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Medication category |
Daily dose |
Adverse-effect monitoring |
Comments |
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Second-generation and third-generation antipsychotics (SGAs and TGAs) |
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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, aripiprazole, or brexpiprazole |
– Best supported SGA for NPSs – Most likely SGA/TGA to cause EPS |
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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/TGA to cause metabolic adverse effects – Availability in rapidly dissolving preparation advantageous in noncompliance |
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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 |
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Aripiprazole |
Initial: 2-5 mg daily Titration: 2-5 mg every 3-7 days Max: 10 mg |
Most likely SGA/TGA to cause akathisia (restlessness) |
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Brexpiprazole
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Initial: 0.5 mg daily Titration: 0.5 mg every 7 days Max: 3 mg |
Most recent antipsychotic approved to treat agitation associated with dementia due to Alzheimer disease |
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Pimavanserin |
Initial: 10 mg Max: 34 mg
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Nausea, constipation, peripheral edema, gait disturbances |
– Selective inverse agonist-antagonist of the 5-HT2A receptor – Approved in the US for Parkinson disease psychosis; however, subgroup analysis of the HARMONY trial showed a significantly reduced risk of psychosis relapse in patients with Parkinson disease dementia |
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First-generation antipsychotics (FGAs) |
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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 |
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SSRI antidepressants |
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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 |
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Escitalopram |
Initial: 5 mg daily Titration: 5 mg every 7 days Max: 10 mg |
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Sertraline |
Initial: 25 mg daily Titration: 25 mg every 7 days Max: 100 mg |
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Anticonvulsants |
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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 |
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Agents for sleep |
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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 |
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Zopiclone |
Initial: 3.75 mg at bedtime Titration: 3.75 mg every 3-7 days Max: 15 mg |
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Trazodone |
Initial: 25 mg at bedtime Titration: 25 mg every 3-7 days Max: 100 mg |
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Cholinesterase inhibitors |
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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 |
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Rivastigmine |
Initial: 1.5 mg bid Titration: 1.5 mg every 4 weeks Max: 12 mg |
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Initial: 4.6 mg patch Titration: 9.5 mg every 4 weeks Max: 13.3 mg |
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Galantamine |
Initial: 8 mg daily Titration: 8 mg every 4 weeks Max: 24 mg |
Extended-release formulation |
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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; TGA, third-generation antipsychotic; US, United States. |
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