, polypharmacy, and potential drug interactions. US Food and Drug Administration black box warnings have clearly shown the potential risks of their use (eg, cerebrovascular accidents, risk of sudden death). Furthermore, metabolic adverse events are extremely dangerous. They are probably linked to an increase in adiposity associated with a variety of adverse physiological effects, including a decrease in insulin sensitivity and changes in plasma glucose and lipid levels.
So, whom could share great experience on this issue?
From an Australian perspective, the only antipsychotic approved for use in older people with dementia is risperidone. The majority of research in this area has studied risperidone and olanzapine, with most evidence for risperidone. However, the use of these medications still requires regularly review (at least every 3 months in Australia) to ensure they are only used for the shortest possible time to minimise the risk of cerebrovascular events and sudden death.
Despite risperidone being the first choice antipsychotic for older people, some patient's may be prescribed quetiapine which is associated with a lower risk of extrapyradimal adverse effects.
Under what circumstances is it thought necessary to prescribe antipsychotics to the elderly?
Dear Anthony,
very interesting question!
Well, usually antipsychotics are used because of a lack of knowledge of pharmacology (easier to prescribe than reconsider). More than 1/3 antipsychotics are used without support of EBM. In term of inappropriate prescribing (PIP) more than 50 % are included in the nursing homes as PIP. More than 2/3 of antipsychotic polypharmacy (APP) can be reduced to monotherapy (AM).
In special population as elderly parients are, there is necessary to reduced the use of antipsychotic if it is possible. Often patients are treated very long period (e.g. 12 months). Very deep evaluation and dose adjustment is necessary if antipsychotics are used in the elderly patients in dementia. However, another options should be calculated as use of antidepressants (e.g. mirtazapine and trazodone) instead of antipsychotics in patients in dementia.
In real clinical practice in patients with dementia risperidone and quetiapine are used often. Olanzapine should almost not be used in these patients (Daniel you have different opinion). With quetiapine we have an evidence that there are no deaths in compare with placebo in small-medium doses of quetiapine (only quetiapine). In this point of view the use of quetiapine is the safest option in patients in dementia. The use of risperidone should be connected with a great caution. In many patients risperidone is titrated very (tapered) fast and often extrapyramidal symptoms are seen (about 20 % patients have tardive dyskinesia in 2 years treatment). Risperidone has one benefit compared to risperidone (e.g. approved indication in patients with dementia). Another benefit is its efficacy in comorbidity with psychotic episodes, where risperidone is often more efficacy. Very big benefit is sedative action of quetiapine and this action is very useful in these patients. In addition, these patients are often treated with polypharmacy and clinical pharmacist specialist within psychiatry can be involved in the treatment of these patients.
You can read this PDF or find other evidence from the following Link: https://bpac.org.nz/report/2020/antipsychotic-medicines.aspx
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