Can you give antipsychotics to clients 60 and older?

Antipsychotic Use in Clients 60 and Older

Antipsychotics should generally be avoided in clients 60 and older due to increased risk of mortality, cerebrovascular events, and other serious adverse effects, except in specific circumstances where benefits clearly outweigh risks. 1

Safety Concerns with Antipsychotics in Older Adults

Antipsychotic medications pose significant risks to older adults:

• Increased mortality risk: All antipsychotics carry an FDA black box warning regarding increased mortality risk in dementia patients 2
• Cerebrovascular events: Higher risk of stroke, especially in the first weeks of treatment
• Cognitive worsening: Can cause deleterious cognitive effects 3
• Extrapyramidal symptoms: Older adults are especially vulnerable to these effects 4
• Metabolic effects: Weight gain, diabetes, dyslipidemia
• QTc prolongation: Risk of cardiac arrhythmias
• Falls and fractures: Due to sedation and postural hypotension

Limited Appropriate Indications

Antipsychotics should only be considered in older adults when:

1. Severe agitation or psychosis: When patients are threatening substantial harm to self or others
2. Behavioral interventions have failed: Non-pharmacological approaches should always be tried first
3. Benefits clearly outweigh risks: After thorough discussion with patient/surrogate

The 2019 American Geriatrics Society Beers Criteria® specifically warns against antipsychotic use in older adults due to the risk of increased mortality 1.

Exceptions to Avoid Recommendation

The AGS Beers Criteria recognizes only three exceptions for antipsychotic use in older adults with Parkinson's disease:

• Quetiapine
• Clozapine
• Pimavanserin

However, the guidelines note that "none of these three excepted drugs is close to ideal in either efficacy or safety, each having its own limitations and concerns." 1

If Antipsychotics Must Be Used

When antipsychotics are deemed absolutely necessary:

1. Use lowest effective dose: Start at 25% of usual adult dose; maintenance doses typically range from 25-50% of adult dose 4
2. Short duration: Use for shortest possible time
3. Daily evaluation: Monitor response and side effects with in-person examinations
4. Consider pharmacokinetic changes: Elderly patients have:
   • Reduced drug clearance
   • Increased elimination half-life (approximately 1.5 times greater) 5
   • Higher plasma concentrations

Monitoring Requirements

If an antipsychotic is prescribed:

• QTc monitoring: Baseline and follow-up ECGs, especially with haloperidol 2
• Metabolic monitoring: Weight, blood glucose, lipids
• Extrapyramidal symptoms: Regular assessment
• Cognitive function: Monitor for worsening
• Falls risk: Regular assessment

Alternatives to Consider

Before using antipsychotics, consider:

• Non-pharmacological approaches: Environmental modifications, de-escalation techniques, behavioral interventions 2
• SSRIs: May help with agitation, particularly in vascular cognitive impairment 2
• Trazodone: Lower-risk option for agitation, starting at 25mg daily 2

Conclusion

The evidence strongly indicates that antipsychotics should be avoided in older adults whenever possible. The 2019 AGS Beers Criteria explicitly warns against their use due to increased mortality risk. When absolutely necessary, they should be used at the lowest effective dose for the shortest duration possible, with close monitoring for adverse effects.