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Suggest the ideal dosage for Mirtazapine taken for depression

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Posted on Thu, 14 Jul 2016
Question: Hello - there is a long history to this question to I'm going to paste it below so you know the background. Basically, I think if we could get my mother with dementia to sleep better at night her anxiety during the day would decrease. I can't understand why something simple like Paracetamol mixed with codeine (say 10 or 15 mg) couldn't be used to send her off to sleep. There's also Tramadol.... Then there are other drugs that I can't seem to get straight answers for.... Benadryl/Restavit (old antihistamines), Lyrica (small doses of 25 mg have recently been shown to help with GAD and sleep), tricyclic antidepressants, Nuedexta, Memantine..... At present, the doctor and nursing home have trialed her on increased Mirtazapine for a month (30 mg), and for two nights (one accidentally) Olanazapine 2.5 mg which caused the akathesia (which only I witnessed so they think I'm exaggerating). I also wonder if the Mirtazapine were lowered whether the Olanzapine might be less likely to cause the akathesia. Would you mind commenting on all the above medications with their pros and cons for elderly people with dementia? Obviously we are after the most efficient one for sleep with the least risky side effects. The nursing home now want her to go into a hospital setting for a couple of months to get her medications adjusted - I, along with quite a few other people including a dementia specialist, think this would be one of the worst things for her severe anxiety. I think it would be better to have more trials in the nursing home, or take her out to my home and trial some things there. Would very much appreciate feedback on the medications listed above. Many thanks Previous posts:

My 88 year old mother with dementia had her Mirtazapine increased from 15 mg to 30 mg three weeks ago. It has made her agitation and sleeplessness worse. So she was started on Olanzapine 2.5 mg last night. I stayed the night in the nursing home to keep an eye on her and it was a horror night. She could not keep any part of her body still - extreme restlessness and some 'jerks' which persisted even when she had some brief sleep from 2.30 to 5 am. She was up and down out of bed about 40 times. Hyperventilating, panicky (she often has those anyway). Asking strange questions bordering on delirium (hasn't had these before). My question is will these side effects go away or does it mean the drug is not suited to her/not suited to her in combination with that dosage of Mirtazapine? I'm not sure I can stand another night like that and it's very upsetting for her too - should we push through it? It's a long weekend over here so can't ask her doctor. Would like your advice but won't use it when talking to her doctor of course. Her calcium serum levels are up around 2.8 due to parathyroid adenoma but her Sensipar is going to be increased to deal with that.

Asked by Me , Sat, 11 Jun 2016

Doctor's reply to your question above...

Brief Answer:

Mirtazapine side effects



Detailed Answer:

Thank you for contacting HCM with your health care concerns



I am sorry to hear that your mother is having such side effects from her medication. The increased restlessness is all due to the mirtazapine. Instead of increasing the dose they should be decreasing it. Higher doses are activating and the lower doses are more sedating. It is due to the changes in the brain with higher doses. i would highly recommend refusing to take the olanzipine and asking to reduce the mirtazapine to 7.5mg. That may help more than adding a medication to counter side effects from a medication. There are significant risks with olanzapine I don't think your mother should have to continue this medication. If your doctor refuses you do have the right to refuse their treatment plan. you need to e your mothers advocate here and not give in to pressure from the doctor. you have the right to question and refuse treatment.



If her behaviors still are a problem then lorazapem can help but this should only be used as needed and sparingly.



I hope I answered your question. Please contact us again if you have any additional questions

Replied by Dr. XXXXXXX Schubert , Sat, 11 Jun 2016

Disclaimer: The Expert's advice is provided for general informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, as a complete assessment of an individual has not taken place. Please consult your nearest physician before acting on it. The advice is not valid for medico-legal purposes also.

Dear Dr Schubert,



Many thanks for your response. Unfortunately with benzodiazapines she gets more panicky when the 'vagueness' and confusion they cause sets in - she also gets more unsteady on her feet and has had a fall with them.



We do need to find something for her very bad generalised anxiety disorder and disturbed sleep - any other suggestions? Would a different anti-psychotic have the same effect?



Many thanks.....

Asked by Me , Sun, 12 Jun 2016

Doctor's reply to your question above...

Brief Answer:

Anitpsychotics



Detailed Answer:

I am sorry to say that any of the antipsychotic medications will all have the same side effects. Has your mother been tried on Trazodone? This is a antidepressant that has sedative side effects and may also help with anxiety.

Replied by Dr. XXXXXXX Schubert , Mon, 13 Jun 2016

Disclaimer: The Expert's advice is provided for general informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, as a complete assessment of an individual has not taken place. Please consult your nearest physician before acting on it. The advice is not valid for medico-legal purposes also.

Dear Dr XXXXXXX Schubert,



Thank you for that suggestion - I can try asking the psycho-geriatrician about it, although I think he is fed up with my questions....



