Atypical Antipsychotics in Older Adults

Abstract

Psychotic symptoms are common in older adults and reflect a variety of psychiatric and medical conditions. Antipsychotic drugs form the core of the treatment of these symptoms; however, treatment of the elderly is complicated by a high frequency of comorbid medical illnesses, risk of side effects, and age-related changes in pharmacodynamics and pharmacokinetics. The superior safety and efficacy of atypical antipsychotics makes them first-line agents for managing psychotic patients with schizophrenia. Their uses now extend to other conditions such as schizoaffective disorders, delusional disorder, and mood disorders with psychotic features. Although the drugs have been studied extensively in young subjects, well-designed, double-blind, placebo-controlled studies are relatively lacking in the elderly. Our knowledge of their safety, efficacy and dosage in older adults is based on a few studies with small samples or extrapolated from studies of younger patients. Several psychiatric and medical conditions that are associated with psychotic symptoms in older people are reviewed, as well as how these patients may benefit from treatment with these agents.

Risk of death associated with the use of conventional versus atypical antipsychotic drugs among elderly patients

“…5 On the basis of extrapolations mainly from younger populations, some have suggested that the conventional formulations could, in theory, pose risks equal to or greater than those associated with the newer, atypical drugs in elderly populations. [10][11][12][13] A cohort study involving US Medicare patients eligible for statefunded low-income pharmacy assistance programs showed a 37% increase in the 180-day mortality associated with the use of conventional antipsychotic medications compared with atypical ones.…”

“…13 During the study period (i.e., before the FDA health advisory 7 was posted in 2005), recommendations were published to avoid the prescription of conventional antipsychotic medications to frail elderly patients, 4,[10][11][12][13]33 and any residual confounding may have therefore led to an underestimation of mortality associated with the use of conventional agents.…”

Augmentation of aripiprazole by flupenthixol decanoate in poorly responsive schizophrenia: a randomized clinical study

“…Despite these interpretations, it could not be disregarded that strengthening of extra-pyramidal side effects by flupenthixol decanoate or similar antipsychotics may precipitate or increase the risk of other serious adverse effects such as tardive dyskinesia or neuroleptic malignant syndrome. On the other hand, though the recognized greater risk of tardive dyskinesia caused by conventional antipsychotics cannot be overlooked, possible metabolic side effects due to a higher dosage of aripiprazole or other SGAs [40,41], which may be prescribed by clinicians in cases of treatment resistance, also need to be considered. In addition, since both of these drugs are substrates of cytochrome P450 2D6, possible pharmacokinetic interaction between them must be noted.…”

Psychotropic medication use for behavioral symptoms of dementia

“…However, extrapolating mainly from studies in younger populations, some have suggested that conventional antipsychotic medications could pose risks greater than those of the newer drugs in older populations [37][38][39][40]. In a recent observational study of elderly patients beginning use of antipsychotic medications, we found that patients prescribed conventional agents had a 37% greater dose-dependent risk of short-term mortality than those prescribed atypical antipsychotics [41••].…”