From the Guidelines
For older adults aged 70 and above, sertraline (Zoloft) is often the preferred SSRI due to its favorable side effect profile, minimal drug interactions, and established efficacy in this population. When prescribing SSRIs to older adults, it's essential to consider the potential risks and benefits, as well as the individual patient's medical history and current medications.
Key Considerations
- Starting at lower doses (typically half the standard adult starting dose) and increasing gradually, for example, starting sertraline at 25mg daily rather than 50mg 1
- Dose adjustments may be necessary for patients with renal or hepatic impairment, as certain SSRIs like citalopram require consideration of dose reduction in renal or hepatic disease 1
- Monitoring for hyponatremia, increased risk of falls, potential for drug interactions (especially with medications metabolized by cytochrome P450 enzymes), and the possibility of QT interval prolongation with certain SSRIs like citalopram 1
- Treatment should continue for at least 6-12 months after symptom resolution, with careful tapering when discontinuing to avoid withdrawal symptoms 1
- Regular follow-up appointments are essential to assess efficacy and monitor for adverse effects, particularly during the initial weeks of treatment 1
Preferred SSRIs for Older Adults
- Sertraline (Zoloft)
- Escitalopram (Lexapro)
- Citalopram (Celexa) These SSRIs are considered appropriate choices for treating depression and anxiety disorders in older adults due to their favorable adverse effect profiles, as noted in the study published in the American Family Physician 1.
Important Safety Information
- Paroxetine is associated with more anticholinergic effects and should be avoided in older adults 1
- Fluoxetine has a greater risk of agitation and overstimulation and should also be avoided in older adults 1 By considering these factors and choosing the most appropriate SSRI, healthcare providers can help older adults manage their depression and anxiety while minimizing the risk of adverse effects.
From the FDA Drug Label
A lower or less frequent dosage should also be considered for the elderly (see Geriatric Use under PRECAUTIONS), and for patients with concurrent disease or on multiple concomitant medications.
The FDA drug label for fluoxetine suggests that it can be used in older adults, but a lower or less frequent dosage should be considered due to potential increased sensitivity.
- Key considerations for older adults include:
- Lower starting dose
- Less frequent dosing
- Monitoring for potential interactions with other medications
- Increased risk of adverse effects due to decreased hepatic and renal function Based on the provided information, fluoxetine may be a suitable option for older adults, but the best choice of SSRI will depend on individual patient factors, such as medical history, concurrent medications, and potential side effects 2.
From the Research
SSRIs Indicated for Older Adults
- The selective serotonin reuptake inhibitors (SSRIs) are considered first-line agents for the treatment of depression in elderly patients 3.
- SSRIs such as fluoxetine, sertraline, paroxetine, and fluvoxamine have been shown to be effective in geriatric patients 4.
- Escitalopram is also considered a suitable option for older adults, with a favorable efficacy and tolerability profile 5.
Considerations for Older Adults
- Physiologic changes that occur with aging can affect the pharmacodynamic and pharmacokinetic properties of drugs, including SSRIs 3.
- The potential for drug-drug interactions and side effects should be carefully considered when prescribing SSRIs to older adults 3, 4.
- Factors such as dose initiation and titration, side effect management, and length of treatment should be taken into account when managing older adults with SSRIs 4.
Choosing the Best SSRI for Older Adults
- Escitalopram may be considered a first-choice option due to its favorable efficacy and tolerability profile, as well as its lower risk of drug interactions 5, 6.
- Sertraline may be a suitable alternative, particularly at high doses, where it has been shown to have a lower risk of recurrent falls compared to citalopram/escitalopram 7.
- Paroxetine and fluvoxamine may not be the best choices due to their higher risk of adverse reactions and drug interactions 4, 6.
- Citalopram should be avoided in patients who are at risk of overdose due to its potential for fatal outcomes 6.