Is Zydis (olanzapine) 5 mg okay for PRN (as needed) use in a 65-year-old patient with agitation?

Olanzapine Zydis 5 mg for PRN Agitation in a 65-Year-Old Patient

Olanzapine Zydis 5 mg can be used as PRN for agitation in a 65-year-old patient, but should be used at the lowest effective dose for the shortest possible duration, only after behavioral interventions have failed, and with daily monitoring for adverse effects. 1

Appropriate Use of Antipsychotics for Agitation in Older Adults

• Antipsychotics may be used at the lowest effective dose for the shortest possible duration to treat patients who are severely agitated and threatening substantial harm to self or others 1
• Treatment with antipsychotics should only be employed after behavioral interventions have failed or are not possible 1
• Daily in-person evaluation is required to assess ongoing need and monitor for adverse effects 1
• Non-pharmacological approaches should be attempted first before resorting to medication 2

Dosing Considerations for Older Adults

• Lower doses are recommended for geriatric patients due to potential for decreased pharmacokinetic clearance and increased pharmacodynamic response 3
• 5 mg is an appropriate starting dose for olanzapine in this age group, though some patients may require dose adjustment based on response 4
• Olanzapine has a relatively rapid onset of action (45-60 minutes) with peak effects at 4-5 hours and duration of 6-8 hours 4
• Patients over 75 years are less likely to respond to antipsychotics, particularly olanzapine, compared to younger patients 1

Monitoring and Safety Concerns

• Monitor for common side effects including sedation, orthostatic hypotension, extrapyramidal symptoms, and metabolic effects 4, 3
• Elderly patients with dementia-related psychosis have increased risk of death and cerebrovascular adverse events with olanzapine 3
• Even short-term treatment with antipsychotics is associated with increased mortality in older adults 1
• Be vigilant about inadvertent chronic administration after initial use - studies show 47% of patients continued receiving antipsychotics after ICU discharge and 33% after hospital discharge 1

Contraindications and Special Considerations

• Olanzapine is not approved for treatment of patients with dementia-related psychosis 3
• Use caution in patients with respiratory compromise, cardiac conditions, or risk factors for QT prolongation 4
• Avoid benzodiazepines as first-line treatment for agitation in older adults except when specifically indicated (e.g., alcohol or benzodiazepine withdrawal) 1
• Do not prescribe antipsychotics for older adults with hypoactive delirium who are not agitated or threatening harm 1

Alternative Approaches

• For mild agitation, structured activities, reassurance, socialization, and environmental interventions should be attempted first 1
• If olanzapine is ineffective or poorly tolerated, consider alternative antipsychotics at appropriate geriatric doses 5
• Intramuscular olanzapine has shown faster onset of action and fewer adverse effects than haloperidol in some studies, but oral formulations are preferred when possible 6, 7
• Orally disintegrating tablet formulations like Zydis may improve medication compliance in agitated patients 7

Important Clinical Pitfalls

• Avoid combining olanzapine with other CNS depressants due to risk of excessive sedation 6
• Be aware that studies show antipsychotics are commonly used for agitation in older adults despite limited evidence of effectiveness and potential for harm 2
• Regularly reassess the need for continued medication to avoid inappropriate long-term use 1
• Remember that olanzapine has a different side effect profile in elderly patients, including increased risk of falls, somnolence, peripheral edema, abnormal gait, and urinary incontinence 3