Abstract
Mood and anxiety disorders are common in the elderly. They are associated with significant morbidity and mortality. Unrecognized psychiatric conditions may have a significant negative effect on treatment outcomes for somatic disorders. Psychopharmacological treatment strategies should aim to provide not only symptomatic response and remission of symptoms but also full functional recovery. While medications are the mainstay for moderate to severe conditions, the use of adjunctive psychotherapy should also be considered. The selective serotonin reuptake inhibitors have become the first-line pharmacological treatment of depression and anxiety for the elderly. Alternative options (benzodiazepines, other antidepressants, and buspirone), while effective, have drawbacks associated with their use which makes them unsuitable as first-line choices. Clinical use of the selective serotonin reuptake inhibitors requires careful consideration of the mental status of the individual patient, their physical health (robust good health for age or frailty), and the presence of somatic illness. The choice of medication and initial dose will be guided by the interaction of these factors. Careful assessment of response to and monitoring of side effects of medication is essential to ensure optimal outcomes.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
References
Ahmed N, Mandel R, Fain MJ (2007) Frailty: an emerging geriatric syndrome. Am J Med 120:748–753
Akoudad S, Aarts N, Noordam R, Ikram MA, Tiemeier H, Hofman A, Stricker BH, Vernooij MW, Visser LE (2016) Antidepressant use is associated with an increased risk of developing microbleeds. Stroke 47:251–254
Alamo C, Lopez-Munoz F, Garcia-Garcia P, Garcia-Ramos S (2014) Risk–benefit analysis of antidepressant drug treatment in the elderly. Psychogeriatrics 14:261–268
Alexopoulos GS (2005) Depression in the elderly. Lancet 365:1961–1970
Alexopoulos GS, Katz IR, Reynolds CF, Carpenter D, Docherty JP (2001) The expert consensus guideline series: pharmacotherapy of depressive disorders in older patients. Postgrad Med Special Report 1–86
Alexopoulos GS, Lerner DM, Salzman C (2005) Treatment of depression with tricyclic antidepressants, monoamine oxidase inhibitors and psychostimulants. In: Salzman C (ed) Clinical geriatric psychiatry, 4th edn. Lippincott, Williams and Wilkins, Philadelphia, pp 233–303
American Geriatrics Society 2015 Beers Criteria Update Expert Panel (2015) American Geriatrics Society 2015 updated beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 63:2227–2246
Andrade C, Sandarsh S, Chethan KB, Nagesh KS (2010) Serotonin reuptake inhibitor antidepressants and abnormal bleeding: a review for clinicians and a reconsideration of mechanisms. J Clin Psychiatry 71:1565–1575
Barrowclough C, King P, Colville J et al (2001) A randomized trial of the effectiveness of cognitive-behavioral therapy and supportive counselling for anxiety symptoms in older adults. J Consult Psychol 69:756–762
Benedetti MS, Whomsley R, Canning M (2007) Drug metabolism in the paediatric population and in the elderly. Drug Discov Today 12:599–610
Benet LZ, Hoener BA (2002) Changes in plasma protein binding have little clinical relevance. Clin Pharmacol Ther 71:115–121
Blazer D, Hughes DC (1987) The epidemiology of depression in an elderly community population. Gerontologist 27:281–287
Bresolin N, Monza G, Scarpini E et al (1988) Treatment of anxiety with ketazolam in elderly patients. Clin Ther 10:536–542
Bruyere O, Reginster J-Y. Osteoporosis in patients taking selective serotonin reuptake inhibitors: a focus on fracture outcome. Endocrine DOI 10.1007/s12020-014-0357-0, August 2014.
