How should the medications of an elderly female patient with Parkinson's disease, currently taking Abilify (aripiprazole), Effexor (venlafaxine) 225mg, Buspirone 20mg, and Ativan (lorazepam) 1mg PO QD PRN for anxiety, be adjusted, considering an increase in Effexor to 262.5mg daily and a 90-day refill of Buspirone 20mg?

Medication Management for Elderly Female with Parkinson's Disease on Abilify

Critical Safety Concern: Buspirone Worsens Parkinson's Disease

Do not continue buspirone in this patient with Parkinson's disease—it should be tapered and discontinued, not refilled for 90 days. Multiple controlled studies demonstrate that buspirone at conventional anxiolytic doses (10-40 mg/day) is ineffective for Parkinson's disease, and at higher doses (≥100 mg/day) significantly worsens parkinsonian disability and increases anxiety 1, 2. Even at standard anxiolytic doses, 41-53% of PD patients experience adverse events consistent with worsened motor function 3.

Why Buspirone is Contraindicated in Parkinson's Disease

• Buspirone produces dose-dependent stimulation of norepinephrine neurons in the locus ceruleus, which adversely affects parkinsonian symptoms 1
• At doses of 50-100 mg/day, buspirone causes significant worsening of disability ratings and paradoxically increases anxiety in PD patients 1
• In a recent 2020 trial, 41% of PD patients failed to complete buspirone treatment due to intolerability, with 53% experiencing worsened motor function 3
• Buspirone's dopaminergic effects appear to reduce central dopamine-mediated synaptic function at higher doses, counterproductive in PD 1

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Lorazepam Dosing: Reduce Frequency and Dose

The current regimen of Ativan 1mg PO daily PRN should be reduced to 0.25-0.5 mg PRN with a maximum of 2 mg per 24 hours in this elderly patient. The FDA label explicitly states that elderly or debilitated patients require reduced doses of 1-2 mg/day in divided doses 4, and guidelines recommend 0.25-0.5 mg doses with a maximum of 2 mg/24 hours for elderly patients 5, 6.

Specific Lorazepam Adjustments

• Start with 0.25-0.5 mg PRN for anxiety episodes, allowing doses every 4-6 hours as needed, but not exceeding 2 mg total in 24 hours 5, 6
• Elderly patients face significantly higher risks of falls, cognitive decline, and paradoxical agitation (occurring in approximately 10% of patients) 6
• The tablets can be used sublingually if swallowing becomes difficult 5, 6
• Avoid daily scheduled dosing—use only PRN to minimize cumulative benzodiazepine exposure and dependence risk 6

Critical Benzodiazepine Warnings in Elderly PD Patients

• Benzodiazepines should be used at the lowest effective dose for the shortest duration possible, ideally no more than 2-4 weeks 6
• Regular use leads to tolerance, addiction, depression, and cognitive impairment 6
• Do not combine lorazepam with other sedatives, as this significantly increases respiratory depression risk 6

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Effexor (Venlafaxine) Increase: Proceed with Caution

The increase from 225 mg to 262.5 mg daily can proceed, but monitor closely for serotonergic effects and drug interactions with Abilify. This represents a modest 16% dose increase within the therapeutic range for venlafaxine.

Monitoring Considerations

• Venlafaxine is an SSRI/SNRI that can be effective for anxiety and depression in elderly patients 5
• Watch for increased sweating, tremors, nervousness, insomnia or somnolence, dizziness, and gastrointestinal disturbances—typical SSRI side effects 5
• In Parkinson's disease, SSRIs/SNRIs are generally well-tolerated and may help with both depression and anxiety without worsening motor symptoms 7

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Alternative Anxiety Management Strategy

After discontinuing buspirone, optimize the venlafaxine dose first (the 262.5 mg increase), then reassess anxiety control before adding other agents. If additional anxiolytic therapy is needed after 4-6 weeks:

Preferred Options for Anxiety in Elderly PD Patients

• Continue optimized venlafaxine as primary anxiolytic (SSRIs/SNRIs are first-line for anxiety in PD) 7
• Use lorazepam 0.25-0.5 mg PRN only for breakthrough anxiety, maximum 2 mg/24 hours 5, 6
• Consider non-pharmacologic interventions: structured activities, reassurance, socialization, education and support for caregivers 5

What to Avoid

• Do not restart or continue buspirone 1, 3, 2
• Avoid tricyclic antidepressants due to anticholinergic effects worsening cognition in elderly 5
• Minimize benzodiazepine use to PRN only, never scheduled daily dosing 6

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Practical Implementation Plan

1. Discontinue buspirone using gradual taper over 1-2 weeks (reduce by 50% for one week, then stop) 4
2. Simultaneously increase Effexor to 262.5 mg daily as planned
3. Reduce lorazepam to 0.25-0.5 mg PRN only, maximum 2 mg/24 hours, with explicit instructions to space doses at least 4-6 hours apart 5, 6, 4
4. Reassess anxiety symptoms in 4-6 weeks after buspirone washout and venlafaxine optimization
5. Monitor for worsening parkinsonian symptoms during buspirone taper (symptoms should improve after discontinuation) 1, 3