As-needed dosing of antipsychotic drugs: limitations and guidelines for use in the elderly agitated patient

OBJECTIVE: To review the as-needed dosing of antipsychotic drugs. Because insufficient data are available to evaluate this therapy, alternative strategies in managing acute agitation in elderly patients are suggested. DATA SOURCES: A MEDLINE search of English-language articles published between 1966 and June 1992 was used to identify studies and reviews of antipsychotic drugs administered in single doses or intermittently. STUDY SELECTION: Because of the paucity of data, all studies obtained were reviewed. Those addressing the use of drug holidays (chronic dosing with days without drug) were excluded. DATA EXTRACTION: No data are available regarding the efficacy of as-needed dosing of antipsychotics in elderly agitated patients; thus, data obtained from treating acutely psychotic patients are described, and differences between this population and elderly agitated patients are discussed. DATA SYNTHESIS: Antipsychotics are used frequently to control agitated behavior in elderly patients, although double-blind studies have not consistently demonstrated the superiority of active drug over placebo. CONCLUSIONS: Rigorous placebo-controlled trials of the safety and efficacy of as-needed dosing of antipsychotics are needed. As-needed dosing of any drug to control behavior should be reserved only for infrequent, sustained agitation that cannot be linked to an eliciting event. Orders for such dosing must include definitive, detailed directions for nursing personnel specifying target behaviors, maximum daily dosages, and monitoring parameters for assessing efficacy and adverse effects.