![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 6 to 30 of 34. Go back in thread:
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.
Posted by SLS on December 17, 2009, at 18:06:10
In reply to Re: SSRIs in Elderly, posted by donnam125 on December 17, 2009, at 16:26:36
Hi Donna.
Unfortunately, I don't know enough to be able to take as much into consideration as a competent doctor would.
Since the cognitive (thinking) and affective (mood) symptoms you are concerned with appeared prior to her beginning lisinopril, I would avoid making any changes to its administration. You don't want to risk a rebound hypertensive reaction.
Did her sleeping patterns change noticeably? Does it appear that her symptoms are worse in the morning? Is she less interested in activities that she was once motivated to be involved with? Are her physical movements slowed down?
- Scott
Posted by SLS on December 17, 2009, at 18:36:35
In reply to Re: SSRIs in Elderly, posted by bleauberry on December 17, 2009, at 17:45:17
It does seem that the noradrenergic drugs are effective. Unfortunately, the drugs that would probably help with late-onset depression the most - the tricyclics - are the ones that are most problematic in the elderly with respect to side effects and toxicity.
- Scott
Posted by Phillipa on December 17, 2009, at 19:30:06
In reply to Re: SSRIs in Elderly » bleauberry, posted by SLS on December 17, 2009, at 18:36:35
Heres a study on SSRI's in elderly. Phillipa
Posted by whitmore on December 17, 2009, at 19:42:15
In reply to Re: SSRIs in Elderly, posted by Phillipa on December 17, 2009, at 19:30:06
That comparison you posted Phillipa was fascinating in that it showed Luvox to be better tolerated and more effective than others in the same class that are prescribed in much larger numbers. Who knew!!?
Posted by Phillipa on December 17, 2009, at 21:24:47
In reply to Re: SSRIs in Elderly, posted by whitmore on December 17, 2009, at 19:42:15
Well according to Blue I'm considered elderly over 50. So many people who post here have also posted their ages and so many over 50. Who knows maybe that's why my brain seems to like the low dose of luvox? I did see one lady when working who was in a wheelchair came in the psych hospital in horrible shape saw her when worked on the second floor for non-suicidal or psychotic patients and couldn't believe what I saw this lady was wearing make-up she applied herself smiling, happy, and she was at least 75 or older in the wheelchair still and her miracle med was prozac and it only came in 20mg capsules then. So who knows. Phillipa
Posted by donnam125 on December 18, 2009, at 6:49:21
In reply to Re: SSRIs in Elderly, posted by SLS on December 17, 2009, at 18:06:10
Yes, Scott, her sleeping patterns have changed. She is unable to sustain any long sleep in one place as she moves from her bed to the living room couch in any given night for about 2 hours at a time. In fact, she was developing severe swelling in her lower legs and ankles for which the Lasix wasn't helping much. I then realized she wasn't sleeping in her bed much and since I told her she must, that problem seems to be abating.
I don't think her symptoms are any different in the morning, but then again, I'm not with her in the mornings and I doubt that she is able to really tell me due to her confused state at times.
Yes she is definitely less interested in activities that use to please her. Even simple things like listening to music and watching tv shows she use to enjoy. The ONLY, and I mean ONLY thing she ever watches is the Game Show Network, and she's gotten into the habit of scratching her head constantly. I literally pay $70/mos. to the cable company for her to watch ONE channel. And she almost never wants to leave her apartment anymore.
And yes, her physical movements seemed to have slowed down as well. She is finding it more difficult to stand from a sitting position.
I'm feeling so helpless and somewhat guilty because she so wants to live with me, but I have a small apartment with two cats. She does not like animals around her and she likes to keep the temperature at around 80 where I like 72. We are, and always have been, incompatible on several levels, but most definitely environmentally, and any quality assisted living facility is not only a financial impossibility, but out of the question in her mind. I have already been through triple bypass several years ago, and have been under so much stress after losing my job earlier this year after 24 years, and trying to take care of her. I fear if I gave up whatever little of my private life is left, it will take a huge toll on me. But she has a way of making me feel guilty, Italian mothers are like that in general.
