What adjustments can be made to an elderly patient's medication regimen, consisting of Abilify (aripiprazole) 2mg at bedtime, Buspar (buspirone) 15mg orally (po) twice a day (bid), and Lexapro (escitalopram) daily, to address increased sleepiness and depressive symptoms?

Medication Adjustment for Increased Somnolence and Depression in Elderly Patient

The most likely culprit for increased sleepiness and worsening depression is the combination of Abilify at bedtime with Lexapro, and the first step should be to discontinue or significantly reduce the Abilify dose while optimizing the antidepressant regimen. 1, 2

Immediate Assessment and Medication Review

Evaluate the current medication regimen systematically, as polypharmacy with sedating agents is likely contributing to excessive somnolence:

• Abilify (aripiprazole) 2mg at bedtime is problematic because:

  • The FDA label reports that escitalopram/citalopram combinations with aripiprazole can cause excessive sedation 2
  • Aripiprazole carries an FDA boxed warning about increased mortality risk in elderly patients with dementia 1
  • The combination of aripiprazole with SSRIs like Lexapro increases CNS side effects, particularly drowsiness and nervousness 3
  • In elderly patients, even low doses (2mg) can accumulate and cause excessive sedation 4

• Lexapro (escitalopram) may be contributing to:

  • Excessive somnolence, particularly in elderly patients where half-life increases by 50% 2
  • SSRIs are associated with increased sedation in older adults and can worsen depression if not optimally dosed 2, 5
  • The FDA label specifically warns about excessive sedation and restlessness as adverse effects 2

• Buspar (buspirone) 15mg BID is generally well-tolerated but:

  • Takes 2-4 weeks to become effective for agitation 6
  • May have additive sedative effects when combined with other CNS depressants 7

Recommended Medication Adjustments

Primary recommendation: Discontinue Abilify and reassess the need for antipsychotic therapy 6, 1:

1. Taper and discontinue aripiprazole over 1-2 weeks, as the risks outweigh benefits in this clinical scenario where depression and somnolence are worsening 1, 4

2. Optimize the antidepressant regimen:

   • Verify the current Lexapro dose (should be 10mg daily maximum in elderly patients per FDA labeling) 2
   • If depression persists after stopping Abilify, consider switching to a more activating antidepressant like bupropion (37.5mg every morning, titrated by 37.5mg every 3 days to maximum 150mg BID) 6
   • Alternatively, consider nortriptyline 10mg at bedtime (maximum 40mg daily) if agitated depression with insomnia is the primary concern 6

3. Continue Buspar 15mg BID as it has minimal sedative effects and may help with residual agitation 6, 7

Management of Excessive Somnolence

If somnolence persists after discontinuing Abilify, implement the following algorithm 1:

• Rule out contributing factors:

  • Check TSH, CBC, CMP, and LFTs to exclude metabolic causes 1
  • Assess for sleep apnea using Epworth Sleepiness Scale 1
  • Evaluate medication timing (ensure Lexapro is given in morning if causing sedation) 2

• Non-pharmacological interventions first:

  • Increase daytime light exposure and physical/social activities 1
  • Maintain regular sleep-wake schedule with consistent bedtimes 1
  • Schedule two brief naps rather than extended daytime sleep 1

• If non-pharmacological measures fail:

  • Consider modafinil 100mg upon awakening (can increase weekly to 200-400mg daily range) 1
  • Avoid benzodiazepines entirely as they worsen cognitive performance in elderly patients with dementia 1, 8

Critical Safety Considerations

Monitor closely for the following during medication adjustments:

• Withdrawal effects from Abilify discontinuation: Monitor for rebound agitation or psychotic symptoms over 2-4 weeks 4
• Worsening depression: Reassess depression severity weekly during the first month using standardized scales 6
• Paradoxical agitation: If agitation worsens after stopping Abilify, consider mood stabilizers like divalproex sodium (125mg BID, titrated to therapeutic level 40-90 mcg/mL) rather than restarting antipsychotics 6
• Avoid melatonin: It should not be used in older patients due to poor FDA regulation and inconsistent preparations 1

Alternative Approach if Agitation Requires Treatment

If severe agitation necessitates continued treatment after Abilify discontinuation 6:

• First-line for agitation without psychosis: Trazodone 25mg daily (maximum 200-400mg in divided doses), which is less sedating than antipsychotics and has mood-stabilizing properties 6
• Second-line: Divalproex sodium 125mg BID, better tolerated than other mood stabilizers with regular liver enzyme monitoring 6
• Avoid typical antipsychotics: They cause extrapyramidal symptoms in 50% of elderly patients after 2 years of continuous use 6