Medication category |
Daily dose |
Adverse-effect monitoring |
Comments |
Second-generation antipsychotics (SGAs) | |||
Risperidone (LAI, ODT, liquid) |
Initial: 0.25 mg once daily to bid Titration: 0.25-0.5 mg every 3-7 days Max: 2 mg |
– Sedation – Postural hypotension – Falls – Anticholinergic adverse effects (dry mouth, constipation, confusion) – EPS, particularly parkinsonian signs and symptoms (rigidity, bradykinesia, shuffling gait, masked facies, tremor) – Olanzapine and quetiapine more sedating than risperidone or aripiprazole |
– Best supported SGA for NPSs – Most likely SGA to cause EPS |
Olanzapine (IM, ODT) |
Initial: 2.5-5 mg at bedtime Titration: 2.5-5 mg every 3-7 days Max: 10 mg |
– Most likely SGA to cause metabolic adverse effects – Availability in rapidly dissolving preparation advantageous in noncompliance | |
Quetiapine |
Initial: 12.5 mg bid Titration: 12.5-25 mg every 3-7 days Max: 150 mg |
– Used for Parkinson disease dementia and dementia with Lewy bodies at lower doses due to high sensitivity to EPS – In those with psychosis and Parkinson disease dementia, if possible, first reduce dopaminergic agents | |
Aripiprazole |
Initial: 2-5 mg daily Titration: 2-5 mg every 3-7 days Max: 10 mg |
– Most likely SGA to cause akathisia (restlessness) | |
First-generation antipsychotics (FGAs) | |||
Haloperidol (IM, IV, LAI, liquid) |
Initial: 0.25 mg bid Titration: 0.5 mg bid every 3-7 days Max: 1.5 mg bid |
Haloperidol more likely to cause EPS than SGAs |
– Gold standard for delirium – Can be given IM in ED when other formulations unavailable or IV in ICU; monitor ECG for QTc prolongation, especially when dosage ≥3 mg/d |
SSRI antidepressants | |||
Citalopram |
Initial: 5-10 mg daily Titration: 10 mg every 7 days Max: 20 mg |
– Headache – Nausea (give with food to ↓GI upset) – Diarrhea – Sweating – Insomnia – Hyponatremia – Risk of GI bleed – QTc prolongation at higher doses of citalopram – Risk of falls, fractures, and osteoporosis |
– Citalopram is the best supported SSRI for NPS; monitor ECG for QTc prolongation, especially when dosage ≥20 mg/d – In FTD patients, SSRIs are first-line agents, particularly for repetitive behaviors |
Escitalopram |
Initial: 5 mg daily Titration: 5 mg every 7 days Max: 10 mg | ||
Sertraline |
Initial: 25 mg daily Titration: 25 mg every 7 days Max: 100 mg | ||
Anticonvulsants | |||
Carbamazepine |
Initial: 50 mg daily Titration: 50 mg every 7-14 days, bid to tid Max: 500 mg |
– Sedation – Ataxia/falls – Neutropenia – Hyponatremia – ↑ Liver function tests – Skin rash |
– Risk of drug-drug interactions – Monitor drug level |
Agents for sleep | |||
Lorazepam (IM, IV, liquid) |
Initial: 0.25-0.5 mg at bedtime Titration: 0.25-0.5 mg every 3-7 days Max: 2 mg |
BZPs: – Sedation – Confusion/cognitive impairment – Ataxia/falls – Disinhibition Trazodone: – Postural hypotension – Dry mouth – Constipation |
– BZPs for short-term use only – BZPs carry risk of tolerance/dependence, falls, worsening cognition, and withdrawal upon discontinuation; their use should be limited to situations that may require rapid onset of action while under close observation – Trazodone can be used in FTD, in 25 mg bid to tid starting dose to 100-300 mg daily |
Zopiclone |
Initial: 3.75 mg at bedtime Titration: 3.75 mg every 3-7 days Max: 15 mg | ||
Trazodone |
Initial: 25 mg at bedtime Titration: 25 mg every 3-7 days Max: 100 mg | ||
Cholinesterase inhibitors | |||
Donepezil |
Initial: 2.5-5 mg daily Titration: 2.5-5 mg every 4-6 weeks Max: 10 mg (23 mg slow release) |
– GI upset (nausea/vomiting/diarrhea) – Loss of appetite – ↓ GI adverse effects with patch – Insomnia, hypervivid dreams – Bradycardia – Urinary incontinence – Muscle cramps |
– ChEIs are first-line agents for psychosis in Parkinson disease dementia and dementia with Lewy bodies – ChEIs can be beneficial in apathy – Take with food to minimize GI upset – Rotate patch site – In FTD, ChEIs are contraindicated |
Rivastigmine |
Initial: 1.5 mg bid Titration: 1.5 mg every 4 weeks Max: 12 mg | ||
Initial: 4.6 mg patch Titration: 9.5 mg every 4 weeks Max: 13.3 mg | |||
Galantamine |
Initial: 8 mg daily Titration: 8 mg every 4 weeks Max: 24 mg |
Extended-release formulation | |
bid, 2 times a day; BZP, benzodiazepine; ChEI, cholinesterase inhibitor; ECG, electrocardiogram; ED, emergency department; EPS, extrapyramidal symptoms; FGA, first-generation antipsychotic; FTD, frontotemporal dementia; GI, gastrointestinal; ICU, intensive care unit; IM, available as intramuscular formulation; IV, available as intravenous formulation; LAI, available as long-acting injectable formulation; NPS, neuropsychiatric symptom; ODT, available as orally dissolving/disintegrating tablet; SGA, second-generation antipsychotic; SSRI, selective serotonin reuptake inhibitor; tid, 3 times a day. |