What is the recommended medication taper and adjustment for an 87‑year‑old woman with major depressive disorder, generalized anxiety disorder, and dementia who is taking bupropion 150 mg daily, escitalopram 5 mg at bedtime, and a Deluxe Teen supplement?

Medication Management for an 87-Year-Old with MDD, GAD, and Dementia

In this 87-year-old woman with dementia, discontinue the "Deluxe Teen" supplement immediately as it contributes to medication burden without evidence of benefit, and consider tapering bupropion given the lack of robust evidence for its use in elderly patients with comorbid anxiety and dementia, while maintaining escitalopram 5 mg at bedtime as it has demonstrated efficacy and tolerability in this population 1, 2, 3.

Immediate Action: Supplement Discontinuation

Stop the "Deluxe Teen" supplement now. Multiple vitamin/mineral supplements in older adults contribute to medication burden and occasionally anorexia without substantiated benefit 1. This is particularly important in an 87-year-old with dementia where polypharmacy increases fall risk, cognitive impairment, and adverse drug events.

Bupropion Assessment and Potential Taper

Evidence Against Bupropion in This Population

The current regimen of bupropion 150 mg daily warrants critical reassessment:

• Anxiety concerns: While recent evidence suggests bupropion may improve anxiety symptoms in some MDD patients 4, 5, its stimulating properties can provoke anxiety, particularly problematic in GAD 5. SSRIs show a modest advantage over bupropion in patients with high baseline anxiety 4.

• Age-related considerations: At 87 years old, this patient requires dose adjustment consideration. The FDA label recommends considering dose reduction and/or frequency adjustment in elderly patients, particularly with any renal impairment (GFR <90 mL/min) 2.

• Dementia context: The polypharmacy guideline emphasizes deprescribing in older adults with dementia to reduce medication burden and associated risks 1.

If Discontinuing Bupropion

Taper gradually: When discontinuing bupropion 150 mg daily, the FDA-approved approach is to taper before complete discontinuation 2. For this dose, consider:

• Reduce to 150 mg every other day for 1-2 weeks
• Then discontinue completely
• Monitor for withdrawal symptoms and worsening depression/anxiety

Escitalopram: Continue Current Dose

Maintain escitalopram 5 mg at bedtime. This represents appropriate management because:

• Proven efficacy in elderly: Escitalopram demonstrates effectiveness and tolerability in elderly patients (≥65 years) with depression and comorbid anxiety 6, 3. In a 12-week trial of elderly patients with comorbid MDD and GAD, escitalopram 10-20 mg/d showed significant improvements in both depression and anxiety symptoms 3.

• Appropriate dosing: The current 5 mg dose is conservative and appropriate for an 87-year-old, particularly with dementia. This allows for potential dose optimization if needed (up to 10 mg) while minimizing adverse effects.

• Dual benefit: SSRIs like escitalopram address both depression and anxiety, making it the cornerstone medication for this patient's comorbid conditions 3.

Monitoring and Optimization Strategy

After Supplement Discontinuation and Bupropion Taper

1. Week 1-2: Monitor for withdrawal symptoms from bupropion (if tapered), assess mood and anxiety levels
2. Week 4: Evaluate response on escitalopram monotherapy
3. If inadequate response: Consider increasing escitalopram to 10 mg at bedtime (still within safe range for elderly patients with comorbid anxiety) 3

Red Flags to Monitor

• Worsening cognition: Any medication change in dementia patients requires monitoring for cognitive/behavioral deterioration 1
• Falls: Antidepressants can cause orthostasis and falls in elderly patients 1
• Hyponatremia: SSRIs carry this risk, particularly in elderly patients
• Activation/agitation: Monitor for increased anxiety or agitation during any medication changes

Rationale for This Approach

This recommendation prioritizes morbidity and mortality reduction by:

• Eliminating unnecessary supplement burden that increases fall risk and medication complexity
• Questioning the benefit-risk ratio of bupropion in an 87-year-old with anxiety and dementia
• Maintaining the evidence-based SSRI that addresses both depression and anxiety with proven safety in this age group
• Simplifying the regimen to improve adherence and reduce polypharmacy complications

The 2021 Mayo Clinic polypharmacy guidelines explicitly recommend deprescribing supplements and carefully evaluating each medication's necessity in elderly patients with dementia 1. The goal is to optimize quality of life while minimizing medication-related harm in this vulnerable population.