Starting Dose of Aripiprazole for Elderly Patients

Start aripiprazole at 5 mg once daily in elderly patients, which is half the standard adult starting dose of 10-15 mg. 1

Recommended Initial Dosing

Begin with 5 mg orally once daily in elderly patients (age ≥65 years), following the geriatric principle of "start low, go slow" to minimize adverse effects in this vulnerable population 1, 2, 3
This reduced starting dose is lower than the standard adult starting dose of 10-15 mg daily 4, 5
Dosage titration should not occur before 2 weeks of continuous therapy, as this is the time needed to achieve steady-state plasma concentrations 5
Allow at least 1-2 weeks, and sometimes up to 4 weeks, for aripiprazole to reach its full therapeutic effect before making dosage adjustments 5

Titrate carefully based on tolerability and clinical response, avoiding doses above 15 mg daily unless absolutely necessary 1
For elderly patients with late-life schizophrenia, expert consensus supports a target dose range of 15-30 mg/day as a high second-line option (after risperidone), though this should be approached cautiously given the lower starting dose recommendation 2
In an open-label trial of elderly bipolar patients (mean age 59.6 years), the mean daily dose was 10.26 mg/day, demonstrating that lower doses can be effective 3

Reduce the dose further in elderly patients who are poor metabolizers of cytochrome P450 2D6, as these individuals will have higher drug concentrations 1
Exercise caution with CYP3A4 and CYP2D6 inhibitors, which increase aripiprazole concentrations and may require dose reduction 1, 4
When aripiprazole is coadministered with CYP3A4 inducers, aripiprazole concentration decreases and dosage adjustment may be necessary 4

For patients with difficulty swallowing, the oral solution formulation may be more appropriate for precise dose reductions 6
Aripiprazole can be administered without regard to meals 5

Monitor closely for extrapyramidal symptoms (EPS) including akathisia, pseudo-parkinsonism, tardive dyskinesia, and dystonia 1
While aripiprazole generally has a placebo-level incidence of EPS in clinical trials, elderly patients remain at higher risk 4

Check blood pressure for orthostatic hypotension, particularly when initiating therapy 1
Obtain ECG to monitor for QTc prolongation, especially in patients with cardiac risk factors or those taking other QT-prolonging medications 1

Monitor body weight regularly, as aripiprazole has a low propensity for clinically significant weight gain compared to other atypicals 4
Assess for changes in glucose and lipid parameters, though aripiprazole shows minimal effects on diabetes and dyslipidemia measures 4

Be extremely cautious when combining with other CNS-active medications, particularly benzodiazepines, as this increases risk of oversedation and respiratory depression 1
Avoid combining with high-dose olanzapine and benzodiazepines, as fatalities have been reported with this combination 1
Exercise caution when combining with adrenergic blockers 1

Do not start with standard adult doses (10-15 mg) in elderly patients, as this significantly increases risk of adverse effects including falls, sedation, and confusion 1
Do not increase the dose before allowing adequate time (at least 2 weeks) to reach steady state 5
Be aware that aripiprazole is considered a potentially inappropriate medication in some elderly populations according to Beers Criteria principles, particularly when anticholinergic effects are a concern 1

Aripiprazole has a mean elimination half-life of approximately 75 hours, with its active metabolite dehydro-aripiprazole having a half-life of 94 hours 4, 5
Steady-state concentrations are attained within 14 days of dosing, with drug accumulation occurring over this period 4, 5
More than 99% of aripiprazole and its active metabolite are bound to plasma protein 4