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

3. 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

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

5. 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.

6. Tricyclic antidepressants: very problematic

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

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

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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. Bleeding with SSRIs and SNRIs
Platelet dysfunction
Dose dependent effect

17. 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

18. 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: , 2009

19. 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: , 2009

20. 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: , 2009

21. 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: , 2009

22. Key Points
In general, TCAs and MAOIs are not recommended

23. 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

24. 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

25. 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

26. Next Presentation - Use of Mood Stabilizers in the Elderly: Selected Concepts