Tricyclic antidepressants, especially amitriptyline and dothiepin,16 are known to pose a high risk of death in overdosage. These drugs should therefore be avoided in older people whose medication is not supervised and who are at risk of taking an overdose.
One particular concern is that antidepressants increase the risk of falls, osteoporosis and fractures. Falls are a known risk for the older tricyclic antidepressants as they increase the risk of orthostatic hypotension.
Those at higher risk include people more than 75 years old, people taking oral steroids, and people taking a blood-thinning medication such as apixaban (Eliquis), aspirin, clopidogrel (Plavix), dabigatran (Pradaxa), edoxaban (Savaysa), rivaroxaban (Xarelto), or warfarin (Coumadin).
Tricyclic antidepressants are no longer considered first-line agents for older adults given their potential for side effects, including postural hypotension, which can contribute to falls and fractures, cardiac conduction abnormalities, and anticholinergic effects.
Tertiary amine tricyclics such as amitriptyline and imipramine have been reported to be effective in depressed geriatric patients, but because of their potential for side effects, it is not advisable to use them in the elderly.
Sertraline is generally well tolerated in elderly patients with major depressive disorder and lacks the marked anticholinergic effects that characterise the adverse event profiles of tricyclic antidepressants (TCAs).
However, elderly patients may be more sensitive to the effects of this medicine than younger adults, and are more likely to have hyponatremia (low sodium in the blood), which may require caution and an adjustment in the dose for patients receiving paroxetine.
Diphenhydramine and amitriptiline are the most common inappropriately prescribed medications with high risk adverse events while propoxyphene and doxazoxin are the most commonly prescribed medications with low risk adverse events.
Below are the top 10 medications prescribed to elderly Americans.
Gurvich and Cunningham state in their article1 on psychotropic drugs in nursing homes that fluoxetine (Prozac) is not recommended in the geriatric population because of its longer half-life of active metabolite relative to other selective serotonin reuptake inhibitors (SSRIs), resulting in the potential for a longer
Among the newer antidepressants, bupropion and venlafaxine were associated with the highest case fatality rates. In addition, among SSRIs, citalopram and fluvoxamine appeared to be related to higher mortality rates in overdose, whereas fluoxetine and sertraline were the safest .
PARIS, FRANCE — September 20, 2006 — Once-daily use of an extended-release formulation of bupropion (Wellbutrin XL(R)) is both efficacious and safe in elderly patients with major depressive disorder, according to a multicentre, randomised, double-blind, flexible-dose, placebo-controlled trial.
In studies, Celexa was as effective and safe in people ages 65 and older as in younger people. However, older people who take Celexa may be at greater risk for a side effect known as hyponatremia, in which there is not enough salt in the fluid surrounding cells in the body.
Buspirone is an anti-anxiety drug that has been shown to be effective for older adults. Benzodiazepines, another anti-anxiety drug, are effective but should be prescribed carefully to older adults because of risk of memory impairment, unsteadiness, and falls.
Use any form of tramadol with extreme caution in patients 75 years and older. The elderly may be especially prone to side effects with tramadol due to lowered liver or kidney function and reduced metabolism or excretion.
Long half-life benzodiazepines usually are not preferred for older patients because of cumulative toxicity. Among the short half-life drugs, high-potency compounds (e.g., lorazepam, alprazolam) may be more toxic than low-potency compounds (e.g., oxazepam).