What's really a pity is that she has a neighbor gentleman in his early 90s who cares for her a lot and likes to visit and watch tv with her. This was going great for a few years, but this last year she's been accusing him of coming into her apartment in the middle of the night (the guy can barely walk mind you) and taking things, or, and this one's really kind of funny in a way, she accuses him of having another woman living with him. Even though she has been celibate since my father died in 1969. So now she hates him and accuses me of taking up for him when I try to tell her he's not doing these things, but I see now that that's a losing battle for me. Her ability to reason out things has pretty much gone.
I'm sorry to go on and on, but I guess I just had to get this out somewhere. I so appreciate everyone's input.
Thank you again.
> Did her sleeping patterns change noticeably? Does it appear that her symptoms are worse in the morning? Is she less interested in activities that she was once motivated to be involved with? Are her physical movements slowed down?
>
>
> - Scott
Posted by donnam125 on December 18, 2009, at 7:14:59
In reply to SSRIs in Elderly, posted by donnam125 on December 17, 2009, at 13:50:09
I just want to thank everyone who has contributed to this thread. I am very grateful for all your input and support. It is very comforting having a place like this to discuss what few in your own inner circle either know how or care to.
Thanks again to all of you and best wishes during these holiday seasons.
Posted by SLS on December 18, 2009, at 7:38:21
In reply to Re: SSRIs in Elderly » SLS, posted by donnam125 on December 18, 2009, at 6:49:21
I'm sorry that things are so overwhelming for you right now. I asked those questions in an attempt to differentiate late-life depression from an organic dementia like Alzheimers or vascular (post-stroke). To me, it sounds more like depression with some psychotic features rather than Alzheimers. I can't be sure, of course. Very often, late-life depression looks very much like dementia and is sometimes referred to as "pseudodementia". It might not be a bad idea to pressure the doctor into committing to a diagnosis. If it is depression, then I hope you can cross your mother over to another drug without too much upset. Did the doctor mention any other antidepressants that could be tried? Perhaps a combination of Effexor and Seroquel? The doctor could cross over directly from Zoloft to another serotonin drug like Effexor or Lexapro to minimize a withdrawal syndrome. I'm not smart enough to know what to do next. I hope the doctor is.
For what it's worth, I read that elderly people metabolize Zoloft at about the same rate as younger people as long as there is no overt liver disease. She probably has not been overmedicated.
- Scott
Posted by bleauberry on December 18, 2009, at 20:53:49
In reply to Re: SSRIs in Elderly » bleauberry, posted by SLS on December 17, 2009, at 18:36:35
> It does seem that the noradrenergic drugs are effective. Unfortunately, the drugs that would probably help with late-onset depression the most - the tricyclics - are the ones that are most problematic in the elderly with respect to side effects and toxicity.
>
>
> - ScottActually it would seem that way. But in the case studies and small studies I recall, the TCAs were actually better tolerated than the SSRIs. The reason may be because they better suited the chemistry, or maybe because the frail and elderly did not require high doses. Low doses did the job.
Posted by SLS on December 19, 2009, at 4:24:47
In reply to Re: SSRIs in Elderly, posted by bleauberry on December 18, 2009, at 20:53:49
> > It does seem that the noradrenergic drugs are effective. Unfortunately, the drugs that would probably help with late-onset depression the most - the tricyclics - are the ones that are most problematic in the elderly with respect to side effects and toxicity.
> >
> >
> > - Scott
>
> Actually it would seem that way. But in the case studies and small studies I recall, the TCAs were actually better tolerated than the SSRIs. The reason may be because they better suited the chemistry, or maybe because the frail and elderly did not require high doses. Low doses did the job.I was more concerned that there wasn't some sort of behavioral toxicity being produced by SSRI over-medication. Whether older people respond better to lower dosages of drugs when they are adjusted for differences in kinetics is another story. If she did not have heart disease, it would be interesting to try a small dose of nortriptyline. Now that I think about it, Effexor might be contraindicated if her blood pressure is elevated and not controlled well by antihypertensives. I'd have to read up on that.
- Scott
Posted by Phillipa on December 19, 2009, at 20:14:34
In reply to SSRIs in Elderly, posted by donnam125 on December 17, 2009, at 13:50:09
Lisinopril does cause depression is it possible to switch the med? Phillipa
Posted by mtdewcmu on December 20, 2009, at 16:19:38
In reply to Re: SSRIs in Elderly » SLS, posted by donnam125 on December 18, 2009, at 6:49:21
If she can't sleep lying down, and she moves to the couch to sleep sitting up, that is a sign of heart failure. Sitting up makes it easier to breathe. It is called orthopnea. You should mention that to her doctor, if he doesn't already know. There may not be anything else he can do, though.