My brother is angry with me, thinking I made a mountain out of a molehill with the akathesia. He thinks that because it stopped the next day (ie whe wasn't walking around or twitching or restless) she probably would have been ok to take the Olanzapine again and give it a fair trial. Maybe he's right. Can the akathesia reduce over time? If it didn't continue during the day is that a sign that it probably wasn't anything to worry about and she would have been ok to continue taking it?



Many thanks

Asked by Me , Tue, 14 Jun 2016

I forgot to mention - I'm not sure if it was true akathesia or whether it was sudden onset of restless legs syndrome. It might be the latter because it didn't continue during the day. Should we try it again?

Asked by Me , Tue, 14 Jun 2016

Doctor's reply to your question above...

Brief Answer:

restless leg side effect



Detailed Answer:

The side effect from all anti-psychotics is called extra pyramidal and manifests as restless legs or tremor. It can also be lip smacking or facial grimacing. These side effects don't usually lessen with time. They actually can get worse and may even become permanent if on the medication of a long time. So I would agree with you to not use the medication for fear of the restlessness and also from an increase in diabetes and stroke with the anti-psychotics.



I recommend perhaps one more trial but if she goes through the same thing stop immediately.

Replied by Dr. XXXXXXX Schubert , Tue, 14 Jun 2016

Disclaimer: The Expert's advice is provided for general informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, as a complete assessment of an individual has not taken place. Please consult your nearest physician before acting on it. The advice is not valid for medico-legal purposes also.

Dear Dr Schubert,



Thank you for your reply.



I slept on the floor at the nursing home on Wednesday night and noticed she was getting the restless legs, unable to stay still and unable to sleep. I thought it was strange - maybe she's like that without the medication. But at 2 am I found out they had given her the Olanzapine by mistake. She got just over two hours sleep that night and was very distressed. However... her restlessness wasn't as bad as the previous time (maybe because I was unaware she had had something or maybe because I'd had a sleeping tablet).



The issue is, the second day after each dose of Olanzapine, her anxiety does seem to be better and she is more content. So we are starting to think it does have a good effect. But how could we get around the sleeplessness/restlessness at night - is that likely to decrease?



Many thanks

Asked by Me , 5 days ago

Doctor's reply to your question above...

Brief Answer:

restless leg side effect



Detailed Answer:

You may want to ask to try benadryl at night. Sometimes it may help with the restless legs. We can use benadryl for Parkinson's disease so this may give her some relief and allow for better sleeo

Replied by Dr. XXXXXXX Schubert ,
doctor
Answered by Dr. Chintan Solanki (25 minutes later)
Brief Answer:
Seroquel is good option, lyrica can be increased

Detailed Answer:
Hello,

Thanks for writing to us. I can understand your concern for your mother.

Mirtazapine 30 mg if not helping in my opinion it should be reduced up to 15 mg. It can cause activation and increase in blood pressure so with dementia we can use in low dose.

For her anxiety lyrica is a good option. Giving more dose at night will help in sleep also. She is already responding to it so increasing the dose of lyrica will likely help.

Olanzapine can cause akathasia or restless leg. I recommend seroquel in low dose at night it has some anti depressant property and sedation with its anti psychotic effects.

Tricyclic should be avoided in dementia at this age.

Benzo diazepines can help if given in low dose tactfully. However you are telling that she gets side effects otherwise lorazepam in low dose is good option.

And one more option is adding setraline or paroxetine for her anxiety instead of mirtazapine. You can discuss with her doctor for switching of that.

Hope I have answered your query, I will be happy to help further.
Regards,
Dr.Chintan Solanki.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Answered by
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Dr. Chintan Solanki

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Practicing since :2007

Answered : 2406 Questions

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Suggest the ideal dosage for Mirtazapine taken for depression

Brief Answer: Seroquel is good option, lyrica can be increased Detailed Answer: Hello, Thanks for writing to us. I can understand your concern for your mother. Mirtazapine 30 mg if not helping in my opinion it should be reduced up to 15 mg. It can cause activation and increase in blood pressure so with dementia we can use in low dose. For her anxiety lyrica is a good option. Giving more dose at night will help in sleep also. She is already responding to it so increasing the dose of lyrica will likely help. Olanzapine can cause akathasia or restless leg. I recommend seroquel in low dose at night it has some anti depressant property and sedation with its anti psychotic effects. Tricyclic should be avoided in dementia at this age. Benzo diazepines can help if given in low dose tactfully. However you are telling that she gets side effects otherwise lorazepam in low dose is good option. And one more option is adding setraline or paroxetine for her anxiety instead of mirtazapine. You can discuss with her doctor for switching of that. Hope I have answered your query, I will be happy to help further. Regards, Dr.Chintan Solanki.