What are the guidelines for using Abilify (aripiprazole) in elderly patients?

Aripiprazole Use in Elderly Patients

Aripiprazole should not be used in elderly patients with dementia-related psychosis due to increased mortality risk, and if absolutely necessary for other indications, it should be started at very low doses with careful monitoring. 1

FDA Boxed Warning and Safety Concerns

Aripiprazole carries significant risks when used in elderly patients:

• The FDA has issued a boxed warning against using aripiprazole in elderly patients with dementia-related psychosis due to increased mortality risk 1
• Cerebrovascular adverse events, including stroke and transient ischemic attacks, occur at higher rates in elderly patients with dementia treated with aripiprazole 1
• In clinical trials of elderly patients with Alzheimer's disease, aripiprazole was associated with:
  • Lethargy (5% vs 2% for placebo)
  • Somnolence/sedation (8% vs 3% for placebo)
  • Urinary incontinence (5% vs 1% for placebo)
  • Excessive salivation (4% vs 0% for placebo)
  • Lightheadedness (4% vs 1% for placebo) 1

Appropriate Use in Elderly (Non-Dementia)

If aripiprazole must be used in elderly patients without dementia:

1. Starting dose: 5 mg once daily is the recommended starting dose for elderly patients 2
2. Dose adjustment: Reduce dose in older patients and in poor metabolizers of cytochrome P450 2D6 2
3. Monitoring requirements:
   • Blood pressure and ECG monitoring
   • Evaluate for orthostatic hypotension
   • Monitor for sedation, extrapyramidal symptoms, and falls 2

Specific Indications and Alternatives

For elderly patients with psychiatric symptoms, consider the following algorithm:

1. First assess if symptoms are dementia-related:

   • If dementia-related psychosis is present: DO NOT USE aripiprazole 1
   • Try non-pharmacological approaches first 3

2. For non-dementia psychiatric conditions:

   • Start with lowest possible dose (5 mg daily) 2
   • Monitor closely for adverse effects
   • Consider alternative atypical antipsychotics with better safety profiles in elderly

3. For agitation/psychosis requiring treatment:

   • Consider other atypical antipsychotics like quetiapine (starting at 25 mg) or olanzapine (starting at 2.5 mg) 2
   • For severe agitation, low-dose risperidone (0.5 mg) may be considered 2

Common Pitfalls to Avoid

• Never use in dementia-related psychosis - despite some studies showing efficacy 4, the mortality risk outweighs potential benefits 1
• Avoid combining with benzodiazepines in elderly patients due to increased risk of oversedation and respiratory depression 2
• Be cautious with drug interactions - aripiprazole dose must be halved when used with CYP3A4 inhibitors 1
• Monitor for falls risk - aripiprazole can cause dizziness and orthostatic hypotension 2
• Watch for extrapyramidal symptoms - though less common than with typical antipsychotics, they can still occur 2

Conclusion

While aripiprazole may be effective for certain psychiatric conditions, its use in elderly patients requires extreme caution. The FDA explicitly warns against its use in dementia-related psychosis, and if used for other indications, it should be at the lowest effective dose with careful monitoring for adverse effects.