Butler JM, Begg EJ (2008) Free drug metabolic clearance in elderly people. Clin Pharmacokinet 47:297–321
Cassidy K-L, Rector NA (2008) The silent geriatric giant: anxiety disorders in late life. Geriatr Aging 11:150–156
Cizza G, Primma S, Csako G (2009) Depression as a risk factor for osteoporosis. Trends Endocrinol Metab 20:367–373
Clayton AH, Croft HA, Handiwala L (2014) Antidepressants and sexual dysfunction: mechanisms and clinical implications. Postgrad Med 126:91–99
Cohen HW, Gibson G, Alderman MH (2000) Excess risk of myocardial infarction in patients treated with antidepressant medications: association with use of tricyclic agents. Am J Med 108:2–8
Conaglen HM, Conaglen JV (2013) Drug-induced sexual dysfunction in men and women. Aust Prescr 36:42–45
Cooke MJ, Waring WS (2013) Citalopram and cardiac toxicity. Eur J Clin Pharmacol 69:755–760
Coupland C, Dhiman P, Morriss R, Arthur A, Barton G, Hippisley-Cox J (2011) Antidepressant use and risk of adverse outcomes in older people: population based cohort study. BMJ 343:d4451
Creighton AS, Davison TE, Kissane DW (2016) The prevalence of anxiety among older adults in nursing homes and other residential aged care facilities: a systematic review. Int J Geriatr Psychiatry 31:555–566
Cresswell KM, Fernando BF, McKinstry B, Sheikh A (2007) Adverse drug events in the elderly. Br Med Bull 83:259–274
de Beurs E, Beekman ATF, van Balkom AJLM et al (1999) Consequences of anxiety in older persons: its effect on disability, well-being and use of health services. Psychol Med 29:583–593
De Picker L, Van Den Eede F, Dumont G, Moorkens G, Sabbe BG (2014) Antidepressants and the risk of hyponatremia: a class-by-class review of literature. Psychosomatics 55:536–547
DeVane CL (2006) Antidepressant–drug interactions are potentially but rarely clinically significant. Neuropsychopharmacol 31:1594–1604
Doucet J, Queneau P (2005) Adverse drug reactions in the elderly. Bull Acad Natl Med 189:1693–1707. discussion, 1708–1709
Driscoll HC, Karp JF, Dew MA, Reynolds CF (2007) Getting better, getting well: understanding and managing partial and non-response to pharmacological treatment of non-psychotic major depression in old age. Drugs Aging 24:801–814
Flint AJ (2005) Generalised anxiety disorder in elderly patients: epidemiology, diagnosis and treatment options. Drugs Aging 22:101–114
Fliser D, Franek E, Ritz E (1997) Renal function in the elderly – is the dogma of an inexorable decline of renal function correct? Nephrol Dial Transplant 12:1553–1555
Frattola L, Piolti R, Bassi S, Albizzati MG et al (1992) Effects of alpidem in anxious elderly outpatients: a double-blind, placebo controlled trial. Clin Neuropharmacol 15:477–487
Froissart M, Rossert J (2005) How to improve estimation of renal function in the elderly. Rev Prat 55:2223–2229
Gallo JJ, Bogner HR, Morales KH, Post EP, Lin JY, Bruce ML (2007) The effect of a primary care practice-based depression intervention on mortality in older adults: a randomized trial. Ann Intern Med 146:689–698
Georgotas A, McCue RE, Hapworth W, Friedman E, Kim OM, Welkowitz J, Chang I, Cooper TB (1986) Comparative efficacy and safety of MAOIs versus TCAs in treating depression in the elderly. Biol Psychiatry 21:1155–1166
Georgotas A, McCue RE, Friedman E, Cooper TB (1987) Response of depressive symptoms to nortriptyline, phenelzine and placebo. Br J Psychiat 151:102–106
Gillman PK (2007) Tricyclic antidepressant pharmacology and therapeutic drug interactions updated. Br J Pharmacol 151:737–748
Giron MS, Fastbom J, Winblad B (2005) Clinical trials of potential antidepressants: to what extent are the elderly represented: a review. Int J Geriatr Psychiatry 20:201–217
Goncalves DC, Byrne GJ (2012) Interventions for generalized anxiety disorder in older adults: systematic review and meta-analysis. J Anxiety Disord 26:1–11
Greenblatt DJ (1979) Reduced serum albumin concentration in the elderly: a report from the Boston Collaborative Drug Surveillance Program. J Am Geriatr Soc 27:20–22
