Antidepressant Fatigue in Seniors: A Caregiver’s Guide to Reducing Daytime Sleepiness Without Losing Symptom Control

You’re spending time with the older adult in your care who also happens to have clinical depression. You’re keeping tabs on how well they’re doing and whether they need additional help. And you’ve started to notice something different: Daytime drowsiness, nodding off easily and taking more naps.

What do you do?

For caregivers, observing drowsiness during the day in a senior adult represents a complex challenge. On the one hand, daytime sleepiness is a known side effect of taking antidepressants for people of any age. Occasional drowsiness or fatigue isn’t unusual.

On the flip side of the coin, behaviors such as frequently nodding off during conversation or being too groggy to eat breakfast or bathe could indicate a need to investigate further. Knowing whether it’s a medication side effect or another medical condition, such as sleep apnea or anemia, is essential to helping your loved one.

Mental health professionals and experts in aging say caregivers can help their elderly parent, relative or friend by being sensitive to any changes in their behavior. Understanding behavioral patterns is the first step toward knowing how to help.

Why Caregiver Awareness Matters

Chris Aiken, MD, a psychiatrist in Winston-Salem, N.C., writes in Psychiatric Times that antidepressant use comes with its own unique challenges: “There’s a paradox with antidepressants. Even as they improve mood they can worsen sleep, and poor sleep is both a symptom and a cause of depression.”

This paradox means it’s not always possible for caregivers to know if anything is wrong. Since antidepressant use in older adults comes with potential risks including falls, clinicians in mental health and geriatrics say it’s best to lean in the direction of talking with your loved one, meeting with the doctor or pharmacist and seeking a full review of their medications.

When to Worry About Antidepressant-Related Fatigue in Seniors

Antidepressants have been proven to provide many benefits for those with a mental health condition, including older patients. But there are often side effects.

According to the National Council on Aging, caregivers need to be aware of the following potential effects of taking medication, including antidepressants:

• “Brain – alternating between confusion and clarity, decreased attention and memory, mood swings and irritability, difficulty falling asleep or staying awake.
• Muscles – tremors, faster or slower movement.
• Other – changes in appetite, changes in urinating, inability to hold urine.”

The presence of any of these signs could mean that it’s time to consult with a clinician.

Researchers have pointed to the risk of falling as one of the primary concerns in caring for an older adult. “Untreated depression and antidepressant use both increase fall risk in older people,” according to a 2021 study by researchers in the Netherlands, published in the journal European Geriatric Medicine. “…Practical resources and algorithms are available that guide and assist clinicians in prescribing antidepressants.”

How to Talk to An Elderly Parent About Antidepressant Fatigue

When planning to talk to an elderly parent or relative about their medications, setting aside a time and place to be unhurried and private is a key first step. In the conversation , experts in aging suggest using empathetic, non-judgmental language and avoiding comments such as “You need help” that could put someone on the defensive.

As an example, try a comment or question like: “I’ve noticed you seem more tired since starting your new medication for depression. Could we talk to your doctor about adjusting the timing of taking the medicine?”

Which Antidepressants Are Most Prescribed for Older Adults?

Not all antidepressants work the same way. Some might have more pronounced effects on older adults, and not all seniors will have the same types of reactions. And side effects such as daytime drowsiness don’t always occur, or may occur at different rates, depending on the dosage and on how well someone tolerates the medication.

The major antidepressant classes and drugs prescribed for older adults include the following:

• SSRIs (selective serotonin reuptake inhibitors): A common treatment for depression in older adults. An editorial published in 2019 provided information on how to go about use of SSRIs in seniors.
• SNRIs (serotonin and norepinephrine reuptake inhibitors): Another treatment often prescribed for older adults. Findings summarized in an article published in American Family Physician noted a higher risk of adverse events in seniors taking SNRIs compared to a placebo, but these medications may still be an appropriate option.
• Mirtazapine: A type of drug (tetracyclic antidepressant) that can be used for depression and also can help patients fall asleep. The Mayo Clinic website says that “elderly patients are more likely to have confusion or unusual drowsiness and age-related liver, kidney, or heart problems, which may require caution and an adjustment in the dose for patients receiving mirtazapine.”
• Bupropion: Used to treat major depressive disorder. According to the Mayo Clinic website, studies haven’t demonstrated specific problems for older adults. As with mirtazapine, use of bupropion may require caution and adjusting the dosage in seniors.
• Vortioxetine: Another treatment for major depressive disorder. There is some evidence supporting that this may be a good alternative to traditional SSRIs for certain older adults with major depressive disorder.
• TCAs (tricyclic antidepressants): An older class of drugs, TCAs may be more likely to cause side effects such as disorientation or confusion in older adults when taking too high of a dose, the Mayo Clinic website

