What treatment should be prescribed for an elderly female patient with delusions and paranoia who has been on Abilify (aripiprazole) 5mg for years?

Management of Delusions and Paranoia in an Elderly Female on Chronic Aripiprazole

You should discontinue aripiprazole immediately and switch to quetiapine, starting at 25 mg and titrating as needed, as aripiprazole is contraindicated in elderly patients with dementia-related psychosis and may be worsening her symptoms.

Critical FDA Black Box Warning

• Aripiprazole carries a black box warning for increased mortality in elderly patients with dementia-related psychosis and is NOT approved for this indication 1
• Elderly patients with dementia-related psychosis treated with antipsychotic drugs, including aripiprazole, are at increased risk of death 1
• In controlled studies, aripiprazole was associated with increased cerebrovascular adverse events (stroke, TIA) including fatalities in elderly dementia patients (mean age 84 years), with a statistically significant dose-response relationship 1

Aripiprazole May Be Causing the Problem

• Aripiprazole can paradoxically worsen psychosis, agitation, paranoia, and aggression in some patients 2
• The mechanism involves aripiprazole's partial dopamine agonist properties, which may increase dopaminergic activity in patients with long-term antipsychotic exposure and upregulated postsynaptic dopamine receptors 2
• Case reports document worsening of delusions and agitation specifically after aripiprazole initiation, with improvement after discontinuation 2, 3
• In elderly patients specifically, aripiprazole caused lethargy (5%), somnolence/sedation (8%), and other adverse effects at twice the rate of placebo 1

Recommended Treatment Algorithm

Step 1: Discontinue Aripiprazole

• Stop aripiprazole immediately given the FDA contraindication in elderly dementia-related psychosis and potential for symptom exacerbation 1, 2

Step 2: Switch to Quetiapine

• Start quetiapine at 25 mg and titrate as needed, as it may be more effective for psychotic symptoms in elderly patients 4
• Quetiapine is available only in oral formulations for acute management 5
• Sedation is a recognized side effect that may be advantageous if agitation is present 5
• Quetiapine appears less likely to cause extrapyramidal symptoms than first-generation antipsychotics 5

Step 3: Alternative Options if Quetiapine Fails

• Olanzapine may offer benefit in symptomatic management and is available in oral or orally dispersible formulations 5
• Olanzapine also has sedating properties that may help with agitation 5
• Both quetiapine and olanzapine have lower risk of extrapyramidal side effects compared to traditional antipsychotics 5

Critical Monitoring Points

• Use the lowest effective dose for the shortest period of time 5
• Pharmacological interventions should be limited to patients with distressing symptoms or safety concerns 5
• Reassess symptoms every 2-4 weeks after medication changes 4
• Monitor for difficulty swallowing or excessive somnolence, which could predispose to accidental injury or aspiration in elderly patients 1
• Monitor for falls risk, as elderly patients are more sensitive to medication effects 6

Common Pitfalls to Avoid

• Do not increase the aripiprazole dose - this will likely worsen symptoms and increase stroke/mortality risk 1, 2
• Do not add haloperidol or risperidone - these have no demonstrable benefit in mild-to-moderate delirium/psychosis and may worsen symptoms 5
• Avoid benzodiazepines as initial therapy, as they are deliriogenic and increase fall risk in elderly patients with mobility 5
• Do not assume treatment failure without first considering that aripiprazole itself may be causing the problem 2, 3