Avoid. Antipsychotics should be avoided in elderly patients with delirium, dementia, dementia-related psychosis, and dementia-related behavioral problems as there is an increased risk of cognitive impairment, tardive dyskinesia, neuroleptic malignant syndrome, stroke, and death. May also increase the risk of hyponatremia or SIADH. Antipsychotics (with the exception of quetiapine, clozapine, and pimavanserin) should be avoided in Parkinson’s disease due to the potential worsening of motor symptoms. Antipsychotics should be avoided in patients with a history of syncope, falls or fractures, due to the potential for impaired motor function, orthostatic hypotension, and bradycardia. They should only be used for indications of schizophrenia and bipolar disorder without dementia. Antipsychotics with strong anticholinergic properties should be avoided in patients with obstructive disease of the genitourinary tract. Antipsychotic use during chemotherapy to prevent vomiting, if used on a short-term basis, may be appropriate.
Taper Approach. As with antidepressants, some antipsychotics are worse than others. Clozapine, olanzapine, quetiapine, and trifluoperazine are the worst, others like perphenazine, flupenthixol, and sulpiride appear better. Based on the effect of missing doses while on treatment, people will often know before starting to withdraw whether there is likely to be a problem. If no hints of a problem and if used daily for a month or so reduce dose by a maximum of 25% every week initially or every month if need be. If hints of a problem or if used for longer than a month consider tapering more gradually and ideally with the help of a liquid. For some drugs such as quetiapine and olanzapine, a combination of a benzodiazepine and an anticholinergic may help. Acute withdrawal responds to the original treatment where protracted withdrawal is less likely to – although tardive dyskinesia can be managed to some extent with the original agent.
Initial Withdrawal Symptoms. Agitation, activation, insomnia, rebound psychosis, withdrawal-emergent abnormal movements, nausea, feeling of discomfort, sweating, vomiting, insomnia, sexual dysfunction.
Protracted Withdrawal Symptoms: Tardive dyskinesia, tardive akathisia, tardive dysthymia, stress intolerance, temperature dysregulation, sensory disturbances, food intolerance, and enduring sexual dysfunction.
Bruyere Research Institute at deprescribing.org
- Antipsychotic deprescribing algorithm
- Whiteboard video on using the Antipsychotic Deprescribing Algorithm
- Antipsychotic deprescribing guideline information pamphlet
- Patient handout on Antipsychotics
- Antipsychotic deprescribing guideline (published in Canadian Family Physician)
- FDA monograph (Seroquel)
- Kuehn BM. (2005). FDA warns antipsychotic drugs may be risky for the elderly. JAMA. 293(20): 2462.
- FDA monograph (Abilify)
- FDA monograph (Loxitane)
- Divac N, Stojanovic R, Savic Vujovic K, et al. (2016). The efficacy and safety of antipsychotic medications in the treatment of psychosis in patients with Parkinson’s disease. Behavioral Neurology. Volume 2016, Article ID 4938154, 6 pages.
- Oderda LH, Young JR, Asche CV, Pepper GA. (2012). Psychotropic-related hip fractures: meta-analysis of first-generation and second-generation antidepressant and antipsychotic drugs. Ann Pharmacother. 46(7-8): 917-28.
- Thompson W, Quay TA, Rojas-Fernandez C, Farrell B, Bjerre LM. Atypical antipsychotics for insomnia: a systematic review. Sleep Med, 2016;22:13–7.