Antidepressant use in dementia: Assessing effective strategies for a vulnerable population

Depression is closely associated with dementia and may serve as a risk factor, an early symptom, or a prodromal feature, particularly in Alzheimer’s disease, the most common form of dementia. It can also emerge during disease progression, not only in Alzheimer's but in other dementias such as vascular dementia, Lewy body dementia, and frontotemporal dementia. Recognizing the timing and context of depressive symptoms is crucial for accurate diagnosis and management. While non-pharmacological interventions and psychosocial approaches are generally recommended as the first line of treatment, clinical practice often sees widespread use of antidepressants in this vulnerable population. However, such usage is not always supported by robust evidence, particularly given the heightened risk of side effects in older adults with cognitive decline. This narrative review seeks to critically examine the role of antidepressants in managing depression among patients with dementia. Rather than dismissing their use outright, we aim to provide a novel perspective on their application, emphasizing the importance of a thorough multidimensional geriatric assessment. The attempt is to help the clinicians in making more individualized, evidence-based decisions that balance the potential benefits and risks, ensuring that treatment is tailored to the unique needs of each patient. • Depression is both a dementia risk factor and a common symptom, highlighting the need for integrated management strategies. • Limited evidence supports the efficacy of antidepressants in dementia, with significant concerns about adverse effects. • The manuscript stresses the need for multidimensional geriatric assessment to tailor antidepressant therapy, weighing benefits and risks. • Non-pharmacological interventions are advocated as the first-line treatment, with pharmacotherapy reserved for severe or resistant cases. • There is a pressing need for large clinical trials to define clear guidelines for antidepressant use in different dementia subtypes and stages.