Is olanzapine (an atypical antipsychotic) suitable for a 71-year-old patient?

From the Guidelines

Olanzapine can be considered for a 71-year-old patient, but its use requires careful evaluation and monitoring due to potential risks and side effects, particularly in elderly populations. The guidelines for managing Alzheimer's disease suggest that atypical antipsychotic agents like olanzapine can be used for controlling problematic delusions, hallucinations, severe psychomotor agitation, and combativeness 1. However, it's crucial to start with a low dose of 2.5 mg daily and gradually increase based on response and tolerability, with a maximum dose generally not exceeding 10 mg daily for elderly patients.

Some key considerations when prescribing olanzapine to elderly patients include:

• Increased risk of mortality in elderly patients with dementia-related psychosis, as indicated by a black box warning 1
• Potential side effects such as sedation, orthostatic hypotension, metabolic effects (weight gain, diabetes, dyslipidemia), and anticholinergic effects
• Higher risk for falls, cognitive impairment, and extrapyramidal symptoms in elderly patients
• Need for regular monitoring, including blood glucose, lipids, weight, blood pressure, and cognitive function

Given these concerns, non-pharmacological approaches should be tried first when possible, especially for behavioral symptoms of dementia. The decision to use olanzapine in an elderly patient should carefully weigh potential benefits against these significant risks, and the medication should be used for the shortest duration necessary. As stated in the guidelines, current research supports the use of low dosages of atypical antipsychotic agents like olanzapine, which are generally well tolerated 1.

From the FDA Drug Label

Of the 2500 patients in premarketing clinical studies with oral olanzapine, 11% (263) were 65 years of age or over. In patients with schizophrenia, there was no indication of any different tolerability of olanzapine in the elderly compared to younger patients Studies in elderly patients with dementia-related psychosis have suggested that there may be a different tolerability profile in this population compared to younger patients with schizophrenia. Elderly patients with dementia-related psychosis treated with olanzapine are at an increased risk of death compared to placebo The presence of factors that might decrease pharmacokinetic clearance or increase the pharmacodynamic response to olanzapine should lead to consideration of a lower starting dose for any geriatric patient

Olanzapine use in elderly patients:

• The drug label does not explicitly state that olanzapine is contraindicated in patients over 71 years old.
• However, it does mention that elderly patients with dementia-related psychosis are at an increased risk of death and have a different tolerability profile.
• For geriatric patients in general, a lower starting dose should be considered due to potential decreased pharmacokinetic clearance or increased pharmacodynamic response.
• Schizophrenia in the elderly does not appear to have a different tolerability profile compared to younger patients.

Given the information provided and the need for caution, olanzapine may be suitable for a 71-year-old patient, but the decision should be made on a case-by-case basis, considering the patient's overall health, potential interactions, and the presence of any factors that might affect the pharmacokinetics or pharmacodynamics of olanzapine. A lower starting dose should be considered, and the patient should be closely monitored for adverse reactions 2.

From the Research

Suitability of Olanzapine for a 71-year-old Patient

• Olanzapine is an atypical antipsychotic that has been studied in various patient populations, including the elderly 3, 4.
• A study published in 2004 found that olanzapine was a high second-line option for agitated dementia with delusions, with a recommended dose of 5.0-7.5 mg/day 3.
• Another study published in 2000 found that olanzapine was effective and well-tolerated in elderly patients with psychotic disorders, with a dose range of 5-20 mg/day 4.
• The pharmacokinetics of olanzapine are linear and dose-proportional, with a mean half-life of 33 hours in healthy individuals 5.
• However, the clearance of olanzapine may be decreased in elderly patients, particularly those with decreased oxidative metabolism, such as debilitated or elderly women who are nonsmokers 5.
• Olanzapine has been associated with several adverse effects, including somnolence, postural hypotension, constipation, dizziness, restlessness, and weight gain 6, 7.
• Despite these potential adverse effects, olanzapine may be a suitable option for a 71-year-old patient, particularly if they have a diagnosis of psychotic disorder or agitated dementia with delusions, and are closely monitored for potential side effects 3, 4.

Key Considerations

• The dose of olanzapine should be carefully selected and monitored in elderly patients, taking into account their individual characteristics and medical history 5.
• Patients should be regularly assessed for potential side effects, such as extrapyramidal symptoms, and for changes in their medical condition 3, 4.
• Olanzapine may interact with other medications, such as fluvoxamine, which can increase plasma concentrations of olanzapine, and inducers of CYP1A2, which can decrease olanzapine concentrations 5.
• The use of olanzapine in palliative care has been identified as an important area of research, with potential benefits for patients with delirium, nausea, and vomiting 7.