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A 75-year-old white female with schizoaffective disorder was admitted to an inpatient psychiatry unit for uncooperativeness in refusing to take scheduled medications. She complained of anticholinergic adverse effects and had abnormal involuntary movements in the oral/buccal region. The patient had been prescribed six psychotropic medications (i.e., thiothixene, lithium, divalproex sodium, amitriptyline, benztropine, and trazodone effects. The treatment team determined that the patient was noncompliant and experienced the effects of polypharmacy. She had been prescribed two mood stabilizers and suffered from anticholinergic adverse effects and the movement disorder tardive dyskinesia (TD). Four medications were discontinued: thiothixene, amitriptyline, lithium, and benztropine. Quetiapine, a second-generation antipsychotic, was recommended, with a daily titration schedule to reach a target dose of 600 mg per day in divided doses. This agent has less propensity to cause movement disorders compared with first-generation antipsychotics. All medications with additive anticholinergic properties also were discontinued. Lithium was stopped secondary to subtherapeutic levels and potential drug interactions. The pharmacist educated the inpatient team on the additive anticholinergic effects of each medication, reduced the total number of medications prescribed, and assisted in appropriate conversion to quetiapine to reduce TD symptoms.

Objective: To evaluate the literature on the pharmacotherapy of psychosis in the elderly., Data Sources: Searches of MEDLINE (1996-April 2002) and the Cochrane Database using the terms psychosis, elderly, geriatric, dementia, Alzheimer's disease, Parkinson's disease, antipsychotics, atypical antipsychotics, clozapine, risperidone, olanzapine, quetiapine, ziprasidone, and haloperidol were performed. An updated search of psychosis, risperidone, olanzapine, quetiapine, ziprasidone, and aripiprazole occurred in April 2003., Study Selection: Reviews, case reports, and open-labeled and controlled trials were selected., Data Synthesis: Psychotic symptoms in the elderly can occur in the context of psychiatric disorders, medical conditions, or as a medication complication. Behavioral problems (e.g., agitation, aggression) can accompany psychosis and may not respond to nonpharmacological strategies. Pharmacological management of psychosis in the elderly with typical antipsychotics (e.g., haloperidol, chlorpromazine) can result in intolerable adverse effects (e.g., sedation, anticholinergic effects, extrapyramidal symptoms, tardive dyskinesia, and orthostatic hypotension). The atypical antipsychotic agents (e.g., risperidone, olanzapine, quetiapine, ziprasidone) and the dopamine-serotonin system stabilizer aripiprazole offer more tolerable adverse effects profiles. Most information supporting the use of the atypical antipsychotics is derived from open-label trials involving patients with dementia or Parkinson's disease; however, data from large randomized, controlled trials is emerging. In general, psychosis in elderly patients responds to low doses of antipsychotics. Patients must be monitored closely for adverse effects, especially in light of the new information associating cerebrovascular adverse events with risperidone in patients with dementia. Further trials are required to determine if this is a disease- or drug-specific phenomenon., Conclusion: Psychosis in elderly patients can be managed with antipsychotic agents. The atypical antipsychotics are effective and offer advantages over typical antipsychotics with regard to a reduced rate of adverse effects.