Clozapine in Older Adults: Benefits and Challenges

Schizophrenia worsens quality of life, causes family disruption, and shortens longevity. Clozapine can be efficacious in schizophrenia refractory to other antipsychotic agents. Many older patients have been on clozapine for decades and may need to continue its use into late life to prevent emergence of psychotic symptoms. However, older adults are more prone to clozapine adverse effects than younger patients. Pneumonia and paralytic ileus are the most common serious adverse effects in older adults with significant mortality. Agranulocytosis and myocarditis usually occur early in treatment and are infrequent in older adults who have been on clozapine for years. Overall, adverse effects of clozapine should be managed by decreasing polypharmacy of both psychotropic and nonpsychotropic agents, by making lifestyle changes, and by reducing the dosage of clozapine under vigilant surveillance. Relapse of psychosis remains a possibility even when clozapine dose reduction is conducted with appropriate clinical monitoring. Shared decision making with patients and their families is important, especially when a clozapine dose reduction is considered. Support measures will be needed in case psychotic symptoms emerge. There are significant gaps in the literature on the management of side effects of clozapine in late life. The recommendations offered here are based on available studies and on clinical experience and will need to be amended as new empirical information becomes available.