What are the best practice recommendations for a 71-year-old woman with a history of falls, persistent daily anxiety, depressive symptoms, and emotional abuse, currently taking fluoxetine (selective serotonin reuptake inhibitor) and mirtazapine (tetracyclic antidepressant)?

From the Guidelines

A comprehensive approach addressing the patient's physical and mental health, including a review of her medication regimen, fall prevention strategies, and interventions for depression and anxiety, is crucial to improve her overall quality of life and reduce morbidity and mortality. The patient's current medication regimen, including fluoxetine and mirtazapine, should be reviewed as both can increase fall risk in older adults 1. Consider switching fluoxetine to a shorter-acting SSRI like sertraline or citalopram, which may have less drug interaction potential and fewer side effects in older adults.

Key Recommendations:

• A geriatric psychiatry consultation would be beneficial to optimize her psychotropic medications, considering the risk of adverse effects, comorbidities, and the presence of behavioral and psychological symptoms associated with her mental health disorders 1.
• Fall prevention strategies should include a home safety assessment, removal of tripping hazards, installation of grab bars in bathrooms, adequate lighting, and appropriate footwear.
• Physical therapy for strength and balance training is essential, with exercises like tai chi particularly effective for fall prevention in older adults.
• A comprehensive geriatric assessment should evaluate vision, hearing, orthostatic hypotension, and cognitive function.
• For her mental health, cognitive behavioral therapy is recommended alongside medication management, particularly given her history of emotional abuse which may contribute to her anxiety and depression 1.
• Regular screening for elder abuse should continue, with appropriate referrals to social services and support groups.
• Encourage regular physical activity, proper nutrition, adequate hydration, and good sleep hygiene to improve overall health and reduce fall risk.

Non-Pharmacological Interventions:

• Non-pharmacological treatments such as exercise, psychotherapy, and behavioral interventions can help to alleviate depressive symptoms and improve mental health 1.
• Interventions targeting frailty can also positively affect depression, including programs focused on physical activity, nutrition optimization, social engagement, and cognitive stimulation 1.

From the FDA Drug Label

Monitor all antidepressant-treated patients for any indication of clinical worsening and emergence of suicidal thoughts and behaviors, especially during the initial few months of drug therapy, and at times of dosage changes. Counsel family members or caregivers of patients to monitor for changes in behavior and to alert the healthcare provider Consider changing the therapeutic regimen, including possibly discontinuing mirtazapine tablets, in patients whose depression is persistently worse, or who are experiencing emergent suicidal thoughts or behaviors.

The patient is a 71-year-old woman with a history of falls, persistent daily anxiety, depressive symptoms, and emotional abuse. She is currently taking fluoxetine (20 mg daily) and mirtazapine (15 mg at bedtime).

• The patient's depressive symptoms and anxiety should be closely monitored, especially during the initial few months of drug therapy, and at times of dosage changes.
• The patient's suicidal thoughts and behaviors should be monitored, and the therapeutic regimen should be changed if necessary, including possibly discontinuing mirtazapine.
• The patient's emotional abuse situation should be addressed, and the patient should be counseled on the importance of seeking help and support.
• The patient's medication regimen should be regularly reviewed and adjusted as necessary to ensure the patient's safety and well-being.
• The patient's lifestyle and environment should be assessed, and modifications should be made to reduce the risk of falls and improve the patient's overall quality of life.
• The patient's support system should be evaluated, and the patient should be encouraged to seek help and support from family, friends, or support groups. 2 2 2

From the Research

Patient Assessment and Recommendations

The patient is a 71-year-old woman with a history of falls, persistent daily anxiety, depressive symptoms, and emotional abuse. She is currently taking fluoxetine (20 mg daily) and mirtazapine (15 mg at bedtime). Based on the provided evidence, the following recommendations can be made:

• Person-centered care: The patient's care should be tailored to her context, possibilities, and situation, focusing on her individual needs and preferences 3. This approach can lead to better health outcomes, more efficient healthcare, and increased job satisfaction for healthcare providers.
• Multidisciplinary cooperation: A multidisciplinary team should be involved in the patient's care, including healthcare providers from different specialties, to address her complex needs and provide comprehensive support 3.
• Anxiety and depression management: The patient's anxiety and depressive symptoms can be managed with a combination of medications and therapies. The use of clonazepam as a therapeutic adjunct to fluoxetine has been shown to be effective in reducing anxiety and depressive symptoms, particularly in patients with anxious depression 4, 5, 6, 7.
• Cotherapy with clonazepam and fluoxetine: The patient may benefit from cotherapy with clonazepam and fluoxetine, which has been shown to be safe and effective in reducing anxiety and depressive symptoms, particularly in patients with anxious depression 4, 5, 6, 7.
• Regular follow-up and monitoring: The patient should be regularly monitored and followed up to assess her response to treatment and adjust her care plan as needed.

Key Considerations

• The patient's emotional abuse and financial hardship should be addressed through social support and counseling services.
• The patient's history of falls and fractures should be taken into account when developing her care plan, with a focus on preventing future falls and promoting mobility and independence.
• The patient's use of marijuana edibles for self-soothing should be monitored and addressed through alternative coping mechanisms and stress management techniques.

Treatment Options

• Clonazepam: The patient may benefit from the addition of clonazepam to her current medication regimen, particularly if she experiences anxiety and depressive symptoms that are not adequately managed with fluoxetine alone 4, 5, 6, 7.
• Alternative therapies: The patient may benefit from alternative therapies, such as cognitive-behavioral therapy (CBT) or mindfulness-based stress reduction (MBSR), to address her anxiety and depressive symptoms.
• Social support: The patient should be connected with social support services, such as counseling and support groups, to address her emotional abuse and financial hardship.