Greenblatt DJ, von Moltke LL, Harmatz JS et al (2002) Pharmacokinetics, pharmacodynamics, and drug disposition. In: Davis KL, Charney D, Coyle JT et al (eds) Neuropsychopharmacology: the fifth generation of progress, 5th edn. Lippincott Williams & Wilkins, Philadelphia, pp 507–524
Haddad PM, Anderson IM (2007) Recognising and managing antidepressant discontinuation symptoms. Adv Psychiatr Treat 13:447–457
Hawton K, Bergen H, Simkin S, Cooper J, Waters K, Gunnell D, Kapur N (2010) Toxicity of antidepressants: rates of suicide relative to prescribing and non-fatal overdose. Br J Psychiatry 196:354–358
Herrlinger C, Klotz A (2001) Drug metabolism and drug interactions in the elderly. Best Pract Res Clin Gastroenterol 15:897–918
Heun R, Ahokas A, Boyer P, Giménez-Montesinos N, Pontes-Soares F, Olivier V (2013) The efficacy of agomelatine in elderly patients with recurrent major depressive disorder: a placebo-controlled study. J Clin Psychiatry 74:587–594
Hilmer SN, McLachlan AJ, Le Couteur DG (2007) Clinical pharmacology in the geriatric patient. Fundam Clin Pharmacol 21:217–230
Hubbard RE, O’Mahony MS, Calver BL, Woodhouse KW (2008) Plasma esterases and inflammation in ageing and frailty. Eur J Clin Pharmacol 64:895–900
Hutchison LC, O’Brien CE (2007) Changes in pharmacokinetics and pharmacodynamics in the elderly patient. J Pharm Pract 20:4–12
Jarvik L, Mintz J, Steuer J, Gerner R (1982) Treating geriatric depression: a 26-week interim analysis. J Am Geriatr Soc 30:713–717
Judge TG, Caird FI (1978) Drug treatment of the elderly patient. Pitman Medical Publishing Tunbridge Wells, UK, p P7
Kapadia A, Wynn D, Salzman B (2010) Potential adverse effects of proton pump inhibitors in the elderly. Clin Geriatr 18:24–31
Katona C, Hansen T, Olsen CK (2012) A randomized, double-blind, placebo-controlled, duloxetine-referenced, fixed-dose study comparing the efficacy and safety ofLu AA21004 in elderly patients with major depressive disorder. Int Clin Psychopharmacol 27:215–223
Katz IR, Reynolds CF, Alexopoulos GS et al (2002) Venlafaxine ER as a treatment for generalized anxiety disorder in older adults: pooled analysis of five randomized placebo-controlled clinical trials. J Am Geriatr Soc 50:18–25
Keller MB (2003) Past, present, and future directions for defining optimal treatment outcome in depression: remission and beyond. JAMA 289:3152–3160
Kennerfalk A, Ruigómez A, Wallander MA, Wilhelmsen L, Johansson S (2002) Geriatric drug therapy and healthcare utilization in the United Kingdom. Ann Pharmacother 36:797–803
Kinirons MT, O’Mahony MS (2004) Drug metabolism and ageing. Br J Clin Pharmacol 57:540–544
Klotz U (2009) Pharmacokinetics and drug metabolism in the elderly. Drug Metab Rev 41:67–76
Koepke HH, Gold RL, Linden ME, Lion JR, Rickels K (1982) Multicentre controlled study of oxazepam in anxious elderly outpatients. Psychosomatics 23:641–645
Kok RM, Nolen WM, Heeren TJ (2012) Efficacy of treatment in older depressed patients: a systematic review and meta-analysis of double-blind randomized controlled trials with antidepressants. J Affect Dis 141:103–115
Krasucki C, Howard R, Mann A (1999) Anxiety and its treatment in the elderly. Int Psychogeriatr 11:25–45
Le Couteur DG, Fraser R, Hilmer S, Rivory LP, McLean AJ (2005) The hepatic sinusoid in aging and cirrhosis: effects on hepatic substrate disposition and drug clearance. Clin Pharmacokinet 44:187–200
Lenze EJ, Pollock BG, Shear K,MD, Mulsant BH, Bharucha A, Reynolds CF (2003) Treatment considerations for anxiety in the elderly. CNS Spectr 12(Suppl 3):6–13
Lin JH, Yamazaki M (2003) Role of P-glycoprotein in pharmacokinetics. Clinical implications. Clin Pharmacokinet 42:59–98
Lindeman RD, Tobin J, Shock NW (1985) Longitudinal studies on the rate of decline in renal function with age. J Am Geriatr Soc 33:278–285
Lugoboni F, Quagli G (2014) Exploring the dark side of the moon: the treatment of benzodiazepine tolerance. Br J Clin Pharmacol 77:239–241
