Brexpiprazole Use in Elderly Patients with Parkinson's Disease

Guideline-Based Contraindication

• The American Geriatrics Society recommends avoiding brexpiprazole in elderly patients with Parkinson's disease, as it is classified as an inappropriate antipsychotic for this population, with only quetiapine, clozapine, and pimavanserin being acceptable alternatives 1, 2
• The 2019 American Geriatrics Society Beers Criteria explicitly removed aripiprazole, brexpiprazole's predecessor, from the list of acceptable antipsychotics for Parkinson's disease patients, due to the risk of worsening Parkinsonian motor symptoms 1, 2

Evidence of Harm in Parkinson's Disease

• Brexpiprazole's mechanism of action, partial dopamine D2 receptor agonism, poses specific risks in Parkinson's disease, including worsening of motor symptoms, such as bradykinesia, rigidity, and tremor in PD patients 1, 2

Safer Alternatives for Psychosis in Parkinson's Disease

• The American Geriatrics Society recommends using pimavanserin, quetiapine, or clozapine as safer alternatives for psychosis in elderly PD patients, as they do not worsen motor symptoms to the same degree as other antipsychotics 1, 2
• Pimavanserin is preferred, while quetiapine and clozapine have significant limitations, but are still considered safer options than brexpiprazole 1, 2

Clinical Decision Algorithm

• The American Geriatrics Society recommends attempting non-pharmacological interventions and treating underlying causes before considering antipsychotic use in elderly PD patients, and choosing pimavanserin as the first-line pharmacologic option 1, 2
• Quetiapine or clozapine may be considered if pimavanserin fails or is unavailable, but brexpiprazole and other typical/atypical antipsychotics should never be used 1, 2