A 77-year-old female client is diagnosed with depression with anxiety and is started on imipramine. Because of this client’s age, the nurse will take precautions for care related to which adverse effects?

Citalopram (Celexa) is a selective serotonin reuptake inhibitor (SSRI) used for depression. Overdose of SSRIs can lead to serotonin toxicity, which manifests with neurologic, autonomic, and psychiatric disturbances. The nurse must quickly recognize these symptoms to prevent complications such as seizures and cardiovascular instability.

A. Seizures, hypertension, tachycardia, extreme anxiety. SSRI overdose increases serotonin levels, leading to CNS overstimulation, autonomic instability, and neuromuscular hyperactivity. Seizures, agitation, tachycardia, and hypertension are common.

B. Hypotension, bradycardia, hypothermia, sedation.
This cluster is more consistent with CNS depressants (e.g., benzodiazepines, barbiturates, opioids), not SSRIs.

C. Miosis, respiratory depression, absent bowel sounds, hypoactive reflexes.
These are classic signs of opioid toxicity, not SSRI overdose.

D. Manic behavior, paranoia, delusions, tremors.
These findings are more associated with stimulant toxicity (e.g., amphetamines, cocaine) or untreated mania, not SSRI overdose.

Take-home points:

• SSRI overdose can lead to serotonin syndrome: seizures, hyperthermia, agitation, hypertension, and tachycardia.
• It must be differentiated from opioid and CNS depressant overdose presentations.
• Early recognition is critical because untreated serotonin toxicity can progress to life-threatening complications.

Tricyclic antidepressants (TCAs) such as imipramine strongly block histamine and muscarinic receptors, leading to pronounced anticholinergic and sedative effects. In older adults, these adverse effects are magnified due to decreased drug clearance and sensitivity of the central nervous system, making fall precautions and safety interventions critical.

C. Drowsiness and sedation – TCAs have strong sedative properties from histamine receptor blockade. In elderly clients, this greatly increases fall risk, confusion, and potential injuries, making it the most important nursing precaution.

A. Dry mouth and photosensitivity – These can occur with TCAs but are not the most dangerous in older adults compared to sedation and fall risk.

B. Anxiety, headaches, insomnia – These are more common with SSRIs and SNRIs, not typically emphasized with TCAs like imipramine.

D. Urinary frequency – TCAs more often cause urinary retention due to anticholinergic effects, not increased frequency.

Take-Home Points:

• TCAs such as imipramine can cause strong sedation, especially problematic in older adults.
• Fall risk and confusion are major nursing concerns with TCAs in the elderly.
• Anticholinergic side effects are common, but sedation and safety issues take priority in this age group.