Bipolar Affective Disorder

Antipsychotics are inappropriate to use in patients aged 65 years or over:

  • other than quetiapine or clozapine) in those with parkinsonism or Lewy Body Disease (risk of severe extra-pyramidal symptoms)
  • in patients with behavioural and psychological symptoms of dementia (BPSD) unless symptoms are severe and other non-pharmacological treatments have failed (increased risk of stroke)
  • as hypnotics, unless sleep disorder is due to psychosis or dementia (risk of confusion, hypotension, extra-pyramidal side effects, falls)
  • if it is a neuroleptic with moderate-marked antimuscarinic/ anticholinergic effects (chlorpromazine, clozapine, flupenthixol, fluphenzine, pipothiazine, promazine, zuclopenthixol) and the patient has a history of prostatism or previous urinary retention (high risk of urinary retention)
  • phenothiazines as first-line treatment, since safer and more efficacious alternatives exist (phenothiazines are sedative, have significant anti-muscarinic toxicity in older people, with the exception of prochlorperazine for nausea/vomiting/vertigo, chlorpromazine for relief of persistent hiccoughs and levomepromazine as an anti-emetic in palliative care)
  • if patient has a history of falls (may cause gait dyspraxia, Parkinsonism).

For people with learning difficulties initiate treatment with low doses and titrate cautiously with frequent monitoring for side effects

 Additional resources

British Association for Psychopharmacology Evidence-based guidelines for treating bipolar disorder

NICE CG185 Bipolar disorder: the assessment and management of bipolar disorder in adults, children and young people in primary and secondary care

NICE Summary of guidance on bipolar disorder

Formulary medications