From the Guidelines
For an 89-year-old female with increased fall risk and aggression on Rexulti 1mg and Ativan 0.5mg TID, I strongly recommend discontinuing the Ativan and adjusting the Rexulti regimen to minimize fall risk and optimize management of aggression. The patient's current medication regimen poses significant risks, particularly the benzodiazepine Ativan, which is known to increase fall risk in elderly patients due to its sedative effects, orthostatic hypotension, and impaired coordination 1. Given the potential for benzodiazepines to accumulate and exacerbate these risks, gradually tapering Ativan to 0.5mg twice daily for one week, then 0.5mg daily for another week, before discontinuing completely is advisable. For the Rexulti, consider reducing to 0.5mg daily or switching to a more geriatric-appropriate antipsychotic like quetiapine, starting at 25mg at bedtime and titrating slowly based on response, as suggested by the process to identify drug therapy problems in cases of polypharmacy 1. Non-pharmacological approaches, including environmental modifications, regular toileting schedules, and consistent daily routines, should be implemented to reduce agitation triggers and fall risks, aligning with recommendations for managing polypharmacy in older patients 1. Close monitoring during medication changes is crucial to watch for withdrawal symptoms from Ativan and the effectiveness of the adjusted regimen in controlling aggression, considering the principles outlined for polypharmacy management and the potential for drug-drug interactions 1.
From the Research
Medication Adjustments for Fall Risk and Aggression
To address the increased fall risk and aggression in an 89-year-old female patient currently taking Rexulti (brexpiprazole) 1mg and Ativan (lorazepam) 0.5mg three times a day, several considerations can be made based on existing research:
- Assessing Medication-Related Fall Risk: Studies have shown that certain medications, including benzodiazepines like lorazepam, can increase the risk of falls in elderly patients 2, 3. The use of a medication fall risk score, as mentioned in 3, could help in identifying patients at higher risk.
- Alternative Medications: Considering alternatives to medications known to increase fall risk is crucial. For example, 4 suggests that pharmacological interventions, including the withdrawal of fall-risk-increasing drugs (FRIDs) or switching to drugs with a lower fall risk, can be effective in reducing fall risk.
- Dose Adjustment: Reducing the dose of medications that may contribute to fall risk, such as benzodiazepines, could be beneficial. However, this should be done under close medical supervision to avoid withdrawal symptoms or worsening of the patient's condition.
- Monitoring and Intervention: Regular monitoring of the patient's condition, including fall risk assessments and adjustments to the medication regimen as needed, is essential. Interventions such as physical therapy, vitamin D supplementation, and ensuring adequate lighting and safety measures in the living environment can also play a critical role in preventing falls 5.
- Psychoactive Drug Load: The total psychoactive drug load should be carefully considered, as the use of multiple psychoactive agents can increase fall risk 2. Reducing the number of psychoactive medications or switching to medications with fewer side effects could help mitigate this risk.
Considerations for Aggression
While the primary concern is the increased fall risk, managing aggression in elderly patients, especially those with dementia or other cognitive impairments, is also critical:
- Behavioral Interventions: Non-pharmacological approaches, such as behavioral interventions, should be considered first-line treatments for aggression in dementia patients.
- Medication Review: A thorough review of the patient's medication regimen to identify any drugs that may be contributing to aggression is necessary. Certain medications, including antipsychotics, can sometimes exacerbate behavioral symptoms in elderly patients.
Given the complexity of managing fall risk and aggression in elderly patients, a multidisciplinary approach involving healthcare professionals, caregivers, and the patient (when possible) is recommended to develop a personalized plan that addresses these concerns effectively 6, 4, 5, 2, 3.