Elderly antidepressants

The MAOI antidepressant drag s are contraindicated in patients widi known hypersensitivity to die drug s, liver and kidney disease, cerebrovascular disease, hypertension, or congestive heart failure and in die elderly. These drag s are given cautiously to patients witii impaired liver function, history of seizures, parkinsonian symptoms, diabetes, or hyperthyroidism. 

Singh, Nalin A., Karen M. Clements and Maria A. Fiatarone Singh, The Efficacy of Exercise as a Long-Term Antidepressant in Elderly Subjects A Randomized, Controlled Trial , Journal of Gerontology 56A, no. 8 (2001) M497-M504... 

These types of antidepressant were introduced around 10 years after the SSRIs. They include the serotonin noradrenaline reuptake inhibitor venlafaxine and the selective noradrenaline reuptake inhibitor reboxetine. Although there are fewer data about these drugs, clinical experience has shown they are well tolerated and, unlike the SSRIs, they are only weak inhibitors of drug metabolism (Kent, 2000). Depression is a common psychiatric disorder seen in the elderly and often remains untreated or inadequately treated (Forsell and Fastbom, 2000). Venlafaxine was shown to improve the mood in a group of 36 older patients without any effect on cognitive function, an important consideration where there is the possibility of the coexistence of mild or undiagnosed dementia (Tsolaki et al., 2000). 

Vandel P (2003). Antidepressant drugs in the elderly Role of the cytochrome P4502D6. World... 

Antidepressants, especially the SSRIs, are preferred in elderly patients and youth. The BZs are second line in these patients because of potential problems with disinhibition. 

The SSRIs are often selected as first-choice antidepressants in elderly patients. 

Elderly patients should receive one-half the initial dose given to younger adults, and the dose is increased at a slower rate. The elderly may require 6 to 12 weeks of treatment to achieve the desired antidepressant response. 

Many different drug classes have shown to cause hypotension and orthostatic reactions and drugs for cardiovascular conditions, psychoactive medicines and polypharmacy, can all have this side effect (Box 5.15). Among the most frequently used drugs in the elderly are diuretics, ACE-inhibitors, angiotensin II antagonists, calcium channel blockers and antidepressants. 

Anticholinergic effect is an important adverse effect that is frequent in the elderly taking tricyclic antidepressants... 

Review of the literature regarding toxic effects of mirex and chlordecone did not reveal any human populations that are known to be unusually sensitive to mirex or chlordecone. However, based on knowledge of the toxicities of mirex and chlordecone, some populations can be identified that may demonstrate unusual sensitivity to these chemicals. Those with potentially high sensitivity to mirex include the very young. Those with potentially high sensitivity to chlordecone include juvenile and elderly person and persons being treated with some antidepressants or the anticonvulsant, diphenylhydantoin. 

Supportive care Supportive care, especially for elderly and people with renal disease Supportive care rv Mannitol Supportive care Tricyclic antidepressants Children more vulnerable than adults... 

Percudani, M., Barbui, C., Fortino, I., Petrovich, L. (2005) Antidepressant drugs prescribing among elderly subjects a population-based study. Ini. J. Geriatr. Psychiatry, 20, 113-118. 

The fifth factor is the potential for side effects. In general, the newer antidepressants have less cumbersome side effects than the older agents. Your patients should be informed of potential side effects when selecting an antidepressant. By discussing side effects in advance, your patient may help you to decide which side effects would be most distressful to him/her. For example, dizziness may be a problem for an elderly patient at risk for falls, and sexual side effects may be more concerning to others. 

In reality, risperidone acts as an atypical antipsychotic at doses up to 4-6mg/day. At higher doses, risperidone begins to act more like a typical antipsychotic, and EPS can become a problem. The dose at which this occurs for individual patients is quite variable. In elderly patients, even low doses can cause EPS. Whether this risk for EPS translates into a risk for TD after long-term use remains unknown. There is now considerable evidence that risperidone is also effective in treating mania and in augmenting antidepressants in particularly low doses. 

In general, the lowest effective dose of the drug should be used, particularly in elderly patients. Dose titration should be undertaken slowly. Similarly, on discontinuation of a drug, the dose should be reduced slowly, the rate of decrease being decided by the elimination half-life of the drug. Some psychotropic drugs produce a discontinuation syndrome that can usually be avoided by slow withdrawal. In particular, sedatives, anxiolytics and antidepressants can cause withdrawal effects. 

These include trazodone and a derivative of its metabolite nefazodone, both of which are strongly sedative, an effect which has been attributed to their potent alpha-1 receptor antagonism rather than to any antihistaminic effects. A main advantage of these drugs in the treatment of depression is that they appear to improve the sleep profile of the depressed patient. Their antidepressant activity is associated with their weak 5-HT reuptake inhibition and also a weak alpha-2 antagonism. However, unlike most of the second-generation antidepressants, neither drug is effective in the treatment of severely depressed patients. Furthermore, there is some evidence that trazodone can cause arrythmias, and priapism, in elderly patients. 

Clearly the major advantage of all the recently introduced antidepressants lies in their relative safety in overdosage and reduced side effects. These factors are particularly important when considering the need for optimal patient compliance and in the treatment of the elderly depressed patient who is more likely to experience severe side effects from antidepressants. 

Central Motor restlessness, progressing to maniacal agitation, psychic disturbances, disorientation, and hallucinations. Elderly subjects are more sensitive to such central effects, in this context, the diversity of drugs producing atropine-like side effects should be borne in mind e.g., tricyclic antidepressants, neuroleptics, antihistamines, antiarrhythmics, antiparkinsonian agents. 

Citalopram (Celexa) [Antidepressant/SSRI] WARNING Closely monitor for worsening depression or emergence of suicidality, particularly in pts <24 y Uses Depression Action SSRI Dose Initial 20 mg/d, may t to 40 mg/d X in elderly hqjatic/renal insuff Caution [C, +/-] Hx of mania, Szs pts at risk for suicide Contra MAOI or w/in 14 d of MAOI use Disp Tabs, cap, soln SE Somnolence, insomnia, anxiety, xerostomia, diaphoresis, sexual dysfxn Notes May cause X Na /SIADH Interactions t Effects W/ azole antifungals, cimetidine, Li, macrolides, EtOH t effects OF BBs, carbamazepine, CNS drugs, warfarin X effects W/ carbamaz ine X effects OF phenytoin may cause fatal Rxn W/ MAOIs EMS Use caution w/ CNS depressants, may need a reduced dose concurrent EtOH... 

Flurazepam (Dalmane) [C-IV] [Sedative/Hypnotic/ Benzodiazepine] Uses Insomnia Action Benzodiazepine Dose Adults Beds >15 y. 15-30 mg PO qhs PRN X in elderly Caution [X, /-] Elderly, low albumin, hepatic impair Contra NAG PRG Disp Caps SE Hangover d/t accumulation of metabolites, apnea, anaphylaxis, angioedema, amnesia Interactions T CNS depression W/ antidepressants, antihistamines, opioids, EtOH T effects OF digoxin, phenytoin T effects W/ cimetidine, disulfiram, fluoxetine, iso-niazid, ketoconazole, metoprolol, OCPs, propranolol, SSRIs, valproic acid. 

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