What experience is there with Risperdal (risperidone) use in the elderly, particularly in elderly p

Fråga: What experience is there with Risperdal (risperidone) use in the elderly, particularly in elderly patients with dementia?

Sammanfattning: In Sweden, risperidone is not approved for use in patients with dementia. However, there are some data which show that risperidone has been used in the elderly population with dementia with good effect and reasonable safety. More studies are needed to accurately determine safety and efficacy parameters.

Svar: Risperidone has been used in elderly patients with dementia, although it is not registered for this use in Sweden and controlled clinical trials are limited. The dose should be reduced in the elderly (0.5 mg BID initially, to be slowly increased by 0.5 mg BID increments; increases above 1.5 mg BID should not occur more frequently than at weekly intervals). This decreased dose is used because of reduced renal clearance in the elderly of both risperidone and its active metabolite 9-hydroxyrisperidone (1,2).

Risperidone has been used in the elderly as an alternative to both conventional neuroleptics and clozapine in the management of agitation, aggression, and psychosis. The phenothiazines are somewhat undesirable because of excess sedation, anticholinergic, and cardiotoxic side effects. Butyrophenones, on the other hand, carry the risk of extrapyramidal side effects and akathisia. Finally, clozapine has the potential to cause serious blood dyscrasias, and requires frequent hematologic monitoring (3).

There have been few large-scale clinical trials examining the safety and efficacy of risperidone in the elderly population. One study examined its use in 122 hospitalized patients (mean age 76.5 years) who carried the DSM-IV diagnoses of dementia, major depression with psychotic features, bipolar disorder with psychotic features, or schizophrenia. Risperidone was judged to be effective in 85 per cent of the patients, but was discontinued in 11.4 per cent due to side effects (symptomatic orthostasis, extrapyramidal side effects, sedation, arrhythmias, and nausea) (4).

Another study examined nursing-home residents with dementia, and found that risperidone was judged by the nursing staff to have varying degrees of efficacy in controlling target behaviors (eg agitation, verbal outbursts) in at least 89 of 100 patients. Only 11 of the 100 patients had to discontinue treatment due to adverse effects (eg oversedation, postural hypotension, among others) (5).

A third study examined risperidone use in elderly patients with chronic psychosis. Twenty-six patients over the age of 65 who were receiving risperidone were identified from their medical records. These patients carried the diagnoses of schizophrenia, schizoaffective disorder, bipolar disorder, or "other psychotic disorders". Twenty-two of the 26 patients experienced clinical improvement as noted in charts or patient reports. Only 2 patients discontinued therapy because of adverse effects (elevated liver enzymes in one patient, and diaphoresis, tachycardia, and hypotension in the other patient) (6).

Finally, other studies and case reports exist which suggest that risperidone should be examined for use in the elderly population (7,8,9,10). 1 Physicians Desk Reference (PDR) 1997 2 Madhusoodanan S, Brenner R, Araujo L, Abaza A: Efficacy of risperidone for psychoses associated with schizophrenia, schizoaffective disorder, bipolar disorder, or senile dementia in 11 geriatric patients: a case series. J Clin Psychiatry 1995; 56: 514-518 3 Finkel SI: Managing the behavioral and psychological signs and symptoms of dementia. Int Clin Psychopharmacol 1997; 12(suppl 4): S25-S28 4 Zarate CA Jr, Baldessarini RJ, Siegel AJ, Nakamura A, McDonald J, Muir-Hutchinson LA, Cherkerzian T, Tohen M: Risperidone in the elderly: a pharmacoepidemiologic study. J Clin Psychiatry 1997; 58: 311-317 5 Goldberg RJ, Goldberg J: Risperidone for dementia-related disturbed behavior in nursing home residents: a clinical experience. Int Psychogeriatr 1997; 9: 65-68 6 Sajatovic M, Ramirez LF, Vernon L, Brescan D, Simon M, Jurjus G: Outcome of risperidone therapy in elderly patients with chronic psychosis. Int J Psychiatry Med 1996; 26: 309-317 7 Thorpe L: The treatment of psychotic disorders in late life. Can J Psychiatry 1997; 42(suppl 1): 19S-27S 8 Kopala LC, Honer WG: The use of risperidone in severely demented patients with persistent vocalizations. Int J Geriatr Psychiatry 1997; 12: 73-77 9 Koponen HJ: Risperidone in the treatment of psychosis and concomitant buccolinguomasticatory dyskinesia in the elderly. Int J Geriatr Psychiatry 1997; 12: 412-413 10 Raheja RK, Bharwani I, Penetrante AE: Efficacy of risperidone for behavioral disorders in the elderly: a clinical observation. J Geriatr Psychiatry Neurol 1995; 8: 159-161