Understanding Antipsychotics Medications in Geriatric Care • PsychoGeriatric Services

Antipsychotic medications play a crucial role in managing severe psychiatric conditions, including schizophrenia, bipolar disorder, and certain behavioral symptoms of dementia. However, their use in older adults, particularly in long-term care settings, requires careful consideration to balance benefits with potential risks.

What Are Antipsychotic Medications?

Antipsychotics are classified into two main categories:

First-generation (typical) antipsychotics (FGAs), such as haloperidol, primarily target dopamine receptors. They also depress the release of hormones by the hypothalamus and pituitary gland. FGAs can have extrapyramidal symptoms such as tremors and slurred speech. FGAs have a higher risk of neurological side effects, such as involuntary movements in the face and extremities.

Second-generation (atypical) antipsychotics (SGAs), such as risperidone and quetiapine, act on both dopamine and serotonin receptors, often with fewer motor side effects. SGAs are typically used to treat schizophrenia and neurological conditions. Side effects associated with SGAs are metabolic, like weight gain, high blood pressure, and high cholesterol. They can also increase the risk of stroke in elderly patients with dementia.

While these medications can help manage severe agitation, hallucinations, and delusions, they are not a first-line treatment for general behavioral disturbances, particularly in dementia patients.

The primary reasons for this include:

Limited Benefit for General Behavioral Symptoms – While FGAs and SGAs can help manage severe psychotic symptoms, they are not particularly effective for many common behavioral disturbances in dementia, such as wandering, repetitive questioning, or resistance to care. Non-pharmacological approaches, like structured routines and environmental modifications, are generally preferred as initial interventions.

Serious Safety Concerns – These medications carry significant risks, especially in elderly dementia patients. Both FGAs and SGAs are associated with an increased risk of cerebrovascular events (e.g., stroke) and mortality in this population. The U.S. FDA has issued a black box warning highlighting these dangers.

Adverse Effects – FGAs, such as haloperidol, have a high risk of extrapyramidal symptoms (EPS), including rigidity, tremors, and tardive dyskinesia, which can be particularly debilitating for elderly patients. SGAs, such as risperidone and olanzapine, have a lower risk of EPS but can still cause sedation, metabolic disturbances (weight gain, diabetes), and orthostatic hypotension, increasing fall risk.

Regulatory and Ethical Considerations – Due to the risks, guidelines from organizations like the American Geriatrics Society (AGS) and the American Psychiatric Association (APA) recommend avoiding routine use of antipsychotics in dementia-related behavioral disturbances unless symptoms are severe, distressing, and pose a risk to the patient or others.

When Are FGAs/SGAs Considered Appropriate?

Despite the concerns, these medications may be used in cases where a patient experiences severe aggression, hallucinations, or delusions that cause significant distress or pose a danger. Even then, they should be used at the lowest effective dose and for the shortest duration possible, with regular reassessment for discontinuation.

Overall, non-pharmacological interventions should always be prioritized, and the decision to use antipsychotics in dementia should be made with careful risk-benefit consideration. Due to these risks, the FDA has issued a black box warning against using antipsychotics for dementia-related behaviors unless other interventions have failed.

New CMS Guidance on Antipsychotic Use

The Centers for Medicare & Medicaid Services (CMS) has recently updated its guidelines to enhance oversight of antipsychotic prescriptions in long-term care settings. Key aspects of this guidance include:

Stricter documentation requirements: Facilities must provide clinical justification for prescribing antipsychotics.

Greater emphasis on non-pharmacological interventions: Behavioral therapies should be prioritized before medication.

Enhanced scrutiny of schizophrenia diagnoses: CMS is closely monitoring the use of antipsychotics for residents newly diagnosed with schizophrenia to ensure accuracy and prevent misclassification.

Best Practices for Antipsychotic Use in Geriatric Care

To align with best practices and regulatory guidance, healthcare providers should:

Use non-drug approaches first – Behavioral therapies, environmental modifications, and staff training should be prioritized.

Assess underlying causes – Behavioral symptoms may be driven by pain, infections, or unmet needs that should be addressed before considering medication.

Obtain informed consent – Residents and families should fully understand the risks and benefits of antipsychotic treatment.

Regularly review medication use – Antipsychotics should be reassessed frequently, with dose reductions attempted when clinically appropriate.

Ensuring Safe and Effective Care

While antipsychotic medications can be essential in managing severe psychiatric conditions in older adults, their use must be approached with caution. The potential risks, including serious side effects and adverse outcomes, require careful consideration of the patient’s overall health and a preference for non-pharmacological interventions. By prioritizing person-centered care and adhering to the latest CMS guidelines, we can ensure the safest and most effective treatment strategies for our aging population.

Ultimately, the goal should always be to treat each individual with the utmost care and respect, keeping their dignity and quality of life at the forefront of all decision-making. If there are concerns regarding antipsychotic use in a long-term care setting, seeking expert guidance from specialists like PsychoGeriatric Services can help navigate the complexities of medication management for this vulnerable population.

If you are concerned about residents in your long-term care facility and need assistance with medication management, contact PsychoGeriatric Services today!

What Are Antipsychotic Medications?

When Are FGAs/SGAs Considered Appropriate?

New CMS Guidance on Antipsychotic Use

Best Practices for Antipsychotic Use in Geriatric Care

Ensuring Safe and Effective Care

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