Severe fatigue in an 89 year old female!

[mjl1717]

An 89 year old female with controlled HTN and controlled hyperlipidemia but prediabetes. In addition she is treated for severe insomnia and an anxiety disorder. Her morning regimen is: Triamterene / HCTZ 37.5mg/25mg, Amlodipine 5mg, Olmesarten medoxomil 40mg, Isosorbide mononitrate ER 30mg, Rosuvastatin 10mg, ASA 81mg all PO QD..The evening dosing is trickier. Melatonin 3mg 1/2 half hour before bedtime. Trazadone 100mg 1/2 hour before bedtime, Also she takes Venlafaxine ER 75mg at 5pm All meds are po and daily. The question is which Rx is most likely to cause severe fatigue that dissipates at 5 or 6 pm every day? The fatigue is such that she barely keeps her head up before 5-6pm

---

Members don't see this ad.

 

[RxPreceptor]

I would be suspicious of venlafaxine ER; low dose it's mechanistically an SSRI and can be quite variable/person specific for causing insomnia or somnolence (more suspicious for causing insomnia if dosed >150mg/day when dosed later in the day when more SNRI activity). Would question consistency in time of day dosing for venlafaxine and history of use

Other factor to consider would be BP monitoring/excessive orthostasis/dizziness from BP lowering meds and VD from isosorbide (re: barely keeps her head up before 5-6pm)

 

[PharmDBro2017]

Melatonin gives me a very hungover/fatigue type feel the next day. I'd DC it and tell the patient to improve their sleep hygiene.

I'm confused at this overall... how do you have severe insomnia and severe fatigue at the same time? So tired that you cannot fall asleep?

 

[johnpharm01]

An 89 year old female with controlled HTN and controlled hyperlipidemia but prediabetes. In addition she is treated for severe insomnia and an anxiety disorder. Her morning regimen is: Triamterene / HCTZ 37.5mg/25mg, Amlodipine 5mg, Olmesarten medoxomil 40mg, Isosorbide mononitrate ER 30mg, Rosuvastatin 10mg, ASA 81mg all PO QD..The evening dosing is trickier. Melatonin 3mg 1/2 half hour before bedtime. Trazadone 100mg 1/2 hour before bedtime, Also she takes Venlafaxine ER 75mg at 5pm All meds are po and daily. The question is which Rx is most likely to cause severe insomnia that dissipates at 5 or 6 pm every day? The insomnia is such that she barely keeps her head up before 5-6pm

Undertreated depression , underlying dementia exacerbated by anticholinergic side effects of meds and dehydration, sundowning leads to increase in energy level at 5 pm

 

[zelman]

Are you asking about fatigue or insomnia?

 

[mjl1717]

Im sorry! The question should be which med most likely causes the severe fatigue! Where during the day before 5pm she can barely lift her head up.
After about 5 pm the fatigue dissipates. As far as the insomnia. She may sleep from 11pm to 3 am, go to restroom and have trouble returning to sleep. Lets just say moderate insomnia.

 

[steveysmith54]

Both could be a sign of under-treated depression
Since the pt has HTN, I'd rather that she not take a norepinephrine reuptake inhibitor, I'd consider changing it to an SSRI.

I am not a big fan of a Trazodone, a male pt had told me that it caused a "hang over/buzzed" type of a side effect.

Why both melatonin and Trazodone? Why not try an optimal dose of one?

 

[mjl1717]

Thank you very much guys!

 

[RxPreceptor]

Trazodone and melatonin: could be much worse in causing daytime fatigue/hangover effect. Both are fairly short half-life drugs. Take on an empty stomach (fat delays peak onset of effect and extends possibility of hangover effect). Like others have mentioned, are both really necessary? Trazodone is not a bad option for elderly for sleep compared to the alternatives (fairly little anticholinergic effects but does have alpha-1 blockade/contributes to orthostasis)

I still believe the evaluation of the SSRI is likely related to the underlying issue or at least a contribution (sure lifestlye, activity, diet, stress relief, sleep hygiene, etc.). Would evaluate how much benefit patient has really derived, history of use/dose/duration of tx, etc.

 

[rxkrafted]

I don't think the 5-6pm fatigue is medication induced but more likely from poor insomnia and anxiety treatment. I don't know how well her anxiety is controlled but that could also be contributing to her uncontrolled insomnia at night. If that's the case, then its a combination of uncontrolled GAD and insomnia. I believe if you optimize treatment for these and her fatigue should improve.

 

[Old Timer]

The question really is why is an 89 Y/o woman on 9 medications? WTF are we trying to accomplish? Rasuvastatin in an 89 Y/O? Why so she can live to 95 instead of 93? There is care and then there is quality of care. This is really poor care and if it was my mother she would be off half of these drugs. At this point you have to balance quality of life V qty of life. At 89, there is not much qty left. She should not be exposed to side effects for little if any benefit at all.

 

[BidingMyTime]

I agree with Old Timer, I would D/C the rosuvastatin. For the fatigue, I would cut both the melatonin and trazodone dose in half. EIther one of those could cause a hung-over feeling, and while 5:00pm seems late for it to dissipate, given her advanced age, she is probably more sensitive to this. Actually, I'd recommend she try cutting out both of them for at least a week, and then reevaluate. But assuming she probably won't want to do that, try halfing the dose of both and see if that helps.

 

[Old Timer]

Ok, here is what I would do.

Medication wise:
Stop Crestor, Melatonin, Trazadone, Venlafaxine and ASA. Just to start. Start cutting back on all other meds by reducing the dose in 1/2. One drug a week. Over 4-5 weeks all other meds would be reduced by 50%. Evalute BP each week to see what is going on. One more thing. Do we know the patient is adherent?

Non Medical: Make sure a social worker visits the patient to asses all of the lifestyle issues.

This reminds me of the advice my then 86 y/o grandather got to stop eating ice cream becuase his cholesterol was high. I told him to eat all of the ice cream he wanted. When you are that far on the back end, what are you trying to accomplish. Let them enjoy the life they have.