Can Risperdal (risperidone) be used to treat delirium in elderly patients with advanced cancer?

Risperidone for Delirium in Elderly Cancer Patients

Risperidone can be used for delirium in elderly cancer patients with advanced cancer, but it is not recommended as first-line therapy due to lack of demonstrated benefit and potential for harm in mild-to-moderate delirium. 1

Evidence-Based Approach to Risperidone Use

Indications and Limitations

• Risperidone has no demonstrable benefit in mild-to-moderate delirium and may actually worsen symptoms 1
• Should only be considered when:
  • Patient has perceptual disturbances (hallucinations, illusions)
  • Patient is severely agitated and poses risk to self or others
  • Non-pharmacological interventions have failed
  • Reversible causes of delirium have been addressed

Dosing Recommendations

• Starting dose: 0.5 mg orally (p.o.) stat 1
• Frequency: Up to every 12 hours if scheduled dosing required 1
• Dose reduction required in:
  • Elderly patients
  • Patients with severe renal impairment
  • Patients with hepatic impairment 1
• Available as oral disintegrating tablet (ODT) for easier administration 1

Monitoring and Adverse Effects

• Increased risk of extrapyramidal symptoms (EPSEs) if dose exceeds 6 mg/24h 1
• Common side effects:
  • Insomnia, agitation, anxiety
  • Drowsiness
  • Orthostatic hypotension 1
• Response should be assessed within days of initiation 2
• Poor response to risperidone has been observed in patients ≥70 years of age 3

Clinical Considerations

Alternative Medications

1. First-line alternatives:

   • Olanzapine: 2.5-5 mg p.o. or s.c. stat (may be more effective in elderly) 1, 3
   • Quetiapine: 25 mg p.o. (less likely to cause EPSEs) 1
   • Aripiprazole: 5 mg p.o. or i.m. (less likely to cause EPSEs) 1

2. For alcohol or benzodiazepine withdrawal delirium:

   • Benzodiazepines are treatment of choice as monotherapy 1

Important Caveats

• Medications should be initially started on PRN (as needed) basis 1
• Regular dosing should be for shortest period possible 1
• No medication is currently licensed worldwide for delirium management 1
• Antipsychotics themselves can cause increased agitation and delirium 1
• The reversibility of delirium in palliative care units can be as high as 50% with appropriate management of underlying causes 1

Special Populations

• For opioid-associated delirium: Consider opioid rotation to fentanyl or methadone rather than antipsychotics 1
• In Parkinson's disease or Lewy body dementia: Risperidone is contraindicated due to risk of worsening extrapyramidal symptoms 4

Implementation Algorithm

1. Identify and treat reversible causes of delirium
2. Implement non-pharmacological interventions
3. If pharmacological intervention needed:
   • For mild-moderate delirium: Avoid risperidone (no benefit, potential harm) 1
   • For severe delirium with agitation/perceptual disturbances:
     • Start with 0.5 mg risperidone p.o.
     • Assess response within 1-2 days
     • If inadequate response and no adverse effects, may increase to 0.5 mg twice daily
     • Consider alternative antipsychotic if poor response or side effects develop

Remember that short-term use of medications at the lowest effective dose should be the goal, with continuous reassessment of the need for ongoing treatment.