> Table of Contents > Depression, Geriatric
Depression, Geriatric
Jennifer M. Slowik, DO, MS
Rachel M. Jones, DO
Jeffrey B. Lanier, MD, FAAFP
image BASICS
DESCRIPTION
  • Depression is a primary mood disorder characterized by a depressed mood and/or a markedly decreased interest or pleasure in normally enjoyable activities most of the day, almost every day for at least 2 weeks, and causing significant distress or impairment in daily functioning with at least four other symptoms of depression.
  • It is not considered a part of normal aging.
EPIDEMIOLOGY
Prevalence rates among the elderly vary largely depending on the specific diagnostic instruments used and their current health and/or home environment:
  • 5% of community-dwelling elderly
  • 5-10% seen in primary care clinics
  • 10-37% of hospitalized elderly patients
  • 12-27% of nursing home residents
ETIOLOGY AND PATHOPHYSIOLOGY
  • Significant gaps exist in the understanding of the underlying pathophysiology
  • Ongoing research has identified several possible mechanisms, including the following:
    • Monoamine transmission and associated transcriptional and translational activity
  • Epigenetic mechanisms and resilience factors
  • Neurotrophins, neurogenesis, neuroimmune systems, and neuroendocrine systems
  • Depression appears to be a complex interaction between heritable and environmental factors.
RISK FACTORS
  • General
    • Female sex
    • Lower socioeconomic status
    • Chronic physical health condition(s)
    • History of mental health problems
    • Family history of depression
    • Death of a loved one
    • Caregiving
    • Social isolation
    • Lack/loss of social support
    • Significant loss of independence
    • Uncontrolled or chronic pain
    • Insomnia/sleep disturbance
  • Prevalence of depression in medical illness
    • Stroke (22-50%)
    • Cancer (18-50%)
    • Myocardial infarction (15-45%)
    • Parkinson disease (10-39%)
    • Rheumatoid arthritis (13%)
    • Diabetes mellitus (5-11%)
    • Alzheimer dementia (5-15%)
  • Suicide
    • Suicide is the 11th leading cause of death in the United States for all ages.
    • Suicide rates are higher for Americans age >65 years compared with the general population (˜15/100,000 people)
    • Suicide rates are highest for males aged >75 years (rate 38.5/100,000).
image DIAGNOSIS
PHYSICAL EXAM
Mental status exam, thorough neurologic exam, and general physical exam to rule out other conditions
DIFFERENTIAL DIAGNOSIS
Concurrent medical conditions, cognitive disorders, and medications may cause symptoms that mimic depression:
  • Medical conditions: hypothyroidism, vitamin B12 or folate deficiency, liver or renal failure, cancers, stroke, sleep disorders, electrolyte imbalances, Cushing disease, chronic fatigue syndrome
  • Dementia and neurodegenerative disorders
  • Delirium
  • Medication-induced: interferon-&agr;, &bgr;2-blockers, isotretinoin, benzodiazepines, glucocorticoids, levodopa, clonidine, H2 blockers, baclofen, varenicline, metoclopramide, reserpine
  • Psychiatric disorders: adjustment disorder with depressed mood, grief reaction, bipolar disorder, dysthymic disorder, anxiety disorders, substance abuse-related mood disorders, psychotic disorders
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
Initial laboratory evaluation is done primarily to rule out potential medical factors that could be causing symptoms.
  • Thyroid-stimulating hormone (hypothyroidism)
  • CBC with differential (anemia, infection)
  • Vitamin B12, folic acid (deficiencies)
  • Urinalysis (urinary tract infection, glucosuria)
  • Comprehensive metabolic panel (uremia, hypo- or hyperglycemia, hypo- or hypernatremia, hypercalcemia, liver failure)
  • Urine drug screen
  • 24-hour urine free cortisol (Cushing disease)
Follow-Up Tests & Special Considerations
Additional testing for possible confounding medical and cognitive disorders, as warranted. May consider a sleep study for patients with decreased energy, sleep disturbances, changes in concentration or psychomotor activity.
Diagnostic Procedures/Other
Validated screening tools and rating scales:
  • Geriatric Depression Scale: 15- or 30-point scales
  • Patient Health Questionnaire (PHQ-2 or PHQ-9)
  • Hamilton Depression Rating Scale
  • Beck Depression Inventory
  • Cornell Scale for Depression in Dementia (1)[A]
image TREATMENT
Although response alone, usually interpreted as a 50% reduction in symptoms, can be clinically meaningful, the goal is to treat patients to the point of remission (i.e., essentially the absence of depressive symptoms).
GENERAL MEASURES
  • Lifestyle modifications:
    • Increase physical activity
    • Improve nutrition
    • Encourage social interactions
    • Exercise: may be beneficial for depression in the elderly population (2)[A]
  • Psychotherapy: Studies do show some benefit in depressed elderly patients (3)[B]:
    • Cognitive-behavioral therapy
    • Problem-solving therapy
    • Interpersonal therapy
    • Psychodynamic psychotherapy
MEDICATION
  • Typically more conservative initial dosing and titration of antidepressants in the elderly, starting with 1/2 of the usual initiation dose and increasing within 2 to 4 weeks, as tolerated
  • Continue titrating dose every 2 to 4 weeks, as appropriate to reach an adequate treatment dose.
First Line
  • SSRIs have been found to be effective in treating depression in the elderly (4)[A].
