Posted by bleauberry on December 17, 2009, at 17:45:17
In reply to SSRIs in Elderly, posted by donnam125 on December 17, 2009, at 13:50:09
I have studies literally by the hundreds, maybe even thousands, on pubmed over the years. They include large formal clinical studies, small clinical studies, case reports, and pilot studies. While none alone provide much guidance, an overall picture can be seen when they are viewed as a whole.
With that in mind, there appears to be a definite trend in the elderly to respond positively to noradrenergic/dopaminergic meds rather than serotonin meds. Of all the SSRIs, the only one I recall that showed any promise in the elderly was zoloft, but still the noradrenergic approach had much stronger convincing evidence.
I have seen several case reports similar to yours...very elderly with depression. In those cases, the doctors did not want to risk the side effects and "unknowns" of antidepressants (but it's ok to subject the rest of us to that, go figure) to the frail and elderly. And there was a sense of urgency. Waiting weeks for a response is not acceptable, and trying one med after another is not acceptable. At that age, who knows how much time there is? Can't mess around. Gotta go straight to what usually works, works fast, is safe, and has a long track record.
The most common med that fit that billing was Ritalin, low dose, once a day. Usually 2.5mg in the morning, perhaps increasing over time to 5mg or 10mg. Ritalin immediately provides physical energy, emotional energy, focus, attention, motivation, and within days improves depression rapidly.
Another approach is to add a low dose noradrenergic med such as Nortriptyline or Savella to a very low dose of a SSRI.
The basic trend I have seen in studies is that under 50 years old SSRIs work better, but over 50 years old the noradrenergic meds work better, and at very old age stimulants like Ritalin become first line instead of antidepressants.
Keep in mind these are just trends, not facts, but with a few dozen hours at pubmed you would see that what I say here is true. We must always respect that mileage varies and there is no prediction of anything. All meds are experimental. Nothing is proven. That said, the trend is strongly in favor of Ritalin or noradrenergic approach, low doses, for the very elderly.
I would not recommend coming off the current meds quickly however. While introducing a new med, one of the ones mentioned above, slowly over a couple months decrease the dose of the other. Don't do it in the dose sizes available. Step down in much smaller steps. This will involve getting good with a razor blade, pill crusher, or customizing empty gelcaps, to reduce doses in 1mg to 2mg increments at a time, with each new lower dose given 4 days before changing anything again.
Somewhere along the line you may find the previous med does not need to be completely stopped, but that it works very well with the new noradrenergic med. Or maybe it does need to be stopped. You'll discover that along the journey.
I hope this helps.
poster:bleauberry
thread:929718
URL: http://www.dr-bob.org/babble/20091217/msgs/929748.html