Posted by Phillipa on December 20, 2009, at 19:24:29
In reply to Re: SSRIs in Elderly » donnam125, posted by mtdewcmu on December 20, 2009, at 16:19:38
Seriously great catch. Phillipa
Posted by mtdewcmu on December 20, 2009, at 20:37:17
In reply to Re: SSRIs in Elderly » mtdewcmu, posted by Phillipa on December 20, 2009, at 19:24:29
> Seriously great catch. Phillipa
Thanks. I am a licensed nurse, so I am supposed to know this stuff.
Posted by Phillipa on December 20, 2009, at 21:22:51
In reply to Re: SSRIs in Elderly » Phillipa, posted by mtdewcmu on December 20, 2009, at 20:37:17
I'm a retired RN. I should have caught that also as did a lot of cardiac. I floated for ll years then got certified in psych. Phillipa
Posted by mtdewcmu on December 20, 2009, at 21:41:28
In reply to Re: SSRIs in Elderly » mtdewcmu, posted by Phillipa on December 20, 2009, at 21:22:51
> I'm a retired RN. I should have caught that also as did a lot of cardiac. I floated for ll years then got certified in psych. Phillipa
Your compliment means a lot more then. Thanks.
Posted by Phillipa on December 20, 2009, at 22:03:05
In reply to Re: SSRIs in Elderly, posted by mtdewcmu on December 20, 2009, at 21:41:28
It's the patient that's health and mental well being and even life that are at stake and your a patient advocate right? Phillipa
Posted by mtdewcmu on December 20, 2009, at 22:29:38
In reply to Re: SSRIs in Elderly » mtdewcmu, posted by Phillipa on December 20, 2009, at 22:03:05
> It's the patient that's health and mental well being and even life that are at stake and your a patient advocate right? Phillipa
Yes. I could probably have a much better job if I wasn't crippled by chronic depression. Not that nursing is at all a bad job. But I'm sure I could have been a pharmacist at least, if not a doctor.
Posted by Phillipa on December 21, 2009, at 18:45:55
In reply to Re: SSRIs in Elderly, posted by mtdewcmu on December 20, 2009, at 22:29:38
Seriously I truly loved nursing. I was sad to have to stop working. Liked patient care and not the paperwork. No all computerized but then we also used computers. Phillipa
Posted by 49er on December 24, 2009, at 8:29:05
In reply to SSRIs in Elderly, posted by donnam125 on December 17, 2009, at 13:50:09
Donna,
My heart breaks when I hear of stories like this. I won't even start because I don't want to disrupt the spirit of the holidays.
Am I reading this right, she is on Zoloft now?
You might want to consider a very slow taper. Normally, I suggest 10% of current dose every 3 to 6 weeks.
But in this case, I might start with 2.5%.
Unfortunately, due to insomnia, I am trouble explaining how to do this. Therefore, you might want to go to http://www.paxilprogress.org where there are very helpful folks. Even though the site says paxil, it is for everyone who wants help tapering off of psych meds.
By going very slowly, you would give your mom time to adjust to the lowering of the dose.
By the way, if she was doing fine, I would say not to bother. But it sounds like you have nothing to lose by lowering the dose since the meds seem to be making the situation worse.
For what sounds like symptoms of Alzheimer's, I would look at phosphatidylserine. I have tried it as the result of having cognitive issues as the result of psych meds and found it helpful. It is used for people with your mom's condition.
Unfortunately, for reasons that would make this post too long, I couldn't stay on it long term. But interestingly, as long as I took it early enough in the day, it helped with sleep.
Have you had her vitamin D level tested? She might need more than 1000IU.
You and your sister sound like wonderful daughters.
Good luck.
49er
Posted by donnam125 on December 24, 2009, at 9:00:01
In reply to Re: SSRIs in Elderly » donnam125, posted by 49er on December 24, 2009, at 8:29:05
49er, thank you for your suggestions and concern. As a follow up, I spoke with my mother's doctor yesterday and he suggested to start giving her the Zoloft every other day for two weeks, and then to revisit her status after that. I asked if the weaning process shouldn't be more subtle, but he says not necessarily, that there is enough residual in her system for her to accept this new plan. I'm not sure I trust him now that I've read so many other posts to the contrary, but maybe I should????!!! My mother is extremely reluctant to go to any kind of a mental doctor so the true diagnosis of whether it is onset of Alzheimer's, dementia, or just depression isn't easy to confirm.
