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Antipsychotic Stewardship Toolkit

Doctor hand showing one capsule

Developed by experts in geriatric medicine, geriatric psychiatry, geriatric nursing and pharmacy, these are recommended doses of antipsychotics for older patients with delirium* and severe behavioural symptoms that are not manageable with non-pharmacological interventions alone. When antipsychotics are used, they should always be accompanied by supportive non-pharmacological interventions.

*Not including delirium secondary to alcohol withdrawal or benzodiazepine withdrawal

Reminders

  • Reassess the patient’s response and the antipsychotic dose every 24 hours
  • Frail patients, those over 70 years and/or those under 60 kg, should receive doses at the lower end of the ranges indicated for older patients

Recommended doses of antipsychotics for older patients… as a last resort!

Haloperidol »

Initial dose:
0.25-1 mg po/sc BID to q6H (regularly or PRN)

Max daily dose:
1.5-3.0 mg po/sc per 24 hours

Notes:

  • Haloperidol 1 mg po = 0.5 mg sc (conversions are approximate)
  • Haloperidol can be used off-label via subcutaneous route as per MAC approved policy
  • Avoid use >1 week


Risperidone »

Starting dose:
0.25-0.5 mg po q12H (regularly or PRN)

Max daily dose:
1.5-2mg po per 24 hours

Notes:

  • Regular and disintegrating tablets available
  • Extrapyramidal adverse effects are dose-related


Quetiapine »

Starting dose:
12.5-25 mg po q12H (regularly or PRN)

Max daily dose:
150-200mg po per 24 hours

Notes:

  • Available as immediate release tablets (25 mg, 100 mg, 200 mg) and once-daily extended release tablets (50 mg, 150 mg, 200 mg)
  • When an antipsychotic is felt to be necessary, this is the best option for patients with Diffuse Lewy Body Dementia or Parkinson’s Disease due to a lower risk of extrapyramidal side effects


Disclaimer

These guidelines are intended for educational and informational purposes only. This information is intended to guide practice and inform care of older patients in the hospital setting. The information is not intended to serve as a comprehensive resource on prescribing of antipsychotics. The information is not meant to be a substitute for professional judgement or advice.


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