What is the recommended starting dose of Selective Serotonin Reuptake Inhibitor (SSRI)/Serotonin-Norepinephrine Reuptake Inhibitor (SNRI) anxiety medication for a 74-year-old woman who is SSRI/SNRI naive?

Starting Dose of Anxiety Medication for a 74-Year-Old SSRI/SNRI-Naive Woman

For a 74-year-old woman who is SSRI/SNRI-naive, the recommended starting dose of an SSRI should be approximately 50% of the standard adult starting dose, with sertraline 25 mg daily or escitalopram 5 mg daily being preferred first-line options. 1, 2

Medication Selection Considerations

First-Line Options

• SSRIs are generally preferred over other antidepressant classes for elderly patients with anxiety due to their favorable safety profile 1
• Preferred SSRI agents for elderly patients include:
  • Sertraline (starting at 25 mg daily, which is half the standard adult starting dose of 50 mg) 1, 3, 2
  • Escitalopram (starting at 5 mg daily, half the standard adult dose of 10 mg) 1, 4
  • Citalopram (starting at 10 mg daily, half the standard adult dose of 20 mg) 1

Second-Line Options

• SNRIs may be considered if SSRIs are not tolerated or effective 1, 5
  • Duloxetine (starting at 20 mg daily, lower than the standard 30-60 mg daily) 1, 5
  • Venlafaxine (starting at 37.5 mg daily) 1, 5

Dosing Principles for Elderly Patients

Starting Dose

• Use approximately 50% of the standard adult starting dose for patients over 60 years 1
• Begin with the lowest available dose to minimize adverse effects 1
• For sertraline specifically: Start with 25 mg daily (half the standard 50 mg starting dose) 3, 2

Titration

• Increase doses slowly with small increments at intervals of at least 1-2 weeks for shorter half-life medications 1
• Allow 3-4 weeks between dose increases for longer half-life medications like fluoxetine 1
• Monitor closely for side effects during the first 24-48 hours after dosage changes 1

Safety Considerations

Cardiovascular Concerns

• Monitor for QT prolongation with citalopram, which should not exceed 20 mg daily in patients over 60 years 1
• Check for potential increases in blood pressure with SNRIs, particularly at higher doses 1, 5

Adverse Effects to Monitor

• Common SSRI side effects in elderly patients include nausea, diarrhea, headache, insomnia, and dizziness 2
• SNRIs may additionally cause diaphoresis, dry mouth, and constipation 1, 5
• Risk of falls may be increased with both medication classes 1

Drug Interactions

• Consider potential drug-drug interactions due to common polypharmacy in elderly patients 1
• Sertraline has a lower potential for drug interactions compared to other SSRIs like paroxetine, fluoxetine, and fluvoxamine 2
• Avoid combining with MAOIs due to risk of serotonin syndrome 1

Follow-up and Monitoring

• Assess response after 4-6 weeks of treatment at the initial dose 1
• Consider dose increases only if response is inadequate and side effects are tolerable 1
• Monitor for suicidal thinking especially in the first months of treatment and following dosage adjustments 1

Special Considerations for Elderly Patients

• Anticholinergic effects should be avoided, making TCAs less suitable for elderly patients 1
• No dosage adjustments based solely on age are needed for sertraline, making it particularly suitable 2
• Cognitive effects should be monitored, as SSRIs may have advantages over other antidepressants for cognitive functioning 2