From the Guidelines
Antidepressants, specifically selective serotonin reuptake inhibitors (SSRIs), can be an effective treatment for depression in people with dementia, and should be used as a first-line treatment due to their favorable side effect profiles. When prescribing antidepressants for individuals with dementia, it is essential to start with low doses and increase gradually ("start low, go slow") to minimize the risk of side effects, including confusion, falls, and anticholinergic effects 1.
Key Considerations
- SSRIs, such as sertraline or escitalopram, are generally preferred due to their more favorable side effect profiles 1.
- Treatment should typically continue for at least 6-12 months after symptom improvement, with regular monitoring for effectiveness and side effects.
- Non-pharmacological approaches, including addressing underlying causes of distress, providing appropriate stimulation, and ensuring good sleep hygiene, should always be tried first 1.
- Some antidepressants, like mirtazapine, may be particularly helpful when sleep disturbance or appetite issues are present 1.
Additional Recommendations
- Interventions targeting frailty, such as physical activity, nutrition optimization, social engagement, and cognitive stimulation, can also positively affect depression and improve quality of life 1.
- Antidepressants with an anticholinergic burden, such as tricyclics, should be avoided in older adults with dementia due to the increased risk of adverse effects 1.
- Among SSRIs, fluoxetine is generally not recommended for older adults due to its long half-life and side effects, whereas venlafaxine, vortioxetine, and mirtazapine are safer options in terms of drug interactions 1.
From the Research
Antidepressant Use in Dementia
- Antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs), have been studied for their effectiveness in treating depression and psychosis in patients with dementia 2, 3.
- A retrospective chart review found that 15 out of 20 patients with depression and psychosis complicating dementia showed moderate to marked improvement in symptoms after treatment with SSRIs 2.
- A systematic review of randomized controlled trials found that SSRIs were associated with a reduction in symptoms of agitation in patients with dementia, although the results were heavily weighted by one large study 3.
- Another study found that SSRIs were tolerated reasonably well in patients with dementia, with no significant differences in adverse events compared to placebo or typical antipsychotics 3.
Cognitive Decline and Antidepressant Use
- A national cohort study found that antidepressant use was associated with faster cognitive decline in patients with dementia, particularly with the use of sertraline, citalopram, escitalopram, and mirtazapine 4.
- The study also found that higher doses of SSRIs were associated with a higher risk of severe dementia, fractures, and all-cause mortality 4.
- However, it is essential to note that the relationship between antidepressant use and cognitive decline in dementia is complex and may depend on various factors, including the type and dose of antidepressant, as well as individual patient characteristics.
Selective Serotonin Reuptake Inhibitors (SSRIs)
- SSRIs are commonly used to treat depression in patients with dementia, and have been shown to be effective in reducing symptoms of depression and agitation 2, 3.
- A review of systematic reviews found that escitalopram was more effective than other SSRIs in terms of response rate, remission rate, and withdrawal rate in patients with major depressive disorder 5.
- However, the choice of SSRI may depend on individual patient characteristics, such as the presence of comorbid medical conditions or the risk of drug-drug interactions 6.