What can be given to a 71-year-old patient with a history of schizophrenia, currently on Zyprexa (olanzapine) 15mg and mirtazapine 7.5mg, who has stopped eating and drinking, experienced 4 falls, and has anxiety?

Management of Anxiety in a 71-Year-Old with Schizophrenia

For anxiety in this elderly patient already on olanzapine 15mg and mirtazapine 7.5mg, add lorazepam 0.5-1 mg orally every 4 hours as needed, while addressing the underlying causes of stopped eating/drinking and falls. 1

Critical Safety Considerations

Avoid long-acting benzodiazepines in this elderly patient as they increase risk of cognitive impairment, delirium, and falls—all already present in this case. 1 The American Geriatrics Society strongly advises against benzodiazepines in patients aged 65+ due to these risks. 1

Be cautious with the current medication combination. The patient is already on both olanzapine and mirtazapine, which together can increase risk of serotonin syndrome, sedation, and metabolic effects. 2, 3 One case report documented serotonin syndrome from combined mirtazapine and olanzapine use complicated by rhabdomyolysis and acute renal failure. 2

Immediate Assessment Priorities

Before adding anxiety medication, evaluate:

• Rule out delirium as the primary cause of anxiety, given the history of falls, stopped eating/drinking, and acute functional decline. 1
• Assess for medication side effects including akathisia from olanzapine, which can present as anxiety and agitation. 4
• Check for medical causes: hypoxia, infection, metabolic derangements, pain, constipation, or urinary retention. 1
• Evaluate for substance withdrawal including alcohol or benzodiazepines. 1

Pharmacologic Management Algorithm

First-Line for Anxiety (if not delirium):

Lorazepam 0.5-1 mg orally every 4 hours as needed is recommended by NCCN guidelines for anxiety contributing to symptoms in palliative/geriatric populations. 1 This short-acting benzodiazepine provides rapid anxiolysis while minimizing accumulation risk in elderly patients.

Alternative Considerations:

• If akathisia is suspected: Reduce olanzapine dose or add propranolol rather than benzodiazepines. 4
• If insomnia accompanies anxiety: The current mirtazapine 7.5mg dose can be increased to 15-30mg at bedtime for dual benefit. 1 Mirtazapine is safe in elderly patients and offers appetite stimulation, which may help with the eating/drinking issues. 1
• If severe agitation/distress: Olanzapine can be titrated up from 15mg (typical range 5-20mg daily) as it has anxiolytic properties. 1, 5 However, monitor closely for increased sedation and falls risk.

Medication Optimization Strategy

Consider whether current medications are optimized:

• Olanzapine 15mg is at the higher end of the therapeutic range and may be contributing to sedation and falls. 5 In elderly patients, lower doses (5-10mg) often suffice. 6
• Mirtazapine 7.5mg is a low dose; increasing to 15-30mg may improve both anxiety and appetite without adding another medication. 1

Critical Monitoring

• Falls risk assessment: This patient has already had 4 falls. Any sedating medication increases this risk further. 1
• Metabolic monitoring: Both olanzapine and mirtazapine cause weight gain; monitor BMI, glucose, and lipids. 4
• Cognitive function: Assess for delirium daily using validated tools, as benzodiazepines can worsen confusion. 1
• Vital signs: Monitor for orthostatic hypotension contributing to falls. 1

Non-Pharmacologic Interventions

• Address dehydration and nutritional status urgently—this may be the primary driver of anxiety and functional decline. 1
• Environmental modifications: Reduce fall hazards, ensure adequate lighting, provide assistive devices. 1
• Cognitive-behavioral approaches: Reassurance, reorientation, and structured routines for anxiety management. 1

Common Pitfalls to Avoid

• Do not add multiple sedating agents without addressing underlying causes—this patient is already on two sedating medications. 2
• Do not use long-acting benzodiazepines (diazepam, clonazepam) in elderly patients due to accumulation and prolonged effects. 1
• Do not assume anxiety is purely psychiatric—in elderly patients with acute functional decline, medical causes predominate. 1
• Avoid antipsychotic polypharmacy—adding another antipsychotic for anxiety is not indicated and increases side effect burden. 1