What is the best approach to manage a 74-year-old patient with self-excoriation, anxiety, and depressive symptoms, on fluoxetine (SSRI), propranolol (Beta Blocker), and Vistaril (Hydroxyzine), with lack of ADL care and apathy?

Management of Self-Excoriation, Anxiety, and Depression in a 74-Year-Old Patient

The current medication regimen requires immediate optimization: discontinue fluoxetine and hydroxyzine due to their unfavorable profiles in older adults, continue propranolol (which may help with anxiety and akathisia prevention), and initiate sertraline or escitalopram at half the standard adult dose while implementing a comprehensive behavioral intervention program for the skin picking. 1

Critical Medication Issues Requiring Immediate Attention

Problems with Current Regimen

• Fluoxetine should be avoided in older adults due to its long half-life, greater risk of agitation and overstimulation, extensive drug interactions, and higher anticholinergic burden compared to other SSRIs 1, 2

• Hydroxyzine (Vistaril) poses significant risks in elderly patients due to excessive anticholinergic burden, which increases risk of cognitive impairment, delirium, falls, and sedation—particularly problematic given the patient's existing apathy and ADL deficits 3, 2, 4

• The combination of fluoxetine and hydroxyzine creates compounded anticholinergic effects that may be contributing to the apathy and functional decline 2

• Propranolol can be continued as it may provide dual benefit for anxiety and can prevent akathisia if switching antidepressants 5

Recommended Medication Changes

Transition to a preferred SSRI for older adults:

• Sertraline or escitalopram are the first-line agents with the highest ratings for efficacy and tolerability in older adults 1

• Start at 50% of standard adult doses: sertraline 25 mg daily or escitalopram 5-10 mg daily 1, 2

• Fluoxetine washout strategy: Given fluoxetine's 1-3 week active half-life, consider a 2-week washout before initiating the new SSRI, or use a conservative cross-taper with close monitoring for serotonin syndrome 6, 7

• Titrate gradually at 1-2 week intervals, monitoring for tolerability and response 2

Addressing Self-Excoriation (Skin Picking)

Understanding the Behavior

• Skin picking in this context likely represents multiple overlapping issues: anxiety manifestation, compulsive behavior, and possibly medication-induced akathisia or agitation from fluoxetine 8, 5

• The behavior may intensify during SSRI treatment due to drug-induced activation or akathisia, which can present as restlessness and compulsive behaviors 8, 5

Behavioral Interventions (First-Line)

• Cognitive behavioral therapy (CBT) should be offered as it has the highest level of evidence for anxiety disorders and can specifically target skin-picking behaviors 3, 2

• Habit reversal training is a specific CBT technique effective for body-focused repetitive behaviors like skin picking 3

• Environmental modifications: Remove or cover mirrors, keep hands occupied with fidget tools, wear gloves or long sleeves as barriers 3

Pharmacological Considerations

• N-acetylcysteine (NAC) 1200-2400 mg daily has evidence for reducing skin-picking behaviors, though this is based on general medicine knowledge rather than the provided evidence

• The new SSRI (sertraline or escitalopram) may help with both anxiety and compulsive skin-picking behaviors, but requires 6-8 weeks for full assessment 1, 9

• If skin picking persists after 8 weeks of optimized SSRI therapy, consider augmentation strategies or referral to psychiatry for specialized management 3

Managing Depression and Apathy

Assessment and Monitoring

• Assess treatment response at 4 weeks and 8 weeks using standardized validated instruments (PHQ-9 or HAM-D) 3, 1

• Distinguish between medication-induced apathy (from fluoxetine/hydroxyzine) versus primary depressive symptoms 3, 1

• Screen for underlying dementia given the age, apathy, and ADL deficits—this would significantly alter the treatment approach 3

Treatment Strategy

• Antidepressants double the likelihood of remission in older adults (36% vs 21% on placebo), with evidence equally strong for psychotherapy 1

• Continue treatment for 4-12 months after first episode remission, or longer if recurrent depression 1, 2

• Address functional decline concurrently: The lack of ADL care may improve with treatment of depression, but may also require occupational therapy evaluation and caregiver support 3

Comprehensive Management Approach

Multidisciplinary Team Involvement

• Establish care coordination with primary care, psychiatry/geriatric psychiatry, and behavioral health 3

• Caregiver education and support is essential—provide written materials about depression, anxiety, and behavioral management strategies 3

• Consider home health evaluation to assess safety, medication management capacity, and ADL support needs given the functional decline 3

Non-Pharmacological Interventions

• Structured physical activity programs have moderate antidepressant effects (standardized mean difference -0.82) and improve anxiety 3, 1

• Address social isolation through referral to local social assistance programs, senior centers, or community resources 1

• Optimize nutrition and encourage social engagement as part of comprehensive geriatric care 1

Safety Monitoring

• Baseline assessments before starting new SSRI:

  • Serum sodium (SSRIs cause hyponatremia in 0.5-12% of elderly patients, typically in first month) 1
  • Renal function (creatinine clearance) 1
  • Blood pressure (orthostatic measurements) 1
  • Fall risk assessment 1

• Monitor for bleeding risk if patient takes NSAIDs, aspirin, or anticoagulants—SSRIs increase GI bleeding risk 15-fold when combined with NSAIDs 1, 2

• Assess for suicidal ideation, though antidepressants appear protective in adults over 65 (OR 0.06) 1

Treatment Timeline and Expectations

Weeks 1-2

• Discontinue hydroxyzine immediately 3, 2
• Begin fluoxetine taper or washout 6, 7
• Continue propranolol 5
• Initiate behavioral interventions for skin picking 3

Weeks 2-4

• Start sertraline 25 mg or escitalopram 10 mg daily 1, 2
• First follow-up assessment at week 4 3, 1
• Monitor for early adverse effects (nausea, anxiety, agitation) which typically resolve within 1-2 weeks 2

Weeks 4-8

• Assess response using standardized measures 3, 1
• If inadequate response, increase dose (sertraline to 50 mg, escitalopram to 15-20 mg) 1, 2
• Continue behavioral therapy 3

Week 8 and Beyond

• If stable or worsening despite good adherence: Consider switching to SNRI (venlafaxine), augmentation strategies, or intensifying psychotherapy 3, 2
• If responding well: Continue treatment for minimum 4-12 months after remission 1, 2

Critical Pitfalls to Avoid

• Never use standard adult starting doses in elderly patients—always reduce by approximately 50% 1

• Do not combine SSRIs with NSAIDs without gastroprotection (PPI) given the 15-fold increased bleeding risk 1, 2

• Do not abruptly discontinue SSRIs—taper gradually over 10-14 days to avoid discontinuation syndrome (dizziness, paresthesias, anxiety, irritability) 2, 6

• Do not attribute all symptoms to depression—consider medication adverse effects, particularly anticholinergic burden from current regimen 3, 2

• Do not overlook caregiver burden—assess caregiver stress and provide support resources 3

• Do not delay evaluation for dementia if cognitive impairment is suspected, as this fundamentally changes the treatment approach 3, 1