2024 Summer GAPNA Newsletter Volume 43 Number 2

Antipsychotic Drug Choice for Behavioral and Psychological Symptoms of Dementia
By Amy M. Lewitz

Here are some key points presented at the March 23, 2024, GAPNA Pharmacology & Prescribing In Older Adults meeting:

  1. 87% of expert clinicians with 20+ years of experience treating older adults endorse the indefinite use of antipsychotic medication for the 10% of patients with dangerous psychosis and agitation.
  2. For patients with less severe illness, median treatment time is between 4-6 months. Gradual dosage reduction can then be attempted but should be done slowly to limit dopamine rebound. If symptoms resurge, the previous dose may need to be resumed. Ongoing inadequately treated psychosis can speed up cognitive decline. Inadequate medication dosage can lead to pain, suffering, and agitation, accompanied by an increased potential for harm to self and/or others.
  3. Antipsychotic drug doses are based on a 100 mg Thorazine dose equivalency: Safe choices of second-generation antipsychotic medications for older adults include:
    • Seroquel started at 37.5mg up to 75mg daily.
    • Risperdal started at 0.5mg up to 1mg daily.
    • Abilify started at 2mg up to 4mg daily.
    • Zyprexa started at 2.5mg up to 5mg daily.

 

The aforementioned medications are used off-label for dementia-related psychosis.

Rexulti now has FDA approval for the treatment of behavioral and psychological symptoms in Alzheimer’s disease specifically; time will provide clinicians with outcome data about this agent’s therapeutic efficacy as compared to similar antipsychotics.

In closing, somatic, behavioral, and environmental interventions can be concurrently employed when caring for patients with behavioral and psychological symptoms of dementia.

Amy M. Lewitz, MS, PMHCNS, BC
GeroPsych SIG Member

References

American Psychiatric Association. (2016). Practice guideline on the use of antipsychotics to treat agitation or psychosis in patients with dementia. Washington, DC: Author.

Devanand, D.P., Mintzer, J., Schultz, S.K., Andrews, H.F., Sultzer, D.L., de la Pena, D., Gupta, S., Colon, S., Schimming, C., Pelton, G.H., & Levin, B. (2012). Relapse risk after discontinuation of risperidone in Alzheimer’s disease. The New England Journal of Medicine, 367(16), 1497-1507. https://doi.org/10.1056/nejmoa1114058

Thippaiah, S.R., Fargason, R., & Birur, B. (2021). Switching antipsychotics: Aguide to dose equivalents. Current Psychiatry, 30(4), 13-14. https://doi.org/10.12788/cp.0103