What can be done for an elderly male patient with hypertension and possible diabetes, taking propanolol, buspar (buspirone), Lexapro (escitalopram), trazodone, metformin, and losartan, who is seeking narcotics and displaying inappropriate behavior?

Management of Agitation and Drug-Seeking Behavior in an Elderly Patient on Multiple Psychotropic Medications

For this elderly male patient displaying agitation, inappropriate behavior, and drug-seeking, immediately initiate low-dose risperidone 0.5-1.0 mg daily while simultaneously conducting a comprehensive medication review to identify and eliminate potentially inappropriate medications that may be contributing to his behavioral disturbance. 1

Immediate Pharmacological Intervention

Risperidone is the first-line antipsychotic for agitated dementia with behavioral disturbances in elderly patients, starting at 0.5-2.0 mg/day. 1 This addresses the acute behavioral crisis of drug-seeking, verbal aggression toward staff, and inappropriate conduct. Quetiapine 50-150 mg/day and olanzapine 5.0-7.5 mg/day are high second-line alternatives if risperidone is not tolerated. 1

Critical Dosing Considerations

• Start at the lowest effective dose (0.5 mg daily) given his extensive polypharmacy and elderly status 1
• Titrate slowly over 1-2 weeks based on response, as elderly patients require more gradual dose adjustments 2
• Plan to taper within 3-6 months to determine the lowest effective maintenance dose for agitated dementia 1

Urgent Medication Review and Deprescribing

This patient's current regimen contains multiple potentially inappropriate medications that must be addressed immediately, as they may be contributing to his behavioral disturbance and increasing his risk of adverse outcomes. 3

High-Priority Medications to Evaluate

Trazodone poses significant concerns in this patient:

• Trazodone is listed as a potentially inappropriate medication in older adults due to CNS effects including sedation and increased fall risk 3
• The combination of trazodone with escitalopram (Lexapro) creates risk for serotonin syndrome, which can manifest as agitation and behavioral changes 4
• Consider tapering and discontinuing trazodone, replacing with non-pharmacological sleep interventions if used for insomnia 3

Propranolol requires careful evaluation:

• Beta-blockers can cause CNS adverse effects including confusion and behavioral changes in elderly patients 3
• Propranolol crosses the blood-brain barrier more readily than other beta-blockers, increasing neurotoxicity risk 3
• If beta-blockade is essential for hypertension control, consider switching to a cardioselective agent with less CNS penetration 5

Buspirone (Buspar) and Escitalopram (Lexapro) combination:

• This combination of two anxiolytic/antidepressant agents may represent overtreatment and contribute to polypharmacy burden 3
• Review whether both agents are providing distinct therapeutic benefit or if consolidation is possible 3
• SSRIs like escitalopram have lower interaction potential than older antidepressants, but the overall medication burden must be reduced 4

Systematic Medication Reconciliation Process

Conduct a structured polypharmacy review using the following stepwise approach: 3

1. Verify actual medication adherence - Confirm what the patient is actually taking versus what is prescribed, as non-adherence or incorrect dosing may contribute to behavioral symptoms 3

2. Screen for drug-drug interactions - The combination of multiple psychotropic medications (propranolol, buspirone, escitalopram, trazodone) with antihypertensives creates significant interaction risk 3, 4

3. Identify drug-disease interactions - Propranolol may worsen cognitive function in a patient already displaying behavioral disturbances 3

4. Apply Beers Criteria screening - Multiple medications in this regimen (trazodone, potentially propranolol) are flagged as high-risk in older adults 3

5. Assess for cognitive impairment - Use a standardized tool like the Mini-Mental State Examination (MMSE), as cognitive decline can manifest as behavioral disturbances and difficulty with medication self-management 3

Addressing the Drug-Seeking Behavior

The narcotic-seeking behavior requires a non-opioid pain management strategy if pain is the underlying driver:

• Never prescribe opioids for this patient given the drug-seeking behavior and high risk of adverse effects in elderly patients 3
• Evaluate for unrecognized pain conditions that may be driving the behavior 3
• Consider whether agitation and drug-seeking represent undertreated psychiatric symptoms, delirium, or medication-induced behavioral changes 3
• Screen for delirium as a reversible cause of behavioral disturbance before attributing symptoms to a primary psychiatric condition 3

Hypertension Management Optimization

The current antihypertensive regimen (propranolol, losartan, metformin) requires evaluation for appropriateness:

• Losartan (ARB) is appropriate for this patient with diabetes and hypertension, as ACE inhibitors or ARBs are recommended first-line agents 3
• Monitor renal function and potassium within the first 3 months, then every 6 months 3
• Target blood pressure <130/80 mmHg for patients with diabetes, though <140/90 mmHg is acceptable in very elderly or frail patients 3, 5
• If propranolol is discontinued, consider adding a thiazide diuretic or calcium channel blocker to the losartan regimen 3

Monitoring Protocol After Intervention

Implement the following monitoring schedule:

• Assess behavioral symptoms daily for the first week after initiating risperidone 1
• Check orthostatic vital signs to detect hypotension from the antipsychotic-antihypertensive combination 5
• Monitor for extrapyramidal symptoms, sedation, and falls risk weekly for the first month 3, 1
• Reassess cognitive function with MMSE at 2-4 weeks to determine if behavioral symptoms improve 3
• Review medication list every 2-4 weeks during the deprescribing process 3

Critical Pitfalls to Avoid

Do not prescribe benzodiazepines (such as lorazepam or diazepam) for agitation, as they are potentially inappropriate medications in older adults with high risk of falls, cognitive impairment, and paradoxical agitation 3, 6

Do not use high-potency typical antipsychotics like haloperidol >2 mg/day, as these are listed as potentially inappropriate medications with higher risk of extrapyramidal symptoms than atypical agents 3, 6

Do not continue all current medications unchanged while adding an antipsychotic, as this increases polypharmacy burden and adverse event risk without addressing potentially reversible medication-induced causes of the behavioral disturbance 3, 2

Do not attribute all behavioral symptoms to a primary psychiatric disorder without first ruling out delirium, medication adverse effects, uncontrolled pain, or metabolic disturbances as reversible causes 3