What is the recommended medication for psychosis and agitation in the elderly?

Management of Psychosis and Agitation in the Elderly

For elderly patients with psychosis and agitation, haloperidol is the first-line medication at low doses (0.5-1 mg orally at night and every 2 hours when required, maximum 5 mg daily in elderly patients). 1

First-Line Pharmacological Management

For Patients Who Can Swallow:

• Haloperidol 0.5-1 mg orally at night and every 2 hours when required
  • Increase dose in 0.5-1 mg increments as required
  • Maximum 5 mg daily in elderly patients
  • Consider higher starting dose (1.5-3 mg) if severely distressed or causing immediate danger to others

For Patients Unable to Swallow:

• Levomepromazine 6.25-12.5 mg subcutaneously as starting dose, then hourly as required
  • Maintain with subcutaneous infusion of 50-200 mg over 24 hours
  • Doses >100 mg over 24 hours should be given under specialist supervision

Important Considerations Before Starting Medication

1. Address reversible causes first:

   • Explore patient's concerns and anxieties
   • Ensure effective communication and orientation
   • Ensure adequate lighting
   • Treat medical causes (hypoxia, urinary retention, constipation)

2. Boxed Warning: Elderly patients with dementia-related psychosis treated with antipsychotics have increased mortality risk 2

Second-Line Options

If haloperidol is ineffective or poorly tolerated, consider:

1. Adding a benzodiazepine:

   • Lorazepam 0.25-0.5 mg orally four times daily as required (maximum 2 mg/24 hours) 1
   • For patients unable to swallow: Midazolam 2.5-5 mg subcutaneously every 2-4 hours

2. Alternative antipsychotics:

   • Risperidone 0.5-2.0 mg/day (for agitated dementia with delusions) 3, 4
   • Quetiapine 50-150 mg/day (especially for patients with Parkinson's disease) 3, 5
   • Olanzapine 5.0-7.5 mg/day 5

Medication Selection Based on Comorbidities

1. For patients with diabetes, dyslipidemia, or obesity:

   • Avoid clozapine, olanzapine, and low/mid-potency conventional antipsychotics 5
   • Prefer risperidone or quetiapine 5

2. For patients with Parkinson's disease:

   • Quetiapine is first-line 5
   • Avoid conventional antipsychotics due to extrapyramidal side effects

3. For patients with cardiac issues (QTc prolongation or CHF):

   • Avoid clozapine, ziprasidone, and conventional antipsychotics 5

Monitoring and Duration of Treatment

1. Regular monitoring:

   • Assess effectiveness using quantitative measures
   • Monitor for side effects (extrapyramidal symptoms, somnolence)
   • Reassess at least every 6 months 3

2. Duration of treatment:

   • For delirium: 1 week after resolution 5
   • For agitated dementia: taper within 3-6 months to determine lowest effective maintenance dose 5
   • For schizophrenia: indefinite treatment at lowest effective dose 5

Common Pitfalls and Caveats

1. Mortality risk: All antipsychotics carry increased mortality risk in elderly patients with dementia-related psychosis 6, 2

2. Extrapyramidal symptoms: More common with typical antipsychotics (haloperidol) than atypicals (risperidone, quetiapine) 7

3. Somnolence: Significant risk with all antipsychotics (RR 1.93 for atypicals, 2.62 for typicals) 7

4. Starting doses: Use very low doses in elderly (e.g., 0.25-0.5 mg haloperidol) and titrate slowly 8

5. Effectiveness vs. placebo: The apparent effectiveness of antipsychotics may be partly explained by natural symptom resolution, as observed in placebo groups 7

6. Non-pharmacological approaches: Should be attempted first but may be insufficient for severe symptoms 3

7. Avoid in non-psychotic conditions: Antipsychotics are not recommended for panic disorder, generalized anxiety, non-psychotic depression, or sleep disturbance without a major psychiatric syndrome 5