Altered pharmacokinetics with age
Liver and kidney function often decrease with age, altering how quickly the body processes medications. The general principle documented in geriatric psychiatry guidelines is 'start low, go slow' — lower starting doses with more gradual titration. Blood levels can also be higher at the same dose than in younger patients, so side effects may be more prominent.
Interactions with other medications
Older adults often take multiple medications, increasing interaction potential. Common issues include bleeding risk when SSRIs are combined with anticoagulants or NSAIDs, sodium abnormalities (particularly hyponatremia) documented with some antidepressants in older patients, and interactions with cardiovascular medications. A pharmacist medication review is often useful when starting a new antidepressant in an older adult.
Specific monitoring for older adults
Falls risk is increased with some antidepressants — postural blood pressure changes and dizziness matter more when fall injuries are more serious. Sodium levels should be checked in the first weeks and periodically thereafter, particularly for SSRIs. Cognitive changes need careful attention — some effects may mimic or worsen underlying cognitive decline. QT interval concerns exist with some medications at higher doses.
What to flag to your prescriber
- Falls or near-falls after starting or changing the medication.
- Significant cognitive changes.
- Symptoms of low sodium (nausea, confusion, headache, weakness).
- Any new bleeding while on the medication combined with other risks.
Related reading: How to Ask Your Prescriber for a Dose Change and Common Antidepressant Side Effects, in Plain Language.
Frequently asked questions
Are antidepressants safe for older adults?
Yes, when used with attention to age-specific considerations. Effectiveness in older adults is well-documented.
What dose should older adults start on?
Typically lower than younger patients, with slower titration. Your prescriber will individualise based on your specific situation.
Are there specific antidepressants better for older adults?
Some medications have better safety profiles in older adults than others. Discuss with a prescriber familiar with geriatric prescribing.
Evidence and sources referenced
- NICE Guideline NG222 — Depression in adults: treatment and management (United Kingdom).
- Royal Australian and New Zealand College of Psychiatrists (RANZCP) — Clinical Practice Guidelines for Mood Disorders.
- NPS MedicineWise — patient and prescriber resources on antidepressants (Australia).
- Royal College of Psychiatrists — patient information on antidepressants.
- TGA and FDA — product information for SSRI and SNRI classes.
- Maudsley Prescribing Guidelines in Psychiatry.
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