How to manage a 65-year-old patient experiencing crying episodes at 2 am for the past week, who is on a medication regimen including Seroquel (quetiapine) XR 200 mg, Lamictal (lamotrigine) 200 mg, clonidine 0.5 mg, Ativan (lorazepam) 0.5 mg in the morning and afternoon, and Belsomra (suvorexant) at night?

Management of 2 AM Crying Episodes in a 65-Year-Old on Complex Psychotropic Regimen

Immediate Priority: Address Polypharmacy and High-Risk Medications

This patient's crying episodes are most likely medication-related, specifically from the excessive benzodiazepine burden (Ativan 1.5 mg daily total) combined with multiple sedating agents, and the first step is to systematically reduce this polypharmacy while investigating for underlying depression or breakthrough mood symptoms. 1

Step 1: Comprehensive Medication Review and Deprescribing Strategy

• Benzodiazepines are high-risk medications in older adults that should be avoided or minimized according to Beers Criteria, as they cause cognitive impairment, falls, paradoxical agitation in 10% of elderly patients, and can worsen mood symptoms. 1

• The current regimen includes Ativan 0.5 mg three times daily (morning, afternoon, bedtime via Belsomra timing), creating significant sedative burden and anticholinergic effects that can paradoxically worsen emotional dysregulation and cause early morning awakening with dysphoria. 1

• Begin tapering Ativan immediately, reducing by 0.25 mg every 1-2 weeks to avoid withdrawal, starting with the afternoon dose first, then morning dose, with the bedtime dose last since Belsomra is already providing sleep support. 1

Step 2: Investigate Underlying Causes of 2 AM Crying

• Systematically rule out medical triggers including pain (major contributor to behavioral symptoms in older adults), urinary tract infection, constipation, urinary retention, and medication side effects before adjusting psychotropics. 1, 2

• Assess for breakthrough depression or inadequate mood stabilization, as crying episodes at 2 AM suggest either REM sleep-related emotional dysregulation, medication-induced mood destabilization, or undertreated depression despite current regimen. 1, 3

• Review the Seroquel XR 200 mg and Lamictal 200 mg dosing to ensure therapeutic levels are maintained, as subtherapeutic mood stabilization can manifest as nocturnal emotional lability. 4, 5

Step 3: Optimize Existing Antidepressant Therapy

• Consider adding or optimizing an SSRI (citalopram 10-20 mg daily or sertraline 25-50 mg daily) as first-line treatment for emotional dysregulation and crying episodes, as SSRIs are the preferred antidepressants in older adults with the best tolerability profile. 3, 6, 5

• Citalopram and sertraline have minimal drug-drug interactions and are particularly suitable in this polypharmacy situation, unlike fluoxetine or paroxetine which inhibit CYP2D6 and could interact with other medications. 6, 5

• SSRIs require 4 weeks at adequate dosing before assessing response, so initiate early while tapering benzodiazepines. 2, 3

Step 4: Address Sleep Architecture and Timing

• The 2 AM timing suggests REM sleep behavior disorder or REM-related emotional dysregulation, which can be exacerbated by the current medication combination, particularly the interaction between Belsomra (orexin antagonist) and multiple sedating agents. 1

• Clonidine 0.5 mg may be contributing to nocturnal hypotension causing early morning awakening with sympathetic surge and emotional dysregulation, so check orthostatic vital signs and consider dose reduction. 1

• Belsomra (suvorexant) is appropriate for sleep maintenance but may need dose adjustment if the patient is experiencing middle-of-night awakening with emotional symptoms. 1

Step 5: Monitor for Drug-Drug Interactions and Anticholinergic Burden

• Review all medications for anticholinergic effects that worsen cognition and mood in elderly patients, though the current regimen appears relatively low in anticholinergic burden. 1

• Monitor for QT prolongation risk given the combination of Seroquel XR and potential SSRI addition, though this combination is generally safe at these doses. 1

• Assess for serotonin syndrome risk if adding an SSRI to the current regimen, though risk is low with this combination. 1

Specific Treatment Algorithm

1. Week 1-2: Reduce afternoon Ativan 0.5 mg to 0.25 mg, add citalopram 10 mg daily in morning, rule out UTI/pain/constipation. 1, 3

2. Week 3-4: Discontinue afternoon Ativan completely, increase citalopram to 20 mg if tolerated, monitor for improvement in crying episodes. 3, 6

3. Week 5-6: Reduce morning Ativan 0.5 mg to 0.25 mg, continue monitoring mood and sleep. 1

4. Week 7-8: Discontinue morning Ativan, assess response to SSRI at 4 weeks, consider increasing to maximum dose (citalopram 40 mg) if partial response. 3, 5

5. Week 9-12: Taper bedtime Ativan if sleep remains stable on Belsomra alone, continue SSRI indefinitely if effective. 1, 3

Critical Safety Warnings

• All antipsychotics including Seroquel carry increased mortality risk in elderly patients, so ensure ongoing indication is clear and dose is minimized. 1, 2

• Benzodiazepine withdrawal can cause rebound anxiety and insomnia, so taper slowly and monitor closely for withdrawal symptoms. 1

• Do NOT add another antipsychotic (such as aripiprazole or risperidone) for these crying episodes, as the patient is already on Seroquel XR and adding another would increase mortality risk without addressing the underlying mood disorder. 1, 2