How should I manage a nursing‑home resident woman in her late 70s with chronic stroke sequelae, recent hip fracture, worsening depression and insomnia despite fluoxetine 40 mg daily for >1 year, stable weight, no renal impairment or hypertension?

Management of Treatment-Resistant Depression with Insomnia in an Elderly Post-Stroke Nursing Home Resident

Switch fluoxetine to sertraline or citalopram, add low-dose trazodone 25-50 mg at bedtime for insomnia, and implement cognitive behavioral therapy for insomnia (CBT-I) with environmental modifications in the nursing home setting. 1

Rationale for Changing the Antidepressant

• Fluoxetine is generally not recommended for older adults due to its long half-life (1-4 days for fluoxetine, 7-15 days for norfluoxetine) and increased side effect burden, including insomnia as a common adverse effect. 2, 3

• The American Geriatrics Society recommends SSRIs as first-line antidepressants for older nursing home residents, with citalopram and sertraline receiving the highest ratings for efficacy and tolerability in this population. 1

• Sertraline is effective and well-tolerated in elderly patients with major depressive disorder, though it can cause insomnia as a side effect, so its use should be carefully monitored. 3

• After more than one year on fluoxetine 40 mg daily with worsening depression, this represents treatment failure requiring a medication change rather than dose escalation. 4

Addressing the Insomnia Component

• The American Geriatrics Society recommends low-dose trazodone 25-50 mg at bedtime as the most practical option for short-term insomnia management in elderly nursing home residents, as it addresses both depression and insomnia without the risks of benzodiazepines. 1

• SSRIs, including fluoxetine, are known to cause or worsen insomnia in elderly patients, making this a likely medication-induced sleep disturbance that must be addressed by switching agents. 3

• Mirtazapine 7.5-15 mg at bedtime is an alternative if the patient has comorbid depression and anorexia/poor appetite, though weight is currently stable. 1

• Benzodiazepines (temazepam, lorazepam) must be avoided due to high risk of falls, cognitive impairment, respiratory depression, paradoxical agitation, and delirium in elderly patients, with particular concern in post-stroke patients. 1, 5

Implementing Non-Pharmacological Sleep Interventions

• Cognitive behavioral therapy for insomnia (CBT-I) is the gold standard first-line treatment for elderly patients with chronic insomnia, with benefits sustained for up to 2 years without medication-related risks. 3, 6

• CBT-I components to implement include: keeping a 2-week sleep log, limiting time in bed to match actual sleep time (sleep restriction), using the bedroom only for sleep, leaving the bedroom if unable to fall asleep within 20 minutes, maintaining consistent sleep-wake times, and avoiding daytime napping. 3

• Environmental modifications in the nursing home setting—decreased nighttime noise and light disruption—can reduce nighttime arousals and are often caused by staff providing care to the resident or roommate. 5

• Multicomponent interventions combining increased daytime physical activity, sunlight exposure (residents with higher light levels had fewer nighttime awakenings), decreased time in bed during the day, bedtime routine, and decreased nighttime noise/light may decrease the duration of nighttime awakenings. 5, 6

• Nearly three-quarters of nursing home residents sleep excessively during the day; those with excessive daytime sleeping were observed more often in bed, were less likely to have any time outdoors, and had less social and physical activity. 5

Addressing Post-Stroke Depression Specifically

• Depression is a common but often unrecognized complication after cerebrovascular stroke, and fluoxetine 20 mg has been shown to reduce the occurrence of depression in post-stroke patients. 7, 8

• However, the FOCUS trial (3127 patients) demonstrated that fluoxetine 20 mg given daily for 6 months after acute stroke does not improve functional outcomes (modified Rankin Scale) and increased the frequency of bone fractures (2.88% vs 1.47%, p=0.0070). 8, 9

• Most fractures in the FOCUS trial resulted from falls (90%), with 40% being neck of femur fractures; independent predictors were age >70 years (HR 1.97), female sex (HR 2.13), and fluoxetine use (HR 2.00). 9, 10

• Given this patient's late 70s age, female sex, recent hip fracture, and post-stroke status, continuing fluoxetine poses significant fracture risk that outweighs potential benefits. 9, 10

Critical Medication Interactions and Monitoring

• If using trazodone with an SSRI (sertraline or citalopram), monitor for serotonin syndrome (agitation, confusion, tremor, tachycardia, hypertension). 1

• Avoid combining multiple sedating medications, as this dramatically increases fall and delirium risk in elderly nursing home residents. 1

• Centrally acting α2-adrenergic receptor agonists (clonidine) and α1-receptor antagonists (prazosin) have been associated with poorer outcomes in stroke recovery and should be avoided if hypertension develops. 5

Practical Implementation Algorithm

1. Taper fluoxetine gradually over 2-4 weeks given its long half-life (7-15 days for norfluoxetine) to minimize discontinuation symptoms. 2

2. Initiate sertraline 25 mg daily in the morning (or citalopram 10 mg daily) during the fluoxetine taper, then increase to sertraline 50 mg daily after 1 week. 1

3. Add trazodone 25 mg at bedtime immediately for insomnia, increasing to 50 mg after 3-5 days if tolerated and needed. 1

4. Implement CBT-I components: work with nursing staff to establish a consistent sleep-wake schedule, increase daytime physical and social activities, maximize bright light exposure during the day, minimize time in bed during the day, and reduce nighttime noise and light interruptions. 5, 6

5. Reassess depression symptoms (using standardized scales like HAM-D or PHQ-9) and sleep quality at 2 weeks, 4 weeks, and 8 weeks after the medication change. 7

6. If depression improves but insomnia persists after 4-6 weeks of trazodone plus CBT-I, consider switching to mirtazapine 7.5-15 mg at bedtime as a single agent for both conditions. 1

Common Pitfalls to Avoid

• Do not use "as needed" dosing for antidepressants, as these must be scheduled daily for efficacy. 1

• Do not assume insomnia requires medication before attempting environmental modifications and CBT-I components, as many cases in nursing home residents are due to institutional factors (noise, light, lack of daytime activity). 5, 1

• Do not prescribe benzodiazepines or antihistamines (diphenhydramine, hydroxyzine) under any circumstances, as these have anticholinergic effects that can accelerate cognitive decline and cause daytime hypersomnolence in elderly patients. 5, 3

• Do not overlook pain, nocturia, or other medical comorbidities as contributors to sleep disturbance and depression in post-stroke nursing home residents. 5, 6

• Do not continue fluoxetine at the current dose given treatment failure after >1 year and the increased fracture risk in this high-risk patient (elderly female, post-stroke, recent hip fracture). 8, 9, 10