What is the recommended management for a 65-year-old male with schizophrenia (unspecified), bipolar disorder, delusional disorder, obsessive-compulsive disorder (OCD), and Alzheimer's disease, experiencing increased aggressive behavior and confusion, with subtherapeutic lithium levels (hypolithemia) and therapeutic lamotrigine levels, despite adjustments to olanzapine (an atypical antipsychotic), diazepam (a benzodiazepine), and fluvoxamine (a selective serotonin reuptake inhibitor)?

From the Guidelines

I strongly recommend a comprehensive and multidisciplinary approach to manage this 65-year-old male's complex psychiatric conditions and behavioral issues, prioritizing his safety, reducing morbidity, and improving his quality of life. Given his multiple diagnoses, including schizophrenia, bipolar disorder, delusional disorder, OCD, and Alzheimer's disease, it is crucial to address each condition while considering potential interactions and side effects of his medications.

The patient's current medication regimen includes diazepam, lithium, olanzapine, lamotrigine, and fluvoxamine. Notably, his lithium level is subtherapeutic at <0.10 mmol/L, and the lamotrigine level of 220 ug/ml appears high compared to typical therapeutic ranges [ 1 ]. Continuing the lithium dose increase to 450 mg twice daily as ordered is advisable, and if the high lamotrigine level is confirmed, reducing the dose should be considered to minimize potential side effects.

For the aggressive behaviors, consider adding or substituting risperidone 0.5 mg twice daily instead of the current olanzapine regimen, as it may provide better behavioral control with fewer side effects in elderly patients with dementia, as suggested by guidelines for managing schizophrenia [ 1 ]. Implementing a fall prevention protocol, including environmental modifications and possibly a physical therapy evaluation, is also crucial given the patient's recent fall. Monitoring sodium levels as ordered and ensuring adequate hydration are important, especially with the use of lithium.

Considering the patient's complex medication regimen and the potential for drug interactions, gradual tapering of diazepam is recommended, as benzodiazepines can increase confusion and fall risk in elderly patients [ 1 ]. A geriatric psychiatry consultation would be highly beneficial if available, to further optimize his medication regimen and manage his multiple conditions effectively.

While waiting for transfer to a higher level of care, implementing non-pharmacological approaches is essential. This includes consistent daily routines, redirection techniques for agitation, and regular assessment for pain or other physical discomfort that might be triggering behaviors. Regular monitoring of vital signs, mental status, and medication side effects is critical given his complex condition and recent medication changes.

Key considerations for his management include:

• Optimizing his medication regimen to ensure therapeutic levels and minimize side effects
• Implementing strategies to reduce aggressive behaviors and prevent falls
• Ensuring adequate hydration and monitoring sodium levels
• Gradually tapering benzodiazepines to reduce risks associated with their use in elderly patients
• Utilizing non-pharmacological interventions to manage his behaviors and improve his quality of life
• Considering a geriatric psychiatry consultation for specialized guidance on managing his complex conditions.

From the FDA Drug Label

The primary rating instrument used for assessing manic symptoms in these trials was the Young Mania Rating Scale (Y-MRS), an 11-item clinician-rated scale traditionally used to assess the degree of manic symptomatology (irritability, disruptive/aggressive behavior, sleep, elevated mood, speech, increased activity, sexual interest, language/thought disorder, thought content, appearance, and insight) in a range from 0 (no manic features) to 60 (maximum score).

The resident is experiencing increased aggressive behaviors and confusion, which are symptoms of manic episodes.

• Olanzapine is effective in reducing Y-MRS total score, which includes assessing manic symptoms such as irritability and disruptive/aggressive behavior 2.
• The current dose of olanzapine is 20 mg po bid, which is within the recommended dose range of 5-20 mg/day.
• Considering the resident's symptoms have not improved, it may be necessary to reassess the treatment plan and consider alternative options or adjustments to the current medication regimen.
• However, without further information on the resident's condition and treatment history, it is difficult to make a specific recommendation.
• It is essential to continue monitoring the resident's symptoms and adjust the treatment plan as needed to ensure their safety and well-being.

From the Research

Medication Management

• The resident's current medication regimen includes diazepam, lithium, olanzapine, lamotrigine, and fluvoxamine 3, 4, 5.
• The resident's lithium level is <0.10mmol/L, which is below the therapeutic range, and lamotrigine level is 220ug/ml, which is within the therapeutic range 3, 5.
• Decreasing olanzapine to 20mg po bid and diazepam to 2mg bid may help reduce the resident's aggressive behavior 3, 5.
• Increasing lithium to 450mg bid may help improve the resident's mood stability 3, 5.
• Decreasing fluvoxamine to 50mg may help reduce the resident's anxiety symptoms 4, 5.

Comprehensive Geriatric Assessment

• A comprehensive geriatric assessment (CGA) is a multidimensional and multidisciplinary diagnostic process that can help determine the resident's clinical profile, pathological risk, residual skills, short- and long-term prognosis, and personalized therapeutic and care plan 6.
• CGA can help identify the resident's specific clinical conditions and develop a personalized care plan to improve their quality of care and reduce hospitalization events 6.
• The Resident Assessment Instrument (RAI) Minimum Data Set is a specific CGA-based assessment tool that can be used in long-term care facilities to assess the resident's needs and develop a care plan 6.

Treatment Approach

• The treatment approach for the resident should be individualized and based on their specific clinical conditions and needs 3, 4, 5, 6.
• A combination of medication management and non-pharmacological interventions, such as behavioral therapy and environmental modifications, may be effective in reducing the resident's aggressive behavior and improving their mood stability 3, 4, 5.
• Regular monitoring of the resident's medication levels, vital signs, and behavioral symptoms is essential to ensure their safety and adjust their treatment plan as needed 3, 4, 5, 6.