What management is recommended for an 85-year-old female with depression with psychotic features who has had brexpiprazole, lithium, mirtazapine, paliperidone, and high-dose venlafaxine abruptly stopped due to inability to swallow?

Management of Abruptly Discontinued Psychiatric Medications in an Elderly Patient with Depression with Psychotic Features

For an 85-year-old female with depression with psychotic features who has had multiple psychiatric medications abruptly discontinued due to swallowing difficulties, long-acting injectable antipsychotics should be immediately initiated to prevent mental state deterioration and potential relapse.

Assessment of Current Situation

The patient's medication regimen that has been abruptly discontinued includes:

• Brexpiprazole (atypical antipsychotic)
• Lithium (mood stabilizer)
• Mirtazapine (antidepressant)
• Paliperidone (atypical antipsychotic)
• High-dose venlafaxine (SNRI antidepressant)

This abrupt discontinuation presents significant risks:

• Withdrawal symptoms from venlafaxine (particularly concerning due to its short half-life)
• Risk of psychotic relapse due to discontinued antipsychotics
• Risk of mood destabilization from lithium discontinuation
• Potential for serotonin discontinuation syndrome

Immediate Management Recommendations

1. Antipsychotic Management

• Initiate long-acting injectable (LAI) antipsychotic immediately
  • Consider paliperidone palmitate LAI as the patient was previously on oral paliperidone 1
  • Starting dose: 150 mg on day 1 and 100 mg on day 8, administered in the deltoid muscle
  • Maintenance dose: 75-100 mg monthly based on response and tolerability

2. Antidepressant Management

• Consider venlafaxine withdrawal management:
  • Monitor for discontinuation symptoms including agitation, anxiety, dizziness, headache, nausea, and sensory disturbances 2
  • If withdrawal symptoms are severe, consider liquid venlafaxine via nasogastric tube if medically appropriate

3. Mood Stabilizer Replacement

• Monitor closely for signs of mood destabilization following lithium discontinuation
• If signs of mania or severe mood instability develop, consider valproate administered via alternative routes (rectal or parenteral formulations if available)

Monitoring Requirements

• Daily assessment for first week for:

  • Signs of psychotic relapse (hallucinations, delusions, disorganized thinking)
  • Mood changes (depression worsening, irritability, agitation)
  • Withdrawal symptoms (particularly from venlafaxine)
  • Vital signs including blood pressure (due to venlafaxine discontinuation)

• Physical health monitoring:

  • Monitor for extrapyramidal symptoms with introduction of LAI antipsychotic
  • Monitor for falls risk, particularly in first 1-2 weeks of treatment changes 3

Alternative Routes of Administration to Consider

1. Transdermal options:

   • Consider transdermal antidepressant options if available in your region

2. Liquid formulations:

   • If swallowing difficulties are temporary, consider liquid formulations of medications via nasogastric tube if appropriate

3. Sublingual/buccal options:

   • Some antipsychotics are available in rapidly dissolving formulations that don't require swallowing

Long-term Considerations

• Gradual reintroduction of oral medications if swallowing ability returns 1
• Simplification of regimen - consider whether all previous medications are necessary or if the regimen can be simplified
• Regular reassessment of swallowing ability by speech pathologist

Common Pitfalls and Caveats

1. Avoid benzodiazepines if possible - while tempting to use for agitation, they increase fall risk in elderly patients and may worsen confusion 1

2. Beware of anticholinergic burden - many psychiatric medications have anticholinergic properties that can worsen cognition in elderly patients

3. Avoid assuming all previous medications need replacement - this is an opportunity to reassess the medication regimen and potentially simplify

4. Monitor for serotonin syndrome if multiple serotonergic agents are reintroduced simultaneously 3

5. Recognize the high mortality risk - depression with psychotic features in elderly patients carries significant mortality risk if undertreated, particularly with abrupt medication discontinuation 4

By implementing these recommendations promptly, the risk of mental state deterioration can be significantly reduced while maintaining patient safety during this challenging clinical situation.