Table 1

Antipsychotic medications for BPSD in the elderly

DRUG, NAME, AND DOSAGE FORMS	USUAL (INITIAL) DOSE RANGE IN THE ELDERLY	COST, $	COMMENTS
Atypical			Approach to use: Start with a low dose; titrate carefully. Assess for benefit and tolerability in 3–7 d; titrate as necessary. Reassess for possible taper or discontinuation every 3 mo.⁸ Efficacy: Antipsychotic drugs are somewhat effective for agitation, aggression, and psychosis (hallucinations and delusions). There is the most evidence with risperidone. SAEs: SAEs limit the clinical value of antipsychotic drugs. They include EPS, stroke, seizures, sedation, increased fall risk, cognitive decline, diabetes, and possibly increased mortality. Increased QT interval is also possible, especially with quetiapine and IV haloperidol; consider ECG. Mortality risk: Risk appears to increase for both atypical and typical agents. Stopping long-term antipsychotic medications, when possible, reduces mortality risk.¹⁷ Sedation: Sedation is more likely with olanzapine or quetiapine; it is less likely with haloperidol or risperidone. Parkinsonism and EPS: These are most likely with haloperidol, olanzapine, or risperidone. Hypotension: Hypotension can be minimized with cautious dosing. Weight gain and diabetes: These are most likely with olanzapine. Swallowing difficulty: Several antipsychotic drugs are available in solution or dissolvable tablet forms that might be easier to swallow.
Risperidone^* Risperdal, generic -tablet, ODT, solution -IM depot injectable^†	0.5–2 mg orally at bedtime (0.25 mg orally at bedtime)	23–47
Quetiapine Seroquel, generic -tablet, XR tablet	25–200 mg orally at bedtime (12.5 mg orally at bedtime)	19–43
Olanzapine Zyprexa, generic -tablet, ODT -IM injectable	2.5–7.5 mg orally at bedtime (1.25 mg orally at bedtime)	37–96
Typical
Haloperidol Haldol, generic -tablet, solution -IM depot injectable^† -subcutaneous injectable	0.25–1 mg orally twice daily (0.25 mg at bedtime) 0.25–0.5 mg subcutaneously or IM once for acute delirium	10–12

BPSD—behavioural and psychological symptoms of dementia, ECG—electrocardiogram, EPS—extrapyramidal symptoms, IM—intramuscular, IV—intravenous, ODT—oral disintegrating tablet, SAE—serious adverse event, XR—extended release.
↵* This is the only drug with an official indication for BPSD.
↵† Depot formulations are included for completeness; however, they have little or no role in BPSD.
Data from Jensen.^15,16