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Antidepressants: Adverse Effects in the Elderly Sandra A. Jacobson, M.D. Research Associate Professor University of Arizona College of Medicine Phoenix

Side effects of antidepressants in elderly patients Orthostatic hypotension Cardiac conduction disturbances Anticholinergic effects Bleeding Delirium and other cognitive effects Syndrome of inappropriate ADH secretion Weight gain

Tolerance develops to: Sedation Dizziness GI distress Jacobson SA. Clinical Manual of Geriatric Psychopharmacology, 2nd Ed. Washington, DC: American Psychiatric Publishing, Inc., 2014.

Tolerance develops to: Sedation Dizziness GI distress Tolerance does not develop to: Orthostasis Cardiac rhythm disturbances Anticholinergic effects Jacobson SA. Clinical Manual of Geriatric Psychopharmacology, 2nd Ed. Washington, DC: American Psychiatric Publishing, Inc., 2014.

Tricyclic antidepressants: very problematic

Tricyclic antidepressants: very problematic Cardiac conduction effects, hypotension, anticholinergic effects

Tricyclic antidepressants: very problematic Cardiac conduction effects, hypotension, anticholinergic effects Not recommended in geriatrics

Tricyclic antidepressants: very problematic Cardiac conduction effects, hypotension, anticholinergic effects Not recommended in geriatrics No tricyclic is safe if pre-existing conduction delay

SSRIs in Geriatrics Fabian TJ1, Amico JA, Kroboth PD, Mulsant BH, Reynolds CF 3rd, Pollock BG: Paroxetine-induced hyponatremia in the elderly due to the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). J Geriatr Psychiatry Neurol.16:160-4, 2003

SSRIs in Geriatrics SIADH 12% incidence Not dose dependent Fabian TJ1, Amico JA, Kroboth PD, Mulsant BH, Reynolds CF 3rd, Pollock BG: Paroxetine-induced hyponatremia in the elderly due to the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). J Geriatr Psychiatry Neurol.16:160-4, 2003

Usually in the first two weeks SSRIs in Geriatrics SIADH 12% incidence Not dose dependent Usually in the first two weeks Fabian TJ1, Amico JA, Kroboth PD, Mulsant BH, Reynolds CF 3rd, Pollock BG: Paroxetine-induced hyponatremia in the elderly due to the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). J Geriatr Psychiatry Neurol.16:160-4, 2003

SSRIs in Geriatrics SIADH Usually in the first two weeks 12% incidence Not dose dependent Usually in the first two weeks First sign can be a change in mental status Fabian TJ1, Amico JA, Kroboth PD, Mulsant BH, Reynolds CF 3rd, Pollock BG: Paroxetine-induced hyponatremia in the elderly due to the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). J Geriatr Psychiatry Neurol.16:160-4, 2003

SSRIs in Geriatrics SIADH Usually in the first two weeks 12% incidence Not dose dependent Usually in the first two weeks First sign can be a change in mental status If hyponatremia is not detected and treated Progression to coma, may be fatal Fabian TJ1, Amico JA, Kroboth PD, Mulsant BH, Reynolds CF 3rd, Pollock BG: Paroxetine-induced hyponatremia in the elderly due to the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). J Geriatr Psychiatry Neurol.16:160-4, 2003

Serum sodium should be checked SSRIs in Geriatrics SIADH 12% incidence Not dose dependent Usually in the first two weeks First sign can be a change in mental status If hyponatremia is not detected and treated Progression to coma, may be fatal Serum sodium should be checked Before an SSRI is started At weeks 1 and 2 after treatment begins Fabian TJ1, Amico JA, Kroboth PD, Mulsant BH, Reynolds CF 3rd, Pollock BG: Paroxetine-induced hyponatremia in the elderly due to the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). J Geriatr Psychiatry Neurol.16:160-4, 2003

Bleeding with SSRIs and SNRIs Platelet dysfunction Dose dependent effect

Bleeding with SSRIs and SNRIs Platelet dysfunction Dose dependent effect Increased risk: History of GI bleeding or coagulation disorder NSAIDs or related drugs ADs with a high affinity for the SERT Fluoxetine, paroxetine and sertraline

Increased risk of falls in the geriatric population Woolcott JC1, Richardson KJ, Wiens MO, Patel B, Marin J, Khan KM, Marra CA: Meta-analysis of the impact of 9 medication classes on falls in elderly persons. Arch Intern Med 169:1952-60, 2009

Increased risk of falls in the geriatric population All AD classes Extrapyramidal side effects and akathisia Woolcott JC1, Richardson KJ, Wiens MO, Patel B, Marin J, Khan KM, Marra CA: Meta-analysis of the impact of 9 medication classes on falls in elderly persons. Arch Intern Med 169:1952-60, 2009

Increased risk of falls in the geriatric population All AD classes Extrapyramidal side effects and akathisia Weight gain Most problematic with MAOIs, tricyclics, paroxetine and mirtazapine Any SSRI used chronically can be associated with significant weight gain Woolcott JC1, Richardson KJ, Wiens MO, Patel B, Marin J, Khan KM, Marra CA: Meta-analysis of the impact of 9 medication classes on falls in elderly persons. Arch Intern Med 169:1952-60, 2009

Increased risk of falls in the geriatric population All AD classes Extrapyramidal side effects and akathisia Weight gain Most problematic with MAOIs, tricyclics, paroxetine and mirtazapine Any SSRI used chronically can be associated with significant weight gain Oral MAOI use: orthostatic hypotension Woolcott JC1, Richardson KJ, Wiens MO, Patel B, Marin J, Khan KM, Marra CA: Meta-analysis of the impact of 9 medication classes on falls in elderly persons. Arch Intern Med 169:1952-60, 2009

Key Points In general, TCAs and MAOIs are not recommended

Key Points In general, TCAs and MAOIs are not recommended SIADH Not dose dependent 12% incidence First sign can be a change in mental status

Key Points In general, TCAs and MAOIs are not recommended SIADH Not dose dependent 12% incidence First sign can be a change in mental status Check serum sodium: Before an SSRI is initiated At weeks 1 and 2 after treatment begins

Key Points In general, TCAs and MAOIs are not recommended SIADH Not dose dependent 12% incidence First sign can be a change in mental status Check serum sodium: Before an SSRI is initiated At weeks 1 and 2 after treatment begins All AD classes: increased risk of falls, EPS and akathisia

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