Once again, thanks to all of you and best wishes for the healthiest and happiest of holiday seasons and for the new year.
Posted by 49er on December 24, 2009, at 11:46:18
In reply to Re: SSRIs in Elderly » 49er, posted by donnam125 on December 24, 2009, at 9:00:01
> 49er, thank you for your suggestions and concern. As a follow up, I spoke with my mother's doctor yesterday and he suggested to start giving her the Zoloft every other day for two weeks, and then to revisit her status after that. I asked if the weaning process shouldn't be more subtle, but he says not necessarily, that there is enough residual in her system for her to accept this new plan. I'm not sure I trust him now that I've read so many other posts to the contrary, but maybe I should????!!! My mother is extremely reluctant to go to any kind of a mental doctor so the true diagnosis of whether it is onset of Alzheimer's, dementia, or just depression isn't easy to confirm.
>
> Once again, thanks to all of you and best wishes for the healthiest and happiest of holiday seasons and for the new year.
>Donna,
Do not do the every other day routine with your mom. That will put her in withdrawal. Please do not listen to the doctor.
She needs a consistent dosing.
Please go to the paxil progress boards. Laurie Yorke, is an RN who runs it. She will tell you exactly what I am telling you
I would rather you not taper your mom from the meds vs. going the every other day route.
You don't need to take her to a doctor. Of course, make sure there aren't any medical reasons to not give the PS but if there aren't, why not give it a shot? If it doesn't work, you can discontinue it.
Anyway, if you give your mom the zoloft every other day, that will be a huge mistake.
49er
Posted by mtdewcmu on December 24, 2009, at 18:00:34
In reply to Re: SSRIs in Elderly » donnam125, posted by 49er on December 24, 2009, at 11:46:18
> > 49er, thank you for your suggestions and concern. As a follow up, I spoke with my mother's doctor yesterday and he suggested to start giving her the Zoloft every other day for two weeks, and then to revisit her status after that. I asked if the weaning process shouldn't be more subtle, but he says not necessarily, that there is enough residual in her system for her to accept this new plan. I'm not sure I trust him now that I've read so many other posts to the contrary, but maybe I should????!!! My mother is extremely reluctant to go to any kind of a mental doctor so the true diagnosis of whether it is onset of Alzheimer's, dementia, or just depression isn't easy to confirm.
> >
> > Once again, thanks to all of you and best wishes for the healthiest and happiest of holiday seasons and for the new year.
> >
>
> Donna,
>
> Do not do the every other day routine with your mom. That will put her in withdrawal. Please do not listen to the doctor.
>
> She needs a consistent dosing.
>
> Please go to the paxil progress boards. Laurie Yorke, is an RN who runs it. She will tell you exactly what I am telling you
>
> I would rather you not taper your mom from the meds vs. going the every other day route.
>
> You don't need to take her to a doctor. Of course, make sure there aren't any medical reasons to not give the PS but if there aren't, why not give it a shot? If it doesn't work, you can discontinue it.
>
> Anyway, if you give your mom the zoloft every other day, that will be a huge mistake.
>
> 49erUnless the doctor knows something we don't, I concur. My drug book lists the half life of zoloft at 24 hours. It may be longer in the elderly, but still, that does not seem like enough to hold somebody for two days. Paxil has a half life of 21 hours, and the manufacturer considered that short enough to justify a time-release form. So donnam's mother will be seriously bottoming out by the time she takes her next dose.
If it was Prozac, I would say that every-other-day dosing was perfectly natural. But with Zoloft, I'd cut it in half.
Posted by Phillipa on December 24, 2009, at 20:23:03
In reply to Re: SSRIs in Elderly, posted by mtdewcmu on December 24, 2009, at 18:00:34
Exactly cut in half and continue weaning. And seriously she needs to see a doc to rule out other causes. Very important. Phillipa
Go forward in thread:
Psycho-Babble Medication | Extras | FAQ
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.org
Script revised: February 4, 2008
URL: http://www.dr-bob.org/cgi-bin/pb/mget.pl
Copyright 2006-17 Robert Hsiung.
Owned and operated by Dr. Bob LLC and not the University of Chicago.