From the Guidelines
For elderly patients requiring SSRI treatment, escitalopram (5-10 mg daily) and sertraline (25-100 mg daily) are generally the preferred options due to their favorable side effect profiles. These medications have fewer drug interactions and less anticholinergic activity compared to other antidepressants, making them safer choices for older adults 1. Start with lower doses (escitalopram 5 mg or sertraline 25 mg daily) and increase gradually every 1-2 weeks as needed and tolerated. Citalopram is also reasonable but has dose limitations (maximum 20 mg daily in elderly) due to QT interval prolongation concerns. When initiating treatment, monitor closely for side effects like dizziness, hyponatremia, and increased fall risk during the first few weeks. SSRIs with higher anticholinergic effects or complex drug interactions (paroxetine, fluoxetine) should generally be avoided in the elderly, as they are associated with more adverse effects in older adults 1.
Some key points to consider when prescribing SSRIs to elderly patients include:
- Lower starting doses are often recommended, approximately 50% of the adult starting dose 1
- Regular monitoring of sodium levels and cognitive function is advisable throughout treatment
- Treatment should continue for at least 6-12 months after symptom resolution, with any discontinuation occurring through slow tapering to minimize withdrawal effects
- Tertiary-amine TCAs (e.g., amitriptyline, imipramine) are associated with significant adverse anticholinergic effects and are considered a potentially inappropriate medication in the American Geriatric Society’s Beers Criteria 1
Overall, the goal is to minimize adverse effects while effectively managing depression in elderly patients, and escitalopram and sertraline are generally the best options to achieve this goal 1.
From the FDA Drug Label
Of 4422 patients in clinical studies of citalopram tablets, 1357 were 60 and over, 1034 were 65 and over, and 457 were 75 and over No overall differences in safety or effectiveness were observed between these subjects and younger subjects, and other reported clinical experience has not identified differences in responses between the elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out Age Sertraline plasma clearance in a group of 16 (8 male, 8 female) elderly patients treated for 14 days at a dose of 100 mg/day was approximately 40% lower than in a similarly studied group of younger (25 to 32 y.o.) individuals.
- Recommended SSRI options:
- Citalopram: 20 mg/day is the maximum recommended dose for patients who are greater than 60 years of age
- Sertraline: lower doses may be advisable for elderly patients due to decreased clearance, with a recommended dose of 100 mg/day or less in elderly patients
- Adverse effects to consider:
From the Research
Recommended SSRI Options in Elderly Patients
The following SSRIs are available for the treatment of depression in elderly patients: citalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline 4.
Adverse Effects in Elderly Patients
- Citalopram, paroxetine, and probably sertraline require lower doses when therapy is initiated in elderly patients due to modified pharmacokinetics 4.
- Fluvoxamine and paroxetine have been associated with a higher risk of adverse effects, such as gastrointestinal symptoms, malaise, sedation, and tremor 5.
- Fluoxetine may cause more agitation, weight loss, and dermatological reactions than other SSRIs 5.
- Sertraline has been found to have a lower risk of recurrent falls compared to citalopram/escitalopram at high doses 6.
Considerations for SSRI Selection
- When selecting an SSRI for elderly patients, clinicians should consider the potential for drug interactions, as well as the patient's medical history and comorbidities 4, 5.
- Citalopram and sertraline may be preferred due to their lower theoretical risk of interactions 5.
- Fluvoxamine and paroxetine should be used with caution in patients prone to SSRI-related adverse reactions 5.
- A risk-benefit analysis should be conducted when prescribing SSRIs to elderly patients, taking into account the potential treatment effects, adverse effects, and dangers of the illness to be treated 7.
Comparative Effectiveness of SSRIs
- A study found no consistent difference in effectiveness between individual SSRIs in terms of switching, augmentation, and hospitalization outcomes in elderly patients with depression 8.
- However, fluvoxamine and venlafaxine were associated with a higher risk of switching, augmentation, and hospitalization compared to sertraline 8.