Atypical antipsychotics for older adults: are they safe and effective as we once thought?

Psychotic disorders are serious mental illnesses at any age, including late life. Whereas schizophrenia and psychotic mood disorders are important causes of psychosis in younger adults, a much more common form of psychosis in older adults is that associated with dementia. Psychotic symptoms in older adults result in considerable distress for patients and their families, and lead to adverse outcomes such as decreased quality of life [1,2], impaired functioning [3], increased caregiver distress [4], greater risk for placement in long-term care facilities [5,6], and higher healthcare costs [7]. At present, atypical antipsychotic medications are commonly used, frequently off-label, to treat psychosis in older adults. With the aging of the general population, numbers of older adults with psychiatric disorders including psychosis are growing rapidly [8]. Learning about the long-term safety and effectiveness of atypical antipsychotics to treat US FDA-approved or off-label psychotic disorders in older adults has, therefore, become an important public health imperative. We recently conducted a pragmatic clinical trial of four commonly prescribed atypical antipsychotics in middle-aged and older adults with different types of psychotic disorders [9]. The results were sobering. Below, we review the background history of antipsychotics, then provide a discussion of our study and conclude with clinical recommendations for treating these patients.