What is the recommended antidepressant for a patient with globus sensation and dementia?

Antidepressant Selection for Patients with Globus Sensation and Dementia

For patients with globus sensation and dementia, a selective serotonin reuptake inhibitor (SSRI), specifically citalopram, is the recommended antidepressant due to its demonstrated efficacy in treating both conditions with minimal cognitive side effects. 1, 2, 3

Understanding the Clinical Presentation

Globus sensation presents as:

• A recurrent, non-painful sensation of a lump in the throat
• Often exacerbated during periods of psychological stress
• May co-occur with functional voice disorders
• Can lead to anxiety, panic, and depression if untreated 1

In patients with dementia, this condition can:

• Further complicate cognitive impairment
• Increase caregiver burden
• Lead to reduced quality of life
• Potentially worsen behavioral symptoms 1

Medication Selection Algorithm

First-line: Citalopram

• Rationale for selection:

  • Demonstrated efficacy in elderly depressed patients with dementia 2
  • Shown to improve emotional disturbances in dementia patients 3
  • Evidence supports its use for globus sensation when associated with depression 4
  • Low anticholinergic burden, minimizing cognitive side effects 1
  • May improve working memory in some patients 5

• Dosing considerations:

  • Start at 10mg daily (lower than standard adult dosing)
  • Titrate slowly to 20mg daily as tolerated
  • Maximum dose of 20mg daily in elderly patients with dementia (due to QT prolongation risk)
  • Monitor for side effects, particularly insomnia 2

Alternative: Sertraline

If citalopram is not tolerated or contraindicated:

• Start at 25mg daily
• Titrate slowly to effective dose (typically 50-100mg)
• Also has minimal anticholinergic effects 1

Monitoring and Follow-up

1. Assess response using quantitative measures 1:

   • Track frequency and severity of globus sensation
   • Monitor for changes in mood and behavior
   • Evaluate cognitive function

2. Watch for potential side effects:

   • Insomnia (more common with citalopram) 2
   • QT prolongation (particularly with citalopram)
   • Hyponatremia
   • Increased risk of falls

3. Evaluate for treatment effectiveness after 4-6 weeks:

   • If no response, consider dose adjustment or medication switch
   • If partial response, continue for additional 2-4 weeks before reassessing

Important Clinical Considerations

• Avoid medications with high anticholinergic burden as they can worsen cognitive function in dementia patients 1

• Integrate non-pharmacological approaches alongside medication:

  • Speech and language therapy for globus sensation 1
  • Cognitive stimulation therapy for dementia 1
  • Caregiver education and support 1

• Pitfall to avoid: Don't mistake globus sensation for dysphagia, which requires different management approaches 1

• Caution: Antipsychotics should not be used for globus sensation and should only be considered for severe behavioral symptoms in dementia when other approaches fail 1

• Regular medication review: Assess ongoing need for antidepressant therapy, particularly if symptoms resolve 1

By following this approach, the treatment addresses both the globus sensation and potential mood disturbances in the context of dementia, while minimizing adverse cognitive effects and improving quality of life.