Risperidone Use in Elderly Patients

Introduction to Risperidone Use

The American Academy of Family Physicians identifies risperidone as having increased risk of extrapyramidal symptoms (EPS) if doses exceed 6 mg/24 hours, and particularly at doses >2 mg in elderly patients, with a hierarchy of EPS risk among atypical antipsychotics from lowest to highest: quetiapine, aripiprazole, olanzapine, risperidone 1

The Mayo Clinic guidelines specifically list risperidone among atypical antipsychotics that should be avoided for cognitive behavioral problems in dementia, as they worsen cognitive function, and the Beers Criteria recommend tapering/avoiding antipsychotics if possible, especially for pharmacological behavioral control in cognitive disease 2
Quetiapine has the lowest risk of EPS among commonly used antipsychotics in elderly patients, with a starting dose of 25 mg, and is preferred over risperidone, while aripiprazole (starting 5 mg) and olanzapine (starting 2.5-5 mg) are intermediate options with lower EPS risk than risperidone 1

Daily evaluation with in-person examination is recommended when using any antipsychotic in elderly patients, and particular caution is required with cardiovascular disease, co-treatment with SSRI antidepressants or valproate, and rapid dose increases 1
The American Academy of Family Physicians recommends avoiding doses above 6 mg/24 hours to prevent excessive EPS risk, and the FDA box warning emphasizes the risk of death when used for dementing disorders 1

The American Academy of Family Physicians recommends starting at 0.25-0.5 mg daily and increasing slowly by 0.25 mg increments, with a maximum dose of 6 mg/24 hours to minimize EPS risk 1