5
Fitzgerald Health Education Associates, Inc., December 2014 fhea.com
I
n an elderly patient who is treatment naïve, selec-
tive serotonin reuptake inhibitors (SSRIs) are pre-
ferred as the initial treatment agent because of
their low side-effect profile and generally positive
safety profile.
1,2
Either sertraline (Zoloft) or escitalopram (Lexapro)
are the preferred SSRI medications in this age-group,
largely because other SSRIs and other classes of anti-
depressants are associated with greater risk of drug-
drug interactions and adverse events in older adults.
For example, fluoxetine (Prozac) and paroxetine
(Paxil) are both CYP450 2D6 inhibitors and thus can in-
crease serum levels of some beta-blockers and statins,
medications often used concomitantly in older adults.
Both fluoxetine and paroxetine can also increase
bleeding risk when used with warfarin and non -
steroid al anti-inflammatory drugs (NSAIDs). Citalopram
(Celexa), once a favorite SSRI for use in older adults, is
now seldom used because of its potential for causing
prolonged QT interval and torsade de pointes.
3
If
citalopram is prescribed, the maximum dose in pa-
tients 60 years of age or older is 20 mg/d. Patients tak-
ing citalopram should undergo routine ECG.
1,2
In the elderly patient who is having difficulty
sleeping and can benefit from weight gain, mirtaza -
pine (Remeron) can be an appropriate first-line med-
ication. Mirtazapine increases norepinephrine and
serotonin neurotransmission in a manner different
from SSRIs. It is classified as an alpha-2 adrenoceptor
antagonist (ie, noradrenergic and specific serotoner-
gic antidepressant, or NaSSA). Mirtazapine blocks his-
tamine receptors, which accounts for its side effects
of drowsiness and weight gain.
2
Careful Dosing and Monitoring Are Key
With the elderly, the adage "start slow, go low" is
important to remember. Elderly patients typically
require a lower oral dose than younger patients to
reach a particular blood level, and they tolerate a
given blood level less well than younger patients.
2
However, this doesn't mean that you must prescribe
at a low dose only.
2,4
Blood levels at which
antidepressant medications are maximally effective
for elderly patients appear to be the same as those
for younger patients.
2
Practitioners should start with
as low a dose as possible and continue to monitor
the medication's effects on depression symptoms,
increasing the dosage of the medication slowly as
tolerated, and only if necessary to achieve remission
of symptoms. Using a free, online measurement-
based tool, such as the
Patient Health Questionnaire
(PHQ-9)
, is recommended to monitor response to
medications over time.
2
Dose regimens should be
adjusted for age-related metabolic changes, paying
close attention to hepatic and renal metabolic
function.
2
For patients who are also taking other
medications, careful attention must be paid to
potential drug interactions.
2
Psychiatric Consult
Which Medication Is Best for an Older Adult with
Depression?
Tess Judge-Ellis, DNP, ARNP, FAANP
Continued on page 7