Prescribing for Older Adults and Pregnant Women

Prescribing for Older Adults and Pregnant Women

Prescribing for Older Adults and Pregnant Women

Schizophrenia in older adults is often referred to as late-onset or very-late-onset schizophrenia-like psychosis. This disorder involves persistent psychotic symptoms such as hallucinations, delusions, disorganized thinking, and social withdrawal. In older adults, the presentation may be less dramatic than in younger individuals and is often dominated by persecutory delusions and auditory hallucinations. Negative symptoms such as flat affect and avolition may overlap with symptoms of cognitive decline or depression, complicating diagnosis (American Psychiatric Association, 2022). Older adults with schizophrenia are also at higher risk of medical comorbidities, polypharmacy, and social isolation, all of which can worsen psychiatric outcomes.

Pharmacological Interventions for Schizophrenia-

For older adults with schizophrenia, risperidone is an FDA-approved atypical antipsychotic commonly used to manage positive symptoms such as hallucinations, delusions, and disorganized thinking. It works by blocking dopamine and serotonin receptors in the brain, which helps reduce psychotic symptoms. In older adults, dosing must start low and increase cautiously due to the higher risk of side effects, including sedation, orthostatic hypotension, extrapyramidal symptoms, and increased risk of cerebrovascular events. Close monitoring of weight, glucose, lipids, and movement disorders is recommended (Stroup et al., 2021). An off-label antipsychotic that may be used in treatment-resistant schizophrenia is clozapine. Although effective in reducing psychotic symptoms when other antipsychotics fail, clozapine requires strict monitoring of white blood cell counts due to the risk of agranulocytosis (Correll et al., 2022). It is not commonly first-line in this population, but remains an option in severe cases.

Nonpharmacological Intervention

A nonpharmacological intervention for schizophrenia in older adults is cognitive-behavioral therapy for psychosis (CBTp), which focuses on helping patients identify and challenge delusional beliefs and maladaptive thinking patterns. It is particularly useful for individuals who retain some insight and are motivated to engage in therapy. CBTp helps reduce emotional distress related to psychotic experiences, improve coping strategies, and promote functioning. Sessions are adapted for cognitive limitations sometimes seen in older adults, such as slower processing speed or memory deficits. Therapists often use repetition, visual aids, and shorter sessions to support engagement. CBTp is also useful in addressing secondary symptoms such as depression and anxiety. Incorporating psychoeducation into the therapy process helps patients and caregivers better understand the illness, manage medication adherence, and recognize early warning signs of relapse, supporting long-term stability.

Risk Assessment to Inform Treatment Decision-Making

When treating schizophrenia in older adults, a comprehensive risk assessment is essential to guide safe and effective treatment. The first step is a medical and psychiatric history review, focusing on age-related changes, comorbidities such as cardiovascular disease or diabetes, history of falls, and cognitive status. A baseline cognitive screen (such as the Mini-Mental State Examination or Montreal Cognitive Assessment) helps distinguish between schizophrenia, dementia, and delirium (Rantala et al., 2022). Medication history is reviewed for polypharmacy, drug interactions, and past adverse reactions, especially to antipsychotics.

Laboratory assessments include complete blood count, metabolic panel, renal and liver function, fasting glucose, lipid profile, and EKG. These identify medical conditions that could complicate pharmacologic treatment. The assessment also includes functional status, psychosocial support, and housing stability to evaluate the patient’s ability to adhere to treatment and attend follow-ups (Rantala et al., 2022). Psychiatric risk factors such as suicidal ideation, aggression, or severe paranoia are evaluated. This risk assessment helps balance therapeutic benefits against the potential for harm, guiding individualized, age-appropriate treatment decisions.

Risks and Benefits of Risperidone (FDA-Approved)

Risperidone is an atypical antipsychotic approved for schizophrenia and commonly prescribed in older adults due to its effectiveness in reducing positive symptoms such as hallucinations, delusions, and agitation. It has a relatively favorable side effect profile compared to first-generation antipsychotics and requires lower doses in elderly populations. Benefits include improved reality testing, reduced paranoia, and decreased caregiver burden when symptoms are managed (Stroup et al., 2021). However, risperidone carries significant risks in older adults, including sedation, orthostatic hypotension, extrapyramidal symptoms, and increased risk of cerebrovascular events and mortality in those with dementia-related psychosis. There is also the potential for metabolic side effects such as weight gain, elevated blood glucose, and lipid abnormalities. For this reason, close monitoring and conservative dosing are recommended.

Risks and Benefits of Clozapine

Clozapine is not FDA-approved for schizophrenia in older adults but may be used off-label in treatment-resistant cases. It is highly effective in reducing persistent psychosis when other medications fail and has a low risk of extrapyramidal symptoms. Benefits include marked symptom reduction, improved social functioning, and reduced hospitalizations in refractory cases (Correll et al., 2022). However, clozapine poses significant risks, including agranulocytosis, seizures, myocarditis, and severe constipation. Weekly to monthly blood monitoring is required to track white blood cell counts. Older adults are particularly vulnerable to sedation, orthostatic hypotension, and cardiac complications. Due to these risks, clozapine is reserved for individuals who have not responded to at least two other antipsychotics and can comply with the necessary monitoring protocol (Correll et al., 2022).

