How to manage a 75-year-old male with schizophrenia, neurocognitive disorder, and senile dementia, on olanzapine and Effexor, with recent rib fractures and suicidal comments?

From the Guidelines

Managing a 75-year-old male with schizophrenia, neurocognitive disorder, and senile dementia who is currently on olanzapine and Effexor, has recent rib fractures, and has made suicidal comments requires immediate comprehensive intervention, prioritizing his safety and well-being above all, as suggested by the American Psychiatric Association practice guideline for the treatment of patients with schizophrenia 1. The patient's complex condition, including schizophrenia, neurocognitive disorder, and senile dementia, necessitates a multifaceted approach that addresses his psychiatric, cognitive, and physical health needs.

• Conduct an urgent suicide risk assessment and consider psychiatric hospitalization if there is imminent risk.
• Continue olanzapine for schizophrenia management but consider reducing the dose to minimize fall risk and sedation; a typical dose might be 5-10mg daily, as recommended by the APA for patients with schizophrenia 1.
• Maintain Effexor (venlafaxine) for depression, typically 75-150mg daily, but monitor closely for side effects.
• Implement fall prevention strategies including physical therapy, home safety evaluation, and assistive devices, which is crucial given his recent rib fractures and the need to prevent further injuries.
• Pain management for rib fractures should utilize acetaminophen (up to 3000mg daily in divided doses) rather than NSAIDs or opioids when possible due to side effect risks in elderly patients.
• Establish a multidisciplinary care team including a geriatric psychiatrist, primary care physician, neurologist, and social worker to oversee his care and adjust the treatment plan as necessary.
• Schedule frequent follow-up appointments, initially weekly, to monitor medication effects, suicidal ideation, and cognitive status.
• Involve family members or caregivers in the treatment plan to ensure medication adherence and safety monitoring, which is particularly important for patients with dementia and other cognitive impairments. Given the patient's recent rib fractures, it is also essential to consider the management of osteoporosis and the prevention of subsequent fractures, as outlined in the EULAR/EFORT recommendations for management of patients older than 50 years with a fragility fracture 1. This approach addresses the complex interplay between psychiatric conditions, cognitive decline, physical injury, and suicide risk while minimizing medication-related complications in an elderly patient with multiple vulnerabilities.

From the FDA Drug Label

Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. ZYPREXA is not approved for the treatment of patients with dementia-related psychosis [see Boxed Warning, Use in Specific Populations (8. 5), and Patient Counseling Information (17)]. The possibility of a suicide attempt is inherent in schizophrenia and in bipolar I disorder, and close supervision of high-risk patients should accompany drug therapy.

The patient's treatment with olanzapine should be carefully considered due to the increased risk of death in elderly patients with dementia-related psychosis.

• Close supervision is necessary for high-risk patients, especially with the patient's history of suicidal comments.
• The patient's medication regimen should be evaluated, considering the potential benefits and risks of continuing olanzapine therapy.
• Alternative treatments may be necessary to manage the patient's schizophrenia and neurocognitive disorder while minimizing the risk of adverse effects.
• The patient's suicidal comments should be taken seriously, and a thorough assessment should be conducted to determine the best course of action 2.