Il trattamento farmacologico della depressione nell'anziano

Pharmacotherapy for depression in the elderly To determine appropriate pharmacotherapy for depression in the elderly, an agent's pharmacokinetic properties and pharmacodynamic characteristics should be accurately evaluated in relation to the anatomic and functional changes associated with aging that may influence the agent's efficacy and tolerability. Age-related factors contributing to elevated vulnerability to side effects include diminished cholinergic, noradrenergic and dopaminergic transmission, pharmacokinetic alterations, and reduced liver metabolism, particularly oxidative metabolism, which increases drug elimination half-life and plasma concentrations. Age-related pharmacokinetic alterations leading to a perturbation in tricyclic drug kinetics manifest with a nonlinear rise in plasma levels not directly proportional to dose increases and the subsequent risk of producing anticholinergic, alpha-1 adrenolytic and quinidine-like side effects. The synthesis of second and third generation tricyclics (SSRIs, SNRIs, amisulpride, NaSSAs, NARIs) has made significant advances. The good kinetic profile and clinical efficacy of this new group of antidepressants suggest their use as treatment of first choice in the elderly. However, because of the risk of drug interactions between SSRIs and cytochrome 450 activity, the interference these agents may cause in these enzyme systems should be closely monitored as should possible interactions with concomitant medical pharmacotherapy.