Clinical Practice Guidelines for Schizophrenia in Older Adults

Clinical practice guidelines for schizophrenia exist and provide recommendations specific to older adults. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Schizophrenia emphasize individualized treatment based on age, comorbidities, and functional status (American Psychiatric Association, 2022). These guidelines recommend starting with second-generation antipsychotics at the lowest effective dose in older adults due to their increased sensitivity to side effects. Risperidone is supported by these guidelines as a first-line agent due to its efficacy and manageable side effect profile at low doses. It is often preferred over first-generation antipsychotics, which carry a higher risk of movement disorders (Orzelska-Górka et al., 2022). The guidelines caution against the use of antipsychotics in patients with dementia-related psychosis due to increased mortality risk, reinforcing the importance of risk-benefit analysis.

Clozapine is mentioned as a treatment for refractory schizophrenia. Guidelines recommend its use only after two failed trials with other antipsychotics and require mandatory monitoring, supporting its off-label use in carefully selected older adults who can comply with blood testing (Correll et al., 2022). These recommendations support risperidone as a first-line treatment and justify cautious clozapine use when necessary.

Conclusion

Schizophrenia in older adults presents unique diagnostic and treatment challenges due to overlapping symptoms with cognitive decline, medical comorbidities, and age-related pharmacological sensitivity. Late-onset or very-late-onset schizophrenia often manifests with persecutory delusions, auditory hallucinations, and prominent negative symptoms that impact quality of life and social functioning. Treatment must be approached cautiously, balancing effectiveness and safety. Clinical practice guidelines support risperidone as a first-line antipsychotic, with careful dose titration and monitoring. Clozapine may be used off-label in treatment-resistant cases, but its serious adverse effects and monitoring requirements limit its use to carefully selected patients. Nonpharmacological interventions like cognitive-behavioral therapy for psychosis play a valuable role in improving insight, reducing distress, and promoting adherence. Comprehensive risk assessments help guide individualized, age-appropriate care by accounting for cognitive, medical, and psychosocial factors. Together, these interventions reflect best practices for managing schizophrenia in older adults while aiming to reduce relapse, preserve autonomy, and improve long-term outcomes.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.).

Correll, C. U., Agid, O., Crespo-Facorro, B., de Bartolomeis, A., Fagiolini, A., Seppälä, N., & Howes, O. D. (2022). A guideline and checklist for initiating and managing clozapine treatment in patients with treatment-resistant schizophrenia. CNS Drugs, 36(7), 659-679. https://doi.org/10.1007/s40263-022-00932-2

Orzelska-Górka, J., Mikulska, J., Wiszniewska, A., & Biała, G. (2022). New atypical antipsychotics in the treatment of schizophrenia and depression. International Journal of Molecular Sciences, 23(18), 10624. https://doi.org/10.3390/ijms231810624

Rantala, M. J., Luoto, S., Borráz-León, J. I., & Krams, I. (2022). Schizophrenia: The new etiological synthesis. Neuroscience & Biobehavioral Reviews, 142, 104894. https://doi.org/10.1016/j.neubiorev.2022.104894

Stroup, T. S., Olfson, M., Huang, C., Wall, M. M., Goldberg, T., Devanand, D. P., & Gerhard, T. (2021). Age-specific prevalence and incidence of dementia diagnoses among older US adults with schizophrenia. JAMA Psychiatry, 78(6), 632-641. 10.1001/jamapsychiatry.2021.0042

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After assessing and diagnosing a patient, PMHNPs must take into consideration special characteristics of the patient before determining an appropriate course of treatment. For pharmacological treatments that are not FDA-approved for a particular use or population, off-label use may be considered when the potential benefits could outweigh the risks.

In this Discussion, you will investigate a specific disorder and determine potential appropriate treatments for when it occurs in an older adult or pregnant woman.

To Prepare:

• Choose one of the two following specific populations: either pregnant women or older adults. Then, select a specific disorder from the DSM-5-TR to use.

• Use the college Library to research evidence-based treatments for your selected disorder in your selected population (either older adults or pregnant women).
• You will need to recommend one FDA-approved drug, one non-FDA-approved “off-label” drug, and one nonpharmacological intervention for treating the disorder in that population.

• Recommend one FDA-approved drug, one off-label drug, and one nonpharmacological intervention for treating your chosen disorder in older adults or pregnant women.

• Explain the risk assessment you would use to inform your treatment decision  making.
• What are the risks and benefits of the FDA-approved medicine? What are the risks and benefits of the off-label drug?

• Explain whether clinical practice guidelines exist for this disorder, and if so, use them to justify your recommendations.
• If not, explain what information you would need to take into consideration.
• Support your reasoning with at least three current, credible scholarly resources, one each on the FDA-approved drug, the off-label, and a nonpharmacological intervention for the disorder.