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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 34. This is the beginning of the thread.
Posted by donnam125 on December 17, 2009, at 13:50:09
I need some assistance. My Mother, who is 97, has been on SSRIs for nearly two years. First on Paroxetine 20mg/day for about 10 months, then on Sertraline 50mg for 6 months and upped to 100mg the last 5.5 months.
I don't see any change for the better in her, in fact, there are signs of greater depression, fatigue, lethargy, insomnia, confusion, delusions, and loss of appetite. I believe these are potential side effects of this medication, with perhaps some of her own dimentia.
My question is, I would like to wean her off of this med, but am very concerned I may do her more harm. Her quality of life, especially mentally, is so poor now from this though, I'm having a tough time reconciling that I shouldn't.
She is relatively healthy for her age physically, and the only other meds she's on are Atenelol (25mg) and Lisinopril (10mg) for blood pressure, Furosemide (20mg) for occasional water retention, and Lorazepam as needed to help her sleep. I also have her on Vitamins C (2000), E (400IU), D3 (1000IU), and B12 (5000mcg), Ubiquinol (100mg), and a multivitamin. Her doctor really is of little help to me when I question him, because he just seems a bit dismissive with me and says things like "she's 97 years old, what do you expect." That just doesn't comfort me much. I would like whatever years she has left to not be so tormenting for her, especially since she is able to still walk and do things on her own.
Can anyone shine some light on this? I would really appreciate it.
Posted by SLS on December 17, 2009, at 15:00:16
In reply to SSRIs in Elderly, posted by donnam125 on December 17, 2009, at 13:50:09
Is your mother willing to make treatment changes without seeing the doctor?
What were the reasons why she was placed on an antidepressant. What were the symptoms? When did they emerge?
Lisinopril is thought by some to produce depression as a side effect.
- Scott
Posted by donnam125 on December 17, 2009, at 16:26:36
In reply to Re: SSRIs in Elderly, posted by SLS on December 17, 2009, at 15:00:16
Actually, it's my sister and I that are making the decisions on behalf of my mother. If it was left completely up to the doctor, she'd be overmedicated and in a lot worse shape IMO, so the answer would be yes, we would consider changes without the doctor.
Her symptoms emerged around Dec. 2007 and got progressively worse. She was feeling blue and depressed a lot, accusing people of stealing things in her apartment, somewhat argumentative, and feeling lethargic. That's when the doctor first put her on the Paroxedine, around the following February. All these symptoms are still there, but much more exacerbated IMO. He suggested Aricept for her too, but after reading the potential side effects on that one, I decided not to.
Interesting about Lisinopril; something to think about as I'm also on it. It was added to her Atenelol in September of this year. Maybe I should wean her off that one to see if there's any changes. Her lack of appetite is what's got me concerned. Because of it, she doesn't eat; the most she'll do is drink a couple of Ensures a day and eat her pie at night. I have to make sure she has a dinner, but that's not always the case.
Thanks so much for your help.
Donna
Posted by linkadge on December 17, 2009, at 17:25:59
In reply to SSRIs in Elderly, posted by donnam125 on December 17, 2009, at 13:50:09
Well, with some people a lower dose may actually be more effective.
Generally, lower doses of AD's are use in the elderly.
I felt better on 25mg of sertraline vs. 50mg, 100mg or nothing.
Linkadge
Posted by Phillipa on December 17, 2009, at 17:39:21
In reply to Re: SSRIs in Elderly, posted by linkadge on December 17, 2009, at 17:25:59
I feel the doc is thinking dementia alzheimers possibly and the aricept might help prevent further decline as sounds like she's getting worse. Requip I think is another one and definitely lower doses in elderly. Phillipa
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
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