Timing of Citalopram Administration in Elderly Alzheimer's Patients
Yes, citalopram can be taken during the day in elderly Alzheimer's patients, though some patients may experience sleep disturbances as a side effect. 1, 2 The American Academy of Family Physicians notes that citalopram is well tolerated but some patients experience nausea and sleep disturbances, without specifying that it must be taken at a particular time of day. 1
Practical Dosing Recommendations for Your Patient
Start citalopram at 10 mg daily (morning or evening based on tolerability), with a strict maximum of 20 mg daily in patients over 60 years due to QT prolongation risk. 2 The European Heart Journal warns that citalopram should not exceed 20 mg daily in patients over 60 years due to FDA/EMA warnings about QT prolongation risk. 2
Switching Protocol from Sertraline
- Taper sertraline over 10-14 days while starting citalopram at 10 mg daily to limit withdrawal symptoms. 2
- After 1-2 weeks at 10 mg, increase to 20 mg daily if tolerated and needed for behavioral symptoms. 2
- Allow 4-8 weeks at the therapeutic dose (20 mg) to assess full response for hypersexuality and other behavioral symptoms. 2
Evidence Supporting Citalopram for Hypersexuality in Alzheimer's Disease
Citalopram has demonstrated efficacy specifically for hypersexuality in Alzheimer's disease. 3, 4 A case report in Neurological Sciences documented a 54-year-old male with Alzheimer's disease and compulsive sexual behavior who showed improvement in both the compulsive pursuit of sex acts and level of frustration when refused after 60 days of citalopram treatment. 3 Another case report in Alzheimer Disease and Associated Disorders described successful reduction of inappropriate sexual behaviors with citalopram 20 mg daily in an elderly male with moderately severe dementia. 4
Timing Considerations: Morning vs. Evening Dosing
The choice between morning and evening dosing should be based on individual side effect profile:
- If the patient experiences insomnia or activation, give citalopram in the morning. 1, 2
- If the patient experiences somnolence or sedation, give citalopram at bedtime. 1
- The American Academy of Family Physicians lists citalopram's maximum dose as "40 mg per day" without specifying timing, indicating flexibility in administration schedule. 1
Critical Safety Monitoring During the Switch
Obtain baseline ECG if the patient has cardiac risk factors before starting citalopram. 2 The European Heart Journal recommends baseline ECG monitoring given citalopram's QT prolongation potential. 2
Monitor for Common SSRI Side Effects:
- Nausea, insomnia, somnolence, dizziness, and gastrointestinal disturbances during the first month. 2
- Assess for hyponatremia symptoms (confusion, weakness, falls) during the first month, as SSRIs can cause SIADH. 2
- Monitor for initial worsening of agitation in the first 1-2 weeks, which typically resolves. 2
Advantages of Citalopram in This Population
Citalopram has a lower potential for cytochrome P450-mediated drug interactions compared to other SSRIs, which is advantageous in elderly patients on multiple medications. 2 This is particularly important given that elderly Alzheimer's patients typically take multiple medications.
Citalopram has a lower activation profile compared to sertraline, making it less likely to cause initial anxiety or agitation when treating behavioral symptoms in dementia patients. 2
Important Caveats
- Review all concurrent medications for potential QT-prolonging agents before starting citalopram. 2 The European Heart Journal warns to review all concurrent medications for potential QT-prolonging agents, as citalopram carries this risk. 2
- Avoid combining citalopram with antipsychotics unless there is clear and imminent risk of harm, as antipsychotics should not be first-line for behavioral symptoms in dementia. 2
- Obtain baseline serum sodium and renal function before starting citalopram, as SSRIs can cause SIADH. 2