Mallet L, Spinewine A, Huang A (2007) Prescribing in elderly people. 2. The challenge of managing drug interactions in elderly people. Lancet 370:185–191
Mangoni AA, Jackson SH (2004) Age-related changes in pharmacokinetics and pharmacodynamics: basic principles and practical applications. Br J Clin Pharmacol 57:6–14
McLean AJ, Le Couteur DG (2004) Aging biology and geriatric clinical pharmacology. Pharmacol Rev 56:163–184
Mock P, Norman TR, Olver JS (2010) Contemporary therapies for depression in older people. J Pharm Pract Res 40:58–64
Mohlman J, Gorenstein EE, Kleber M et al (2003) Standard and enhanced cognitive-behaviour therapy for late-life generalized anxiety disorder: two pilot investigations. Am J Geriatr Psychiatry 11:24–32
Montgomery S, Chatamra K, Pauer L, Whalen E, Baldinetti F (2008) Efficacy and safety of pregabalin in elderly people with generalised anxiety disorder. Br J Psychiatry 193:389–394
Mottram P, Wilson K, Strobl J (2006) Antidepressants for depressed elderly. Cochrane Database Syst Rev 1:CD003491
Mukai Y, Tampi RR (2009) Treatment of Depression in the Elderly: A Review of the Recent Literature on the Efficacy of Single- Versus Dual-Action Antidepressants. Clin Therap 31:945–961
Mulsant BH, Alexopoulos GS, Reynolds CF, PROSPECT Study Group (2001) Pharmacological treatment of depression in older primary care patients: the PROSPECT algorithm. Int J Geriatr Psychiatry 16:585–592
Nair NPV, Amin M, Holm P, Katona C, Klitgaard C, NgYing Kin NMK, Kragh-Sorensen P, Kiihn H, Leek CA, Stage KB (1995) Moclobemide and nortriptyline in elderly depressed patients: a randomized, multicentre trial against placebo. J Affect Disord 33:1–9
Nelson JC, Wohlreich MM, Mallinckrodt CH, Detke MJ, Watkin JG, Kennedy JS (2005) Duloxetine for the treatment of major depressive disorder in older patients. Am J Geriatr Psychiatry 13:227–235
Olver JS, Burrows GD, Norman TR (1999) Discontinuation syndromes with SSRIs: are there clinically relevant differences? CNS Drugs 12:171–177
Osgood NJ (1991) Prevention of suicide in the elderly. J Geriatr Psychiatry 24:293–305
Pizzuti R, Caffari B, Binkin N, Argento G (2006) Prescription drugs and the elderly: results of the Argento study. Ig Sanita Publ 62:11–26
Rajji TK, Mulsant BH, Lotrich FE, Lokker C, Reynolds CF (2008) Use of antidepressants in late-life depression. Drugs Aging 25:841–853
Raskin J, Wiltse CG, Siegal A, Sheikh J, Xu J, Dinkel JJ et al (2007) Efficacy of duloxetine on cognition, depression, and pain in elderly patients with major depressive disorder: an 8-week, double-blind, placebo-controlled trial. Am J Psychiatry 164:900–909
Reiger DA, Boyd JH, Burke JD et al (1988) One month prevalence of mental disorders in the US – based on five epidemiologic catchment area sites. Arch Gen Psychiatry 45:977–986
Reynolds CF, Frank E, Kupfer DJ, Thase ME, Perel JM, Mazumdar S, Houck PR (1996) Treatment outcome in recurrent major depression: a post hoc comparison of elderly (“Young Old”) and midlife patients. Am J Psychiatry 153:1288–1292
Reynolds CF, Frank E, Perel JM et al (1999) Nortriptyline and interpersonal psychotherapy as maintenance therapies for recurrent major depression: a randomized controlled trial in patients older than 59 years. JAMA 281:39–45
Reynolds CF, Dew MA, Pollock BG et al (2006) Maintenance treatment of major depression in old age. N Engl J Med 354:1130–1138
Roden DM (2004) Drug induced prolongation of the QT interval. N Engl J Med 350:1013–1022
Roose SP, Schatzberg AF (2005) The efficacy of antidepressants in the treatment of late-life depression. J Clin Psychopharmacol 25:S1–S7
Roose SP, Sackeim HA, Krishnan KR et al (2004) Old-Old Depression Study Group. Antidepressant pharmacotherapy in the treatment of depression in the very old: a randomized, placebo controlled trial. Am J Psychiatry 161:2050–2059
Roth M, Mountjoy CQ, Amrien R (1996) Moclobemide in elderly patients with cognitive decline and depression: an international double-blind, placebo-controlled trial. Br J Psychiatry 168:149–157
