Psychosis & related disorders

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 neuroleptic with moderate-marked antimuscarinic/ anticholinergic effects (chlorpromazine, clozapine, flupenthixol, fluphenzine, pipothiazine, promazine, zuclopenthixol) and patient has a history of prostatism or previous urinary retention (high risk of urinary retention)
• phenothiazines should not be used 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).