Is sertraline (Zoloft) a suitable initial treatment for agitation in a geriatric patient prior to referral to psychiatry?

From the Guidelines

Sertraline can be an appropriate medication to start for an agitated geriatric patient before referring to psychiatry, but caution is warranted. Begin with a low dose, typically 25mg daily, which is half the usual adult starting dose, and increase gradually if needed 1. Monitor closely for side effects, particularly in the first few weeks, as SSRIs like sertraline can occasionally worsen agitation or cause other adverse effects in older adults. The medication may take 2-4 weeks to show therapeutic benefits. While initiating sertraline, it's essential to expedite the psychiatry referral as the underlying cause of agitation requires comprehensive evaluation. Geriatric patients often have complex presentations that may involve depression, anxiety, early dementia, or other conditions that benefit from specialist assessment. Non-pharmacological approaches should be implemented concurrently, including maintaining routine, providing reassurance, and addressing sensory deficits. Sertraline is generally preferred in older adults due to its favorable side effect profile and lower risk of drug interactions compared to many other psychotropics, but the ultimate treatment plan should be refined following psychiatric evaluation.

Some key considerations when using sertraline in geriatric patients include:

• Starting with a low dose to minimize the risk of adverse effects
• Gradually increasing the dose as needed and tolerated
• Monitoring closely for side effects, particularly in the first few weeks of treatment
• Implementing non-pharmacological approaches to manage agitation and other symptoms
• Expediting psychiatry referral to ensure comprehensive evaluation and treatment planning

It's also important to note that other medications, such as antipsychotics and benzodiazepines, may be considered for the management of agitation in geriatric patients, but their use should be carefully weighed against the potential risks and benefits 1. Ultimately, the treatment plan should be individualized to the patient's specific needs and circumstances, and should involve collaboration between healthcare providers, patients, and their families.

From the FDA Drug Label

A subset of these patients who completed the randomized controlled trials (sertraline n=99, placebo n=122) were continued into a 24-week, flexible-dose, open-label, extension study. U. S. geriatric clinical studies of sertraline in major depressive disorder included 663 sertraline-treated subjects ≥65 years of age, of those, 180 were ≥75 years of age No overall differences in the pattern of adverse reactions were observed in the geriatric clinical trial subjects relative to those reported in younger subjects SSRIs and SNRIs, including sertraline, have been associated with cases of clinically significant hyponatremia in elderly patients, who may be at greater risk for this adverse event

Sertraline use in geriatric patients with agitation is not directly addressed in the provided drug label. However, the label does mention the use of sertraline in geriatric patients with major depressive disorder, and it notes that no overall differences in the pattern of adverse reactions were observed in geriatric clinical trial subjects relative to younger subjects.

• The label also warns of the risk of hyponatremia in elderly patients.
• Given the lack of direct information on the use of sertraline for agitation in geriatric patients, it is recommended to exercise caution and consider consulting a specialist before initiating treatment. 2

From the Research

Agitation Management in Geriatric Patients

• The management of agitation in older adults with dementia is a complex issue, and the choice of pharmacological options depends on patient comorbidities, specific symptoms, and patient tolerance of medications 3.
• Non-pharmacological strategies, such as environmental modifications, should be implemented first to maximize patient safety 4, 5.
• If pharmacological intervention is necessary, it is essential to start with low doses and gradually increase as needed, using small increments of dose increase 4.

Use of Sertraline in Agitation Management

• Sertraline, an SSRI, has been associated with a reduction in symptoms of agitation in patients with dementia when compared to placebo 6.
• SSRIs, including sertraline, appear to be reasonably well-tolerated when compared to placebo, typical antipsychotics, and atypical antipsychotics 6.
• However, the evidence base for the use of sertraline in agitation management is limited, and more studies are needed to determine its safety and efficacy 6.

Referral to Psychiatric Care

• Referral to psychiatric care may be necessary for patients with agitation, especially if the symptoms persist or worsen despite initial treatment 4, 5.
• A comprehensive assessment of the patient's condition, including the underlying cause of agitation, is crucial in determining the best course of treatment 4, 3.
• Collaboration between healthcare providers, including psychiatrists, geriatricians, and other specialists, is essential in managing agitation in older adults with dementia 4, 5.