“If they’re not using [SGAs], they might be using something more dangerous,” Dr. Kamholz says. “For example, haloperidol is an old standby, but very few studies address its global effects. So we’re groping around in the dark. I’ve also seen some bad deliriums caused by benzodiazepines.”
When to prescribe SGAs
At what point does the need to manage psychosis, aggression, or agitation in Alzheimer’s disease outweigh SGAs’ risks?
“Frankly, I’d rather not use medications unless I have to—and then only enough to preserve function while treating the behavioral disturbance,” Dr. Verma says. “I don’t want to anesthetize these patients. I just want to maintain their function, dignity, and quality of life.”
Seeking other causes of acute behaviors is essential before prescribing an SGA, Drs. Verma and Schneider say. Psychotic disorientation, for example, can occur with underlying psychiatric problems (such as delirium), hearing and sight deficits, disrupted schedules, poor sleep and appetite, incontinence, pain, unrelated medical complications, or environmental stressors.
For many older patients with problem behaviors, SGAs are worth the risk after other interventions have failed, Dr. Kamholz says. Weighing behavioral against pharmacologic risks is key, Dr. Schneider adds.
“What are the consequences of the behavior or paranoid ideation?” Dr. Schneider asks. “What about when the patient is refusing food? Or when caregivers cannot approach the patient, or the behavior creates a rift between family members so that the patient’s basic needs cannot be met? If psychosocial and environmental interventions haven’t worked, [SGAs] are worth a try.”
Because acute behavior hastens caregiver burnout—a major cause of nursing home admission6—appropriate SGA use also can help older patients remain at home, Drs. Schneider, Kamholz, and Verma say.
Practical applications
Drs. Schneider, Verma, and Kamholz agree that SGAs are a short-term intervention for problem behaviors in dementia. Because Alzheimer’s symptoms wax and wane as the disease progresses, patients need to be monitored continually, and medication regimens should be modified as needed and discontinued if possible.
Dr. Verma advises starting risperidone, olanza-pine, or quetiapine at low dosages, titrating slowly, and monitoring the patient carefully (Table).
Dr. Schneider suggests discontinuing the SGA after 12 to 20 weeks in patients who have responded. If behavior worsens after an SGA is discontinued, restart the medication, he says.
“If patients have adverse events with SGAs, do not try to tough it out,” Dr. Schneider adds. “Either adjust medications to eliminate adverse events or change the medication. If patients have been tolerating the medication for, say, 12 weeks, that doesn’t mean adverse reactions cannot develop later, so be ready to make adjustments.”
To guard against medicolegal risk when prescribing SGAs to older patients, Dr. Verma suggests that you clearly document:
- the reason you are prescribing the SGA
- your understanding of the risk/benefit ratio in using SGAs and that, in your clinical judgment, using an SGA in this patient is warranted because the benefits outweigh the risks
- that you considered other medications and the reasons those medications are inappropriate (for example, “I opted against a benzodiazepine because it could be too sedating and could increase the risk of falls and consequent injury”).
Also, get updates from the patient’s primary care physician on the patient’s cardiopulmonary and cerebrovascular health. Finally, provide extensive information about SGAs’ risks to family members, and keep signed documentation that you provided these warnings.
Table
Recommended second-generation antipsychotic dosing for older patients
| Drug | Starting dosage | Titration | Most-common side effects |
|---|---|---|---|
| Olanzapine | 2.5 to 5 mg/d, depending on the patient’s body mass and frailty | 2.5 mg every 2 to 3 days to 15 to 20 mg/d or therapeutic effect | Weight gain, orthostasis, sedation |
| Quetiapine* | 25 mg/d | 25 mg every 2 to 3 days to 350 mg/d or therapeutic effect | Sedation, weight gain |
| Risperidone | 0.25 mg bid | 0.25 mg every 2 to 3 days to 2 to 3 mg bid or therapeutic effect | Extrapyramidal symptoms, orthostasis |
| * Recommended for patients with Lewy body dementia or parkinsonian movement problems. | |||
| Source: Sumer Verma, MD | |||
Related resources
- American Association for Geriatric Psychiatry. AAGP position statement: Principles of care for patients with dementia resulting from Alzheimer disease.www.aagponline.org/prof/position_caredmnalz.asp.
Drug brand names
- Haloperidol • Haldol
- Olanzapine • Zyprexa
- Quetiapine • Seroquel
- Risperidone • Risperdal
Acknowledgment
Peter A. Kelly is senior editor, Current Psychiatry.
Lynn Waltz, a medical writer and editor in Norfolk, VA, helped prepare this article from transcripts of interviews with Drs. Kamholz, Schneider, and Verma.