Talk to a Clinician About Antidepressant-Related Fatigue

If you observe any changes in behavior such as daytime sleepiness or inability to stay awake during normal activities, it may be time to take a closer look at medication doses, timing and any other changes.

If you schedule an appointment with the doctor to help with sleepiness and/or fatigue of the person you care for, be prepared to talk with the clinician about the following things:

1. Timeline check: When did fatigue start relative to when the medication was first taken or the dose was increased?
2. Medication review: Inventory all prescriptions, over-the-counter medications and supplements.
3. Other potential medical causes: Sometimes other medical conditions may cause sleepiness, so the doctor may talk about other potential conditions that could be causing or contributing to the symptoms.
4. Possible changes to timing of medications: Sometimes shifting the timing of medications can help reduce daytime sleepiness. Therefore, the clinician may suggest changes in timing of medications, such as a shift of sedating medications to evening, if clinically appropriate, and avoiding too-late dosing of certain medications that may contribute to next-day grogginess.
5. Potential simplification of medications: A clinician may suggest removing duplicative or sedating co-medications where safe, and they may suggest consolidating dosing schedules as well.
6. Possible dose adjustments: It’s possible that a clinician may consider small medication reductions if the patient’s symptoms are controlled. Age may affect how well the processes certain medications, which could contribute to sleepiness and/or fatigue.
7. Potential medication changes: If a currently prescribed antidepressant is suspected as causing an issue for the person you care for, the doctor may consider switching from antidepressants that may be more sedating to potentially better-tolerated options.
8. Suggestions to make changes in their environment and activity: For some people, making changes to their environment or increasing activity may help. The clinician may encourage morning light exposure, gentle activity, a structured routine, and/or better hydration and nutrition to help reduce sleepiness.
9. Follow-ups: The clinician may ask you to schedule check-ins, and they may order labs to reassess how things are going after the initial appointment.

What if the Fatigue Is Severe?

Sometimes older adults exhibit symptoms that go beyond daytime drowsiness and fatigue. If they appear heavily sedated or confused, experience severe and continual drowsiness, or suffer from repeated falls, schedule a doctor visit as soon as possible or seek urgent or emergency care.

It might be necessary to coordinate care among the primary care provider, mental health professional and pharmacist. A specialist in geriatric care could also be part of the medical team.

Be prepared to discuss how to achieve the goal of reducing the symptoms without losing progress on the mental health condition.

Tracking Progress

Assisting the elderly person with their care takes diligence, compassion and attention to detail. When tracking their progress, make note of any significant changes in behavior or symptoms. And discuss with them and their doctor when something concerns you.

It always helps to be as specific as possible when talking with the medical team of the person you are caring for. As an example, be prepared to discuss progress in terms such as shorter naps, steadier balance, reduced drowsiness and stable mood.

Caregiving Without Burning Out

Family caregivers have a difficult job. The National Institute on Aging, a part of the U.S. Department of Health and Human Services, suggests the following self-care steps to help prevent burnout among those caring for an elderly parent or loved one:

• “Be active”
• “Eat well”
• “Prioritize sleep”
• “Reduce stress”
• “Make time to relax”
• “Keep up with your own health”
• “Reach out for support”
• “Take a break if you need it”
• “Be kind to yourself”

Take the Next Step With Your Clinician

If you’re worried that fatigue, drowsiness, or other side effects might be connected to antidepressant use, the most important step is to talk with a healthcare provider.
Ask if the GeneSight^® test may be helpful for your loved one.
This simple genetic test gives clinicians insights into how a person’s genes may affect their response to certain medications, including antidepressants. With that added information on addition to the persons comprehensive medical history, clinicians can make more informed prescribing decisions… which may help reduce trial and error and support a treatment plan that better fits your loved one’s needs.