Use of antipsychotics in the elderly

The elderly are particularly susceptible to the side effects of conventional neuroleptics. For example, extrapyramidal symptoms (EPS) are more common than in younger patients, added to which anticholinergic drugs are poorly tolerated and may even be contraindicated in some elderly patients. In addition to constipation, urinary retention, blurred vision, xerostomia and aggravation of glaucoma, anticholinergic drugs can cause confusion, delirium and impaired cognitive function. The newer antipsychotics, such as clozapine, risperidone, olanzapine and quetiapine, cause fewer EPS than the conventional neuroleptics and less anticholinergic medication is therefore needed. Tardive dyskinesia (TD) can develop after long-term use of conventional neuroleptics, and the risk is markedly higher in the elderly. The TD risk in the elderly with risperidone may be considerably less than with haloperidol, and the lower EPS liability of the other new antipsychotics suggests that they may also cause less TD. Many conventional neuroleptics and some of the new antipsychotics are sedative, and this can create problems in the elderly; risperidone in low doses causes relatively little over-sedation. Dosages of the newer antipsychotics should be lower than in younger patients, and titrations should be relatively slow. With risperidone, for example, the starting dose may be 0.25-0.5 mg/day, increasing by no more than 0.25-0.5 mg/day once or twice per week.