What alternative treatments can be considered for an 85-year-old female with long-standing depression and insomnia, currently taking Lexapro (escitalopram), who has tried numerous medications in the past?

Treatment Options for Depression and Insomnia in an 85-Year-Old Female

For an 85-year-old female with long-standing depression and insomnia who has tried multiple medications including Lexapro (escitalopram), low-dose doxepin (3-6mg) is recommended as the most appropriate next treatment option for her insomnia while continuing to address her depression. 1

Medication Considerations for Elderly Patients with Depression and Insomnia

Current Assessment

• 85-year-old female with:
  • Depression of several years duration
  • Chronic insomnia of many years duration
  • Currently on Lexapro (escitalopram)
  • History of multiple medication trials

Pharmacological Options for Insomnia

First-Line Medication Options

1. Low-dose doxepin (3-6mg)

   • Specifically recommended for sleep maintenance insomnia in elderly patients 1
   • American Academy of Sleep Medicine suggests this for short-term use where benefits outweigh risks 1
   • Has minimal anticholinergic effects at low doses, making it safer for elderly patients 2

2. Suvorexant

   • Recommended for sleep maintenance insomnia 3
   • Orexin receptor antagonist with different mechanism than previously tried medications

3. Eszopiclone

   • Effective for both sleep onset and maintenance insomnia 3
   • Provides moderate-to-large improvement in sleep quality 1

Medications to Avoid in Elderly Patients

• Benzodiazepines (temazepam, triazolam)

  • High risk of falls, cognitive impairment, and dependence in elderly patients 1
  • Should be avoided in this 85-year-old patient

• Trazodone

  • Despite common use, the American Academy of Sleep Medicine suggests against using trazodone for insomnia 3
  • However, low-dose (25-50mg) may be considered with careful monitoring in certain cases 1

• Diphenhydramine and other antihistamines

  • Not recommended for sleep in elderly patients due to anticholinergic effects 3

Addressing Depression and Insomnia Together

Antidepressant Considerations

• Current Lexapro (escitalopram) therapy

  • May contribute to insomnia as SSRIs can worsen sleep through 5-HT2 receptor stimulation 4
  • Consider whether depression is adequately controlled on current regimen 5

• Alternative antidepressant options

  • Mirtazapine: Has 5-HT2 blocking properties that can improve sleep architecture while treating depression 4
  • Can significantly shorten sleep-onset latency and improve sleep efficiency 4
  • Starting dose of 15mg recommended for elderly patients 2

Treatment Algorithm

1. Evaluate current depression control

   • If depression is well-controlled on Lexapro, add low-dose doxepin (3mg initially) for insomnia
   • If depression is inadequately controlled, consider switching to mirtazapine (15mg) which addresses both conditions

2. Non-pharmacological approaches

   • Implement Cognitive Behavioral Therapy for Insomnia (CBT-I) as highest priority 1
   • Include sleep hygiene education, sleep restriction, stimulus control, and cognitive therapy
   • Regular morning light exposure and avoiding bright light in evening 1

3. Medication initiation principles

   • Start with lowest possible dose (e.g., doxepin 3mg)
   • Use intermittently rather than nightly when possible
   • Limit duration to shortest possible time
   • Regularly reassess need and effectiveness 1

Monitoring and Follow-up

• Schedule follow-up within 2-4 weeks to assess effectiveness 1
• Monitor for side effects, particularly dizziness which can increase fall risk
• If switching from Lexapro to mirtazapine, monitor for discontinuation symptoms 1, 5
• Evaluate for sleep apnea as a potential contributor to insomnia, especially given patient's age 1

Common Pitfalls to Avoid

• Overreliance on medications without addressing sleep hygiene and CBT-I
• Polypharmacy - carefully review all current medications for interactions
• Inadequate trial of non-pharmacological approaches before adding medications
• Inappropriate dosing - elderly patients require lower doses due to altered pharmacokinetics 1
• Failure to address underlying causes of insomnia beyond depression

By following this approach, the patient's insomnia can be addressed while continuing to manage her depression, with careful consideration of her advanced age and medication history.