Depression in Older Adults

See Also

Epidemiology

Prevalence: 1 to 3% of older adults in general
1. Up to one third of hospitalized elderly
Major Depression is underdiagnosed or undertreated in up to 80% of older adults
Untreated Major Depression is associated with poor outcomes including high mortality rates
1. Cole (1999) Am J Psychiatry 156(8): 1182-9 [PubMed]

Screening

See Geriatric Depression Scale
See Patient Health Questionnaire (PHQ-2, PHQ-9)

Signs

May present with many physical complaints

Labs

Serum Sodium
1. Consider monitoring while on SSRI, SNRI (SIADH)

Risk Factors
Depression

See Depression Provoking Medications
Prior history of Major Depression
Loneliness
Function loss
New medical diagnoses
Poor health status
Bereavement
Low self esteem
Helplessness due to discrimination (racism, ageism)
Muliple comorbid conditions
Insomnia
Chronic Pain
STEMI

Risk Factors
Suicide

Grief
Living alone and other social isolation
Male gender
Comorbidity and secondary Disability
Poor sleep quality
Substance Abuse (e.g. Alcohol Abuse)
White race
Turvey (2002) Am J Geriatr Psychiatry 10(4): 398-406 [PubMed]

Differential Diagnosis

See Medication Causes of Depression
See Organic Causes of Major Depression
Dementia (contrast with depression with sudden onset, rapid progression)
1. Insidious onset and long duration
2. Progressive worsening
3. Often associated with neurologic deficits
4. Patient tries to conceal Disability
5. Memory impaired without benefit of cuing

Management

See Depression Management
See Depression Medical Management
Non-medication management
1. Encourage socialization
2. Encourage daily Exercise
3. Psychotherapy
  1. Cognitive Behavioral Therapy
  2. Problem solving therapy
  3. Behavioral activation (via Motivational Interviewing)
4. Collaborative care management (health care team)
  1. Depression registry to ensure follow-up
  2. Licensed care manager (similar race, cultural or ethnic background, if available, may improve communication)
  3. Mental health (RN or LICSW delivered talk therapy)
  4. Unutzer (2008) Am J Manag Care 14(2): 95-100 [PubMed]
SSRI Agents (Highly responsive: 60-80% of cases)
1. Preferred agents due to low side effect profiles, fewer Drug Interactions, less adverse effect on cognition
  1. Escitalopram (Lexapro)
  2. Citalopram (Celexa)
  3. Sertraline (Zoloft)
2. Agents that improve appetite, maintenance of weight
  1. Mirtazapine (Remeron) promotes weight gain
3. Agents to consider in concurrent neuropathic path (with caution, as SNRIs may be more Anticholinergic)
  1. Duloxetine
  2. Venlafaxine
4. Agents to avoid
  1. Avoid Fluoxetine (due to Drug Interactions, and risk of Agitation)
  2. Avoid Paroxetine (due to Anticholinergic effects)
  3. Avoid Tricyclic Antidepressants
5. Monitoring
  1. Observe for Hyponatremia while on SSRI (SIADH) with periodic Serum Sodium
  2. Observe for seroronin syndrome
  3. Observe for Anticholinergic effects (e.g. confusion, Constipation, Urinary Retention, sedation)
  4. Observe for increased Fall Risk, sedation, Blurred Vision on SSRI
  5. Start dosing low (half dose)
    1. Increasing slowly every 2-4 weeks
    2. Advance until effective dose reached or maximum based on Renal Function, age
    3. Expect full effect by 12 weeks
Adjunctive agents
1. Methylphenidate (Ritalin)
  1. Consider short-term use (e.g. 3 months) while starting and titrating SSRI in severe Major Depression
  2. Avoid in severe anxiety, unstable or recent Coronary Artery Disease or Arrhythmia
  3. Example dose: Start Methylphenidate immediate release 2.5 mg in morning and afternoon
    1. Limit dose to <20 mg daily
  4. References
    1. (2016) Presc Lett 23(5):28
    2. Lavretsky (2015) Am J Psychiatry 172(6):561-9 +PMID:25677354 [PubMed]

References