What can be added to carbidopa-levodopa, rivastigmine patch, and hydroxyzine 50mg PRN for an elderly female with Parkinson’s disease to manage anxiety and depression without increasing falls?

Management of Anxiety and Depression in Elderly Female with Parkinson's Disease

Start sertraline 25 mg daily as the safest and most evidence-based option for treating both anxiety and depression in this patient, while simultaneously discontinuing hydroxyzine due to its anticholinergic properties that worsen cognition and significantly increase fall risk in elderly Parkinson's patients. 1, 2

Critical Medication Review: Hydroxyzine Must Be Discontinued

Hydroxyzine is contraindicated in this patient and should be tapered off immediately. Anticholinergic medications like hydroxyzine worsen confusion, agitation, and cognitive function in elderly patients, particularly those with Parkinson's disease and dementia 3. The American Geriatrics Society explicitly recommends minimizing or discontinuing all anticholinergic medications including hydroxyzine, as they increase fall risk, worsen parkinsonian symptoms, and impair cognition 3.

First-Line Pharmacological Treatment: SSRIs

Sertraline as the Preferred Agent

Sertraline is the optimal choice for this patient based on multiple factors:

• Starting dose: 25 mg daily, titrating to 50 mg after 1 week 1
• Target dose range: 50-200 mg daily, with most patients responding to 50-100 mg 3, 1
• Timeline: Allow 4-8 weeks for full therapeutic effect 3

Evidence supporting sertraline in Parkinson's disease:

• Open-label studies demonstrate sertraline is generally well-tolerated in PD patients, with significant improvement in depression scores without worsening motor symptoms 1
• Sertraline has minimal drug interactions compared to other SSRIs, making it safer in polypharmacy situations 3
• The American Academy of Family Physicians designates sertraline as the top choice due to excellent tolerability and significant benefits in cognitive functioning and quality of life 3

Alternative SSRI: Citalopram

If sertraline is not tolerated, citalopram 10 mg daily (maximum 40 mg daily) is an equally safe alternative 4, 3. However, citalopram carries a higher risk of QTc prolongation compared to sertraline, requiring ECG monitoring in elderly patients 4.

Critical Drug Interaction Warning

Important caveat regarding selegiline: If this patient is taking selegiline (a MAO-B inhibitor commonly used in Parkinson's disease), there is increased risk of adverse effects when combined with SSRIs 1, 2. A "serotonin syndrome" has occurred frequently enough that some sources recommend caution with this combination 2. However, modern practice generally considers low-dose SSRI therapy acceptable with selegiline at standard doses, with careful monitoring for serotonin syndrome symptoms (tremor, diarrhea, delirium, neuromuscular rigidity, hyperthermia) 4.

Why NOT Other Antidepressants

Avoid these medication classes in elderly Parkinson's patients:

• Tricyclic antidepressants (TCAs): Significant anticholinergic effects worsen cognition, increase fall risk, cause orthostatic hypotension, and have cardiac toxicity 4, 2
• Monoamine oxidase inhibitors: Not well tolerated in PD patients despite theoretical benefits 2
• Mirtazapine: While safe from a cardiovascular standpoint, efficacy in treating depression in CVD/PD patients has not been adequately assessed 4
• Bupropion: Lowers seizure threshold, particularly concerning in elderly patients on multiple medications 3

Fall Risk Mitigation Strategy

This patient has multiple fall risk factors that must be addressed:

1. Discontinue hydroxyzine immediately - anticholinergics are independent risk factors for falls 4
2. Optimize Parkinson's motor symptoms with carbidopa-levodopa to reduce postural instability 4
3. Monitor for orthostatic hypotension when initiating sertraline, though SSRIs have lower risk than TCAs 4
4. Assess home safety - install grab bars, improve lighting, remove tripping hazards 4
5. Physical therapy consultation for gait training and balance exercises 4

Monitoring and Reassessment Protocol

Week 1-2:

• Monitor for initial side effects (nausea, sleep disturbances) 3
• Assess for serotonin syndrome if on selegiline 2
• Evaluate fall risk and orthostatic vital signs 4

Week 4:

• Assess response using quantitative measures (Beck Depression Inventory or similar) 1
• If inadequate response at 50 mg, increase to 100 mg daily 3

Week 8:

• Full therapeutic trial complete - if no clinically significant response, consider increasing to maximum 200 mg daily or switching to citalopram 3, 1

Ongoing:

• Continue treatment for minimum 9 months after first episode of depression 3
• Reassess need for continued medication after 9 months 3
• Monitor motor symptoms to ensure no worsening of parkinsonism 1

What NOT to Use for Anxiety

Benzodiazepines should be avoided despite their rapid anxiolytic effects. The American Geriatrics Society lists benzodiazepines on the Beers Criteria as potentially inappropriate medications in older adults due to increased risk of cognitive impairment, falls, paradoxical agitation (10% of elderly patients), tolerance, and addiction 4, 3. Hydroxyzine 50 mg PRN should be discontinued for the same reasons 3.

Rivastigmine Patch Considerations

Continue the rivastigmine patch - it is appropriate for Parkinson's disease dementia and may actually help with behavioral symptoms 4, 5. Rivastigmine is the only cholinesterase inhibitor approved specifically for Parkinson's disease dementia and should not be discontinued 5.

Common Pitfalls to Avoid

• Do not add buspirone - it takes 2-4 weeks to become effective and has limited evidence in PD, contributing to unnecessary polypharmacy 3
• Do not use antipsychotics for anxiety/depression - reserve only for severe psychosis refractory to other treatments, using quetiapine or clozapine if absolutely necessary 5
• Do not continue hydroxyzine - the anticholinergic burden outweighs any anxiolytic benefit 3
• Do not expect immediate results - SSRIs require 4-8 weeks for full effect, counsel patient accordingly 3