Curriculum · Elderly / Community care
Antidepressant selection in older adults
What it is
The choice of an antidepressant in an older patient starts from the same treatment options that are used in younger patients. They include the selective serotonin reuptake inhibitors, monoamine oxidase inhibitors, atypical antidepressants, tricyclic antidepressants, electroconvulsive therapy (ECT), and psychotherapy. What changes with age is which agent within that list is preferred and how it is dosed, since older patients have decreased metabolism and clearance rates and are more sensitive to side effects.
How it is treated
Escitalopram is a preferred antidepressant for older patients (SOR C). Paroxetine should generally be avoided in older patients, because adverse effects are more likely with it (SOR C). The Beers Criteria name three of these drugs and give all three an avoid recommendation (SOR A): first amitriptyline, second imipramine, third paroxetine, each of them highly anticholinergic and sedating. Because metabolism and clearance rates are decreased, older patients may require smaller doses to achieve a therapeutic effect. The rule of thumb when titrating an antidepressant in this population is to start low and go slow.