Sami MB, Nilforooshan R (2015) The natural course of anxiety disorders in the elderly: a systematic review of longitudinal trials. Int Psychogeriater 27:1061–1069
Samuels SC, Katz IB (1995) Depression in the nursing home. Psychiatr Ann 25:419–424
Schoevers RA, Deeg DJ, van Tilburg W, Beekman AT (2005) Depression and generalized anxiety disorder: co-occurrence and longitudinal patterns in elderly patients. Am J Geriatr Psychiatry 13:31–39
Schuurmans J, Comijs H, Emmelkamp PMG et al (2006) A randomized, controlled trial of the effectiveness of cognitive- behavioral therapy and Sertraline versus a Waitlist Control group for anxiety disorders in older adults. Am J Geriatr Psychiatry 14:255–263
Schwartz JB (2007) The current state of knowledge on age, sex, and their interactions on clinical pharmacology. Clin Pharmacol Ther 82:87–96
Sloman JG, Norman TR, Burrows GD (1983) Clinical studies of antidepressant cardiotoxicity. In: Burrows GD, Norman TR, Davies BM (eds) Drugs in psychiatry, vol. 1., antidepressants. Elsevier Biomedical Press, Amsterdam, pp 173–186
Small GW, Bystritsky A (1997) Double-blind, placebo-controlled trial of two doses of abecarnil for geriatric anxiety. J Clin Psychiatry 58:24–29
Spina E, Scordo MG (2002) Clinically significant drug interactions with antidepressants in the elderly. Drugs Aging 19:299–320
Steffens DC, McQuoid DR (2005) Impact of symptoms of generalized anxiety disorder on the course of late-life depression. Am J Geriatr Psychiatr 13:40–47
Taylor EM (2002) The impact of efflux transporters in the brain on the development of drugs for CNS disorders. Clin Pharmacokinet 41:81–92
Taylor WD, Doraiswamy PM (2004) A systematic review of antidepressant placebo-controlled trials for geriatric depression: limitations of current data and directions for the future. Neuropsychopharmacol 29:2285–2299
Toornvliet R, van Berckel BNM, Luurtsema G, Lubberink M, Geldorf AA, Bosch TM, Oerlemans R, Lammertsma AA, Franssen EJF (2006) Effect of age on functional P-glycoprotein in the blood-brain barrier measured by use of (R)-[11C] verapamil and positron emission tomography. Clin Pharmacol Ther 79:540–548
U.S. Food and Drug Administration. FDA drug safety communication: revised recommendations for Celexa (citalopram hydrobromide) related to a potential risk of abnormal heart rhythms with high doses. http://www.fda.gov/drugs/drugsafety/ucm297391.htm
United Nations Department of Economic and Social Affairs, Population Division (2002) http://www.un.org/esa/population/publications/worldageing19502050/
Viramontes TS, Truong H, Linnebur SA (2016) Antidepressant-induced hyponatremia in older adults. Consult Pharm 31:139–150
Wauthier V, Verbeeck RK, Calderon PB (2007) The effect of ageing on cytochrome P450 enzymes: consequences for drug biotransformation in the elderly. Curr Med Chem 14:745–757
WHO (2015) http://www.who.int/mediacentre/factsheets/fs404/en
Wilson K, Mottram P, Sivanranthan A, Nightingale A (2001) Anti-depressants versus placebo for the depressed elderly (Cochrane Review). Cochrane Database Syst Rev 2:CD000561
Wolitzky-Taylor KB, Castriotta N, Lenze EJ, Stanley MA, Craske MG (2010) Anxiety disorders in older adults: a comprehensive review. Depress Anxiety 27:190–211
Woodhouse KW, O’Mahony MS (1997) Frailty and ageing. Age Ageing 26:245–246
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2017 Springer Science+Business Media Singapore
About this entry
Cite this entry
Norman, T.R. (2017). Pharmacotherapy for Mood and Anxiety Disorders. In: Chiu, H., Shulman, K. (eds) Mental Health and Illness of the Elderly. Mental Health and Illness Worldwide. Springer, Singapore. https://doi.org/10.1007/978-981-10-2414-6_19
Download citation
DOI: https://doi.org/10.1007/978-981-10-2414-6_19
Published:
Publisher Name: Springer, Singapore
Print ISBN: 978-981-10-2412-2
Online ISBN: 978-981-10-2414-6
eBook Packages: Behavioral Science and PsychologyReference Module Humanities and Social SciencesReference Module Business, Economics and Social Sciences