What considerations are necessary for managing acute psychosis in the elderly?

From the Guidelines

Managing acute psychosis in the elderly requires a comprehensive assessment to identify the underlying cause, followed by a tailored treatment plan that prioritizes non-pharmacological approaches and low-dose antipsychotics, with careful consideration of medical comorbidities and potential side effects. The most recent and highest quality study, 1, published in 2025, emphasizes the importance of non-pharmacological strategies as first-line management for individuals with vascular cognitive impairment (VCI) who are displaying behavior changes. This approach is also relevant to managing acute psychosis in the elderly, as it often stems from medical conditions like delirium, dementia, medication side effects, or metabolic disturbances rather than primary psychiatric disorders.

When pharmacological intervention is necessary, low-dose antipsychotics are typically the first-line treatment, with second-generation options like quetiapine (starting at 12.5-25mg) or risperidone (0.25-0.5mg) preferred due to their more favorable side effect profiles, as suggested by 1. Medication doses should be started at roughly one-quarter to one-half the usual adult dose, following the principle "start low, go slow." Close monitoring for extrapyramidal symptoms, orthostatic hypotension, sedation, and anticholinergic effects is essential, as elderly patients have altered pharmacokinetics and pharmacodynamics.

Key considerations in managing acute psychosis in the elderly include:

• Identifying and addressing the underlying cause of psychosis
• Implementing non-pharmacological approaches, such as maintaining a calm environment, providing orientation cues, ensuring adequate hydration and nutrition, and addressing sensory deficits
• Selecting medications with careful consideration of medical comorbidities, cardiovascular status, renal and hepatic function, and potential drug interactions
• Regular reassessment of the need for continued antipsychotic therapy, given the black box warnings for increased mortality in elderly patients with dementia-related psychosis, as highlighted by 1 and 1.

From the FDA Drug Label

Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Cerebrovascular adverse events (e.g., stroke, transient ischemic attack), including fatalities, were reported in patients in trials of olanzapine in elderly patients with dementia-related psychosis.

Considerations for managing acute psychosis in the elderly:

• Increased risk of mortality: Elderly patients with dementia-related psychosis are at a higher risk of death when treated with antipsychotic drugs.
• Cerebrovascular adverse events: There is a higher incidence of cerebrovascular adverse events, including stroke and transient ischemic attack, in elderly patients treated with antipsychotic drugs.
• Caution with antipsychotic use: Antipsychotic drugs, such as olanzapine and risperidone, are not approved for the treatment of dementia-related psychosis in the elderly.
• Monitoring and supervision: Close supervision and monitoring of elderly patients with acute psychosis is necessary to minimize the risk of adverse events. 2 2 3

From the Research

Considerations for Managing Acute Psychosis in the Elderly

• The management of acute psychosis in the elderly requires careful consideration of the underlying cause, which can be organic or functional 4.
• A thorough history, examination of the patient's mental state, and collateral history are essential for diagnosis and treatment 4.
• In elderly patients, psychosis can be a manifestation of various conditions, including Alzheimer's disease, Parkinson's disease, or schizophrenia 5.
• Age-related pharmacokinetic changes, polypharmacy, and comorbid diseases must be considered when planning antipsychotic pharmacotherapy for elderly patients 5.
• Atypical antipsychotics are preferred over traditional antipsychotics due to their lower risk of extrapyramidal symptoms, particularly in patients with Parkinson's disease 6, 5.
• The choice of atypical antipsychotic should be based on ease of use and adverse effect profile, as most have comparable efficacy in improving psychosis 6.
• Non-pharmacological interventions, such as supportive therapy, should also be considered, especially in patients who are sensitive to the side effects of antipsychotic medications 7.
• In cases where psychosis is associated with subcortical stroke, antipsychotic medications may provide symptomatic relief, but the location of the stroke within the brain can influence the clinical characteristics of psychotic symptoms 8.

Key Factors to Consider

• Thorough diagnostic evaluation to determine the underlying cause of psychosis
• Consideration of age-related pharmacokinetic changes and polypharmacy
• Selection of antipsychotic medication based on ease of use and adverse effect profile
• Monitoring for extrapyramidal symptoms, particularly in patients with Parkinson's disease
• Consideration of non-pharmacological interventions, such as supportive therapy
• Awareness of the potential for psychosis to be a manifestation of various conditions, including neurologic disorders such as stroke 8