What is the best alternative to Lexapro (escitalopram) for an 83-year-old female patient with dementia, anxiety, and chronic pain, currently taking Norco (hydrocodone/acetaminophen) and Aricept (donepezil), who is experiencing drowsiness due to Lexapro?

Medication Management for an 83-Year-Old Female with Dementia, Anxiety, and Chronic Pain

Sertraline is the best alternative to Lexapro (escitalopram) for this 83-year-old female patient with dementia, anxiety, and chronic pain who is experiencing drowsiness with Lexapro while taking Norco and Aricept. 1

Rationale for Sertraline Selection

Sertraline offers several advantages for this specific patient:

1. Safety profile in cardiovascular disease: Among SSRIs, sertraline has been extensively studied and appears to have a lower risk of QTc prolongation than escitalopram (Lexapro) 1

2. Efficacy for anxiety in dementia: SSRIs are first-line pharmacological treatments for agitation in dementia and have been shown to significantly reduce neuropsychiatric symptoms 2

3. Less sedation: Sertraline is less likely to cause drowsiness compared to escitalopram, addressing the patient's current complaint 1

4. Compatibility with current medications: Sertraline has minimal interactions with Aricept (donepezil) and Norco (hydrocodone/acetaminophen) 1

Dosing Recommendations

• Starting dose: 25 mg daily for 1-2 weeks 2
• Target dose: 50-100 mg daily, based on response and tolerability 2
• Administration: Morning dosing may help minimize any sleep disturbances

Medication Interactions and Considerations

Interactions with Current Medications

• Aricept (donepezil): No significant interactions with sertraline
• Norco (hydrocodone/acetaminophen): Monitor for potential serotonin syndrome, though risk is low with this combination

Special Considerations for Elderly Patients with Dementia

• Start low, go slow: Begin with lower doses (25 mg) and titrate gradually due to age and dementia 2
• Monitor for cognitive changes: SSRIs generally have favorable cognitive profiles in dementia patients compared to other psychotropic medications 2
• Fall risk: While all psychotropic medications carry some fall risk, sertraline has a more favorable profile than escitalopram in this regard 2

Alternative Options (If Sertraline Is Not Tolerated)

1. Mirtazapine:

   • Offers additional benefits including appetite stimulation and sleep improvement 1
   • Starting dose: 7.5-15 mg at bedtime
   • Caution: May cause more sedation than desired

2. Buspirone:

   • Non-SSRI anxiolytic that may be effective for elderly patients 3
   • Starting dose: 5 mg twice daily, gradually increasing to 15-30 mg/day in divided doses
   • Well-tolerated in elderly patients receiving treatment for other chronic medical conditions 3

Monitoring Recommendations

• Follow-up: Schedule within 2 weeks to assess response and side effects 2
• Monitor for:
  • Anxiety and agitation levels
  • Cognitive function
  • Fall risk
  • Serotonin syndrome (though rare with this combination)
  • Changes in pain control

Common Pitfalls to Avoid

• Avoid benzodiazepines: Despite their effectiveness for anxiety, they increase fall risk and cognitive impairment in elderly patients with dementia 2
• Avoid tricyclic antidepressants: These have significant cardiovascular side effects, including hypertension, hypotension, and arrhythmias 1
• Avoid monoamine oxidase inhibitors: These also have significant cardiovascular side effects 1
• Avoid serotonin-norepinephrine reuptake inhibitors (SNRIs): These may cause hypertension at high doses, which could be problematic in elderly patients 1

By switching from escitalopram to sertraline, this patient is likely to experience improved management of anxiety with less drowsiness while maintaining compatibility with her current medications for dementia and pain management.