What are the recommended medications for treating psychosis in elderly patients?

Medications for Elderly Psychosis

For elderly patients with psychosis, antipsychotics should only be used when symptoms are severe, dangerous, or cause significant distress, and only after attempting nonpharmacological interventions first. 1

Initial Assessment and Non-Pharmacological Management

Before considering any medication, you must:

• Assess for reversible causes including delirium, medication effects, pain, metabolic disturbances, and infections 2
• Implement nonpharmacological interventions first, including structured activities, caregiver support, environmental modifications, and reassurance 1, 2
• Quantify symptoms using standardized measures to track severity, frequency, and pattern 1
• Discuss risks and benefits with the patient (if feasible) and surrogate decision-makers before initiating any antipsychotic 1

When to Use Antipsychotics

Antipsychotics are appropriate only when: 1

• Symptoms are severe, dangerous, or cause significant patient distress
• Nonpharmacological interventions have been attempted and failed
• The potential benefits outweigh substantial risks (increased mortality, stroke, falls, metabolic effects)

First-Line Medication Choices by Clinical Context

For Dementia with Psychosis/Agitation

Risperidone is the first-line choice at 0.5-2.0 mg/day 3

Alternative options (high second-line): 3

• Quetiapine 50-150 mg/day
• Olanzapine 5.0-7.5 mg/day

Critical caveat: All antipsychotics carry a black box warning for increased mortality in elderly patients with dementia-related psychosis 1. Even short-term treatment is associated with increased death risk. 1

For Lewy Body Dementia or Parkinson's Disease with Psychosis

Quetiapine is the preferred agent, starting at 12.5 mg twice daily and titrating slowly to a maximum of 200 mg twice daily 2, 4

Alternative options: 1, 2

• Pimavanserin (specifically for Parkinson's disease psychosis)
• Clozapine (requires blood monitoring for agranulocytosis)

Avoid all typical antipsychotics (haloperidol, etc.) due to severe sensitivity reactions and high risk of extrapyramidal symptoms in these patients 2, 4

For Late-Life Schizophrenia

Risperidone is first-line at 1.25-3.5 mg/day 3

High second-line alternatives: 3

• Quetiapine 100-300 mg/day
• Olanzapine 7.5-15 mg/day
• Aripiprazole 15-30 mg/day

Dosing Principles

Start low and go slow: 1

• Initiate at the lowest possible dose
• Titrate to the minimum effective dose as tolerated
• Elderly patients (>75 years) are less likely to respond to antipsychotics, particularly olanzapine 1

Monitoring Requirements

You must monitor: 2

• Sedation and orthostatic hypotension (especially with quetiapine)
• Extrapyramidal symptoms and parkinsonism
• Cognitive worsening
• Metabolic effects: weight gain, glucose, lipids (especially with olanzapine and clozapine) 1, 5
• QTc prolongation (especially with ziprasidone) 1

Duration of Treatment and Discontinuation

If no response after 4 weeks at an adequate dose, taper and discontinue the medication 1

If there is a positive response, attempt tapering based on: 3

• Delirium: 1 week after resolution
• Agitated dementia: Taper within 3-6 months to determine lowest effective maintenance dose
• Schizophrenia: Indefinite treatment at lowest effective dose
• Delusional disorder: 6 months to indefinitely

Daily in-person evaluation is required to assess ongoing need for treatment 1

Medications to Avoid

Never use as first-line in elderly patients: 1

• Benzodiazepines (except for alcohol/benzodiazepine withdrawal) - associated with increased delirium, falls, and mortality
• Cholinesterase inhibitors for delirium prevention/treatment - ineffective and potentially harmful 1

Avoid in specific conditions: 1, 3

• Clozapine and olanzapine in patients with diabetes, dyslipidemia, or obesity
• Ziprasidone and low-potency typical antipsychotics in patients with QTc prolongation or heart failure
• Typical antipsychotics in patients with Parkinson's disease or Lewy body dementia

Critical Safety Warnings

The evidence shows that: 1

• 47% of patients continue antipsychotics after ICU discharge without clear indication
• 33% continue as outpatients inappropriately
• Short-term treatment carries risks of QT prolongation, sudden death, pneumonia, falls, DVT, and increased mortality 1

Olanzapine specifically carries a boxed warning regarding death in patients with dementia-related psychosis and should be used with extreme caution in elderly patients 1