Prescribing antipsychotics in older adults is never straightforward. Aging changes the way drugs are absorbed, metabolised, and tolerated — making this population more sensitive to both therapeutic effects and adverse reactions.
While antipsychotics may be necessary in conditions like psychosis, bipolar disorder, delirium, agitation in dementia, or severe behavioural disturbances, they must be used cautiously, with clear indication and close monitoring.

👴 Why Are Elderly More Vulnerable to Antipsychotic Side Effects?

Physiological changes with age affect pharmacokinetics and pharmacodynamics:

📌 Indications for Antipsychotic Use in Elderly

✅ Schizophrenia or late-onset psychosis
✅ Bipolar disorder (acute mania)
✅ Psychosis in Parkinson’s disease or dementia (with caution)
✅ Severe agitation or aggression in dementia only after non-drug methods fail
✅ Delirium with severe agitation (short-term only)

❌ Not indicated for insomnia, mild irritability, or caregiver convenience.

⚠️ Major Risks & Side Effects in Elderly

🛑 FDA & EMA Warning: Antipsychotics increase mortality in elderly dementia patients — mainly due to cardiovascular and infectious causes.

🧪 Typical vs Atypical Antipsychotics in Elderly

✅ Best Practices for Prescribing Antipsychotics in Elderly

✔ Start Low, Go Slow:
Start at 1/3 – 1/2 of adult dose, titrate cautiously.

✔ Choose the Right Drug:

• Dementia psychosis: Risperidone (≤1 mg), Quetiapine, Pimavanserin

• Parkinson’s psychosis: Quetiapine or Clozapine (low dose)

• Agitation in delirium: Haloperidol low IV/IM in acute setting

✔ Regular Monitoring:

• Blood pressure (orthostatic)

• ECG (QTc interval)

• Blood sugar, lipids, weight

• EPS / Tardive Dyskinesia (AIMS score)

• Liver and kidney function tests

✔ Use Time-Limited Trials:
Re-evaluate every 4–12 weeks; taper if no improvement.

✔ Non-pharmacological Approaches First:
Orientation therapy, sleep hygiene, caregiver education, behavioural modifications should always be first-line in dementia.

📉 Deprescribing Antipsychotics — When and How?

1. If symptoms have been stable for 3–6 months

2. Gradually taper by 25% every 2–4 weeks

3. Watch for return of agitation or psychosis

4. Support with psychosocial & environmental strategies

🌟 Key Takeaways

• Antipsychotics can be life-saving in elderly, but high-risk if used casually

• Always weigh risk vs benefit, especially in dementia

• Combine medication with structured routines, caregiver training, sleep regulation, environmental changes

• Start low, go slow, review often, stop if unnecessary

👨‍⚕️ Author & Clinical Services

Dr. Srinivas Rajkumar T
MD (AIIMS, New Delhi), DNB Psychiatry
Consultant Psychiatrist | Geriatric Mental Health Specialist
Mind & Memory Clinic – Apollo Clinic (Opp. Phoenix MarketCity), Velachery, Chennai
📞 +91-8595155808 | 🌐 www.srinivasaiims.com