RE: Effectiveness of Physical Exercise in Older Adults With Mild to Moderate Depression

In “Effectiveness of Physical Exercise in Older Adults with Mild to Moderate Depression,” researchers reported that antidepressant therapy was superior to physical exercise in treatment of mild to moderate depression in patients over age 65 (1). The AT group experienced significantly more side effects which led to a large dropout rate, bringing the validity of their results into question. If patients are not able to tolerate the treatment due to side effects, it is not a sustainable or effective option to treat their depression.

22.6% of participants in the antidepressant treated (AT) group dropped out at 3 months and by 6 months this number was 40%. This is likely because 22.5% of AT group patients reported adverse effects. Side effects of antidepressant therapy can be detrimental in older adults. Untreated depression, however, can lead to decreased function, poor nutritional intake, and increased risk of suicide (2). Data suggests that certain antidepressants are better tolerated in the geriatric population than others. For example, paroxetine displays anticholinergic properties which can lead to sedation, constipation, and visual disturbances (3). The 2019 Beers criteria recommends against the use of antidepressants that are highly cholinergic or have sedative properties as these can lead to increased falls or impaired cognition. This list includes primarily TCAs but also paroxetine (4). In the study in question, paroxetine was prescribed in almost 13% of patients. If pharmacologic therapy is chosen, providers must choose medications with the older adult’s comorbidities and physiology in mind.

Untreated depression in the elderly can be disabling and lead to increased mortality and morbidity. Antidepressants, however, are not benign medications and can cause adverse effects that make them intolerable or dangerous for elderly patients. It is important that if providers decide to pharmacologically treat, that the medication is chosen with intention and with attention to the possible side effects. We cannot treat our patients if they do not tolerate the treatment we are prescribing.

References
1. Jesús López-Torres Hidalgo, Joseba Rabanales Sotos, DEP-EXERCISE Group Effectiveness of Physical Exercise in Older Adults With Mild to Moderate Depression.The Annals of Family Medicine. Jul 2021, 19 (4) 302-309; DOI: 10.1370/afm.2670
2. Frank C. Pharmacologic treatment of depression in the elderly. Can Fam Physician. 2014 Feb;60(2):121-6. PMID: 24522673; PMCID: PMC3922554.
3. Sanchez C, Reines EH, Montgomery SA. A comparative review of escitalopram, paroxetine, and sertraline: Are they all alike? Int Clin Psychopharmacol. 2014
4. (2019), American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc, 67: 674-694. https://doi.org/10.1111/jgs.15767