Should the dose of Lexapro (escitalopram) be increased for this patient?

Management of Depression in an Elderly Patient on Escitalopram

The dose of Lexapro (escitalopram) should be increased to 20 mg daily for this 81-year-old female patient with persistent depressive symptoms despite stable treatment on 10 mg daily for three years. 1, 2

Assessment of Current Status

• Patient has been stable on Lexapro 10 mg daily for three years
• Recent complaint of worsening depression
• Geriatric Depression Scale score of 7/8, showing only minimal improvement (1 point) from last month
• At 81 years old, the patient falls into the geriatric population requiring careful medication management

Rationale for Dose Increase

According to the FDA drug labeling for escitalopram, the recommended dose range for adults with major depressive disorder is 10-20 mg daily 2. The American Family Physician guidelines support that escitalopram is an appropriate antidepressant for elderly patients due to its favorable adverse effect profile 1.

Key considerations:

• For patients showing partial response, dose optimization should be attempted before considering medication switches or augmentation
• FDA labeling states that dose increases to 20 mg should occur after a minimum of one week on the 10 mg dose 2
• Since this patient has been on a stable dose for three years, a dose increase is appropriate given the persistent symptoms

Dose Titration Protocol

1. Increase escitalopram from 10 mg to 20 mg once daily
2. Administer in the morning or evening, with or without food 2
3. Monitor for response over the next 4-6 weeks
4. Use standardized measures (like the Geriatric Depression Scale) to track progress

Monitoring Considerations

• Assess for common side effects: nausea, dizziness, dry mouth, fatigue, headache, sexual dysfunction, sweating, tremor, and weight gain 3
• Monitor for QT interval prolongation, though escitalopram has less risk compared to citalopram 1
• Evaluate for hyponatremia, which is more common in elderly patients on SSRIs 4

Potential Pitfalls and Cautions

• Elderly patients may be more sensitive to medication side effects, but escitalopram is generally well-tolerated in this population 5
• Unlike some other antidepressants, escitalopram does not require significant dose reduction in elderly patients with normal renal function 2, 5
• If the patient does not respond to the increased dose after 4-6 weeks, consider:
  1. Checking medication adherence
  2. Evaluating for medical comorbidities that might be contributing to depression
  3. Considering augmentation strategies or switching to another agent 6

Alternative Approaches if Dose Increase Fails

If the patient does not respond adequately to the 20 mg dose after 4-6 weeks:

1. Consider augmentation with another agent (e.g., mirtazapine, which has additional benefits for sleep and appetite in elderly patients) 3
2. Consider switching to another SSRI or SNRI with favorable geriatric profiles, such as sertraline 1, 3
3. Evaluate for psychotherapy options, as combination treatment may be more effective than pharmacotherapy alone 7

The evidence strongly supports that escitalopram is effective and well-tolerated in elderly patients with depression, and increasing to the maximum recommended dose of 20 mg daily is appropriate for this patient showing persistent symptoms despite treatment at 10 mg daily for an extended period 8, 5.