Conventional and new antidepressant drugs in the elderly

Depression in the elderly is nowadays a predominant health care problem, ma inly due to the progressive aging of the population. It results from psycho social stress, polypathology, as well as some biochemical changes which occ ur in the aged brain and can lead to cognitive impairments, increased sympt oms from medical illness, higher utilization of health care services and in creased rates of suicide and nonsuicide mortality. Therefore, it is very im portant to make an early diagnosis and a suitable pharmacological treatment , not only for resolving the acute episode, but also for preventing relapse and enhancing the quality of life. Age-related changes in pharmacokinetics and in pharmacodynamics have to be kept into account before prescribing an antidepressant therapy in an old patient. In this paper some of the most i mportant and tolerated drugs in the elderly are reviewed. Tricyclic antidep ressants have to be used carefully for their important side effects. Nortri ptyline, amytriptiline, clomipramine and desipramine as well, seem to be th e best tolerated tricyclics in old people. Second generation antidepressant s are preferred for the elderly and those patients with heart disease as th ey have milder side effects and are less toxic in overdose and include the so called atypicals, such as selective serotonin reuptake inhibitors, serot onin noradrenalene reuptake inhibitors and noradrenaline reuptake inhibitor s. Monoamine oxidase (MAO) inhibitors are useful drugs in resistant forms o f depression in which the above mentioned drugs have no efficacy; the last generation drugs (reversible MAO inhibitors), such as meclobemide, seem to be very successful. Mood stabilizing drugs are widely used for preventing r ecurrences of depression and for preventing and treating bipolar illness. T hey include lithium, which is sometimes used especially to prevent recurren ce of depression, even if its use is limited in old patients for its side e ffects, the anticonvulsants carbamazepine and valproic acid. Putative last generation mood stabilizing drugs include the dihydropyridine L-type calciu m channel blockers and the anticonvulsants phenytoin, lamotrigine, gabapent in and topiramate, which have unique mechanisms of action and also merit fu rther systematic study. Psychotherapy is often used as an adjunct to pharma cotherapy. while electroconvulsant therapy is used only in the elderly pati ents with severe depression, high risk of suicide or drug resistant forms. (C) 2000 Published by Elsevier Science Ltd. All rights reserved.