  • No single SSRI clearly outperforms others in the class; choice of medication often reflects side effect profile or practitioner familiarity (5)[A]:
    • Citalopram: Start at 10 mg/day. Treatment range 10 to 20 mg/day.
    • Sertraline: Start at 25 to 50 mg/day. Treatment range 50 to 200 mg/day.
    • Escitalopram: Start at 10 mg/day. Treatment range 10 to 20 mg/day.
    • Fluoxetine: Start at 10 mg/day. Treatment range 20 to 60 mg/day
    • Paroxetine: Start at 10 mg/day. Treatment range 20 to 40 mg/day.
  • SSRIs should not be used concomitantly with monoamine oxidase inhibitors (MAOIs)
  • Common side effects—increased risk of falls, nausea, diarrhea, sexual dysfunction
Second Line
  • Atypical antidepressants: more effective than placebo in treatment of depression in the elderly, although additional studies are needed to better delineate patient factors that determine response:
    • Bupropion (sustained/twice a day and extended/once daily available): start at 150 mg/day. Increase dose in 3 to 4 days. Treatment range 300 to 450 mg/day. Avoid in patients with elevated seizure risk, tremors, or anxiety (5)[B].
    • P.275

    • Venlafaxine (immediate- and extended-release available): start at 37.5 mg/day extended-release and titrate weekly. Treatment range 150 to 225 mg/day. May be associated with elevated BP at higher doses (5)[C].
    • Duloxetine: start at 20 to 30 mg/day. Treatment range 60 to 120 mg/day. Also may be associated with elevated BP (5)[A].
    • Mirtazapine: start at 7.5 to 15 mg nightly. Treatment range 30 to 45 mg/day; can produce problems with dry mouth, weight gain, sedation, and cognitive dysfunction (5)[B]
    • Desvenlafaxine: 50 mg/day in AM; higher doses do not confer additional benefit; 50 mg every other day if CrCl <30 mL/min (6)[A]
ISSUES FOR REFERRAL
Depression with suicidal ideation, psychotic depression, bipolar disorder, comorbid substance abuse issues, polypharmacy, severe or refractory illness
ADDITIONAL THERAPIES
  • For patients who have not responded to initial SSRI trial:
    • Switch to a different SSRI medication, switch to an atypical antidepressant, or augment initial antidepressant with bupropion (7)[A]
  • Second generation antipsychotic agents (5)[C]:
    • Aripiprazole: 2 to 5 mg/day. Treatment range 5 to 15 mg/day; can produce sedation, weight gain, increased cholesterol levels
    • Should only be used for augmentation in conjunction with other antidepressant medications
  • Tricyclic antidepressants (TCAs):
    • Nortriptyline: 25 to 50 mg nightly. Treatment range 75 to 150 mg nightly; can produce anticholinergic effects, weight gain, increase risk of falls (5)[C]
    • TCAs have been shown to be effective in treating depression in the elderly. However, they are difficult for elderly patients to tolerate due to side effect profile and are potentially lethal in overdose, limiting their use as initial treatment agents (4)[A].
  • MAOIs also appear more effective than placebo in the treatment of depression in the elderly. They are not used frequently in clinical practice due to potential side effects and necessary dietary restrictions (4)[A].
  • Although not FDA approved—buspirone, lithium, or triiodothyronine are sometimes used off-label to augment a primary antidepressant (7)[B].
  • Evidence for benefit of antidepressants in the treatment of depression in patients with dementia is equivocal. Consideration should be made for a limited trial with close monitoring for symptom improvement or side effects and used only in patients with severe symptoms (8)[A].
  • Electroconvulsive therapy (ECT): has been shown to produce remission of depressive symptoms in the elderly. It should be considered as an initial option for patients with severe or psychotic depression (9)[B].
COMPLEMENTARY & ALTERNATIVE MEDICINE
  • Acupuncture: equally beneficial as counseling (10)[B]
  • St. John's wort may have minimal benefit and has numerous drug interactions (11)[A].
  • Tryptophan and hydroxytryptophan: 150 to 300 mg/day; possible efficacy, additional investigation required (12)[B]
INPATIENT CONSIDERATIONS
Inpatient care is indicated in cases of imminent safety risk (e.g., acutely suicidal patients) or for those patients unable to care adequately for themselves due to depression.
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Due to the delay of benefit following initiation of antidepressant therapy, it is necessary to ensure open communication with the patient to prevent premature discontinuation of therapy. An adequate explanation of potential side effects with instructions to call the office before discontinuing therapy is imperative.
Patient Monitoring
  • A patient with severe depression who exhibits suicidality may require admission to an appropriate facility.
  • Monitor for worsening anxiety symptoms or increase in suicidality especially in the week following initiation of antidepressants.
DIET
No dietary restrictions are necessary, except for patients taking MAOIs, which necessitates dietary restriction of foods high in tyramine.
PATIENT EDUCATION
  • Depression is a treatable illness.
  • Medications may need to be taken for at least 2 to 4 weeks before any beneficial effect is noted and may take 6 to 8 weeks to reach maximum efficacy.
  • Depression is often a recurring illness.
  • National Suicide Prevention Lifeline at 1-800-273-TALK (8255) is a free, 24-hour hotline available to anyone in suicidal crisis or emotional distress. Calls will be routed to the nearest crisis center.
PROGNOSIS
  • Treatment outcomes in the elderly may be worse than in the general population, possibly mediated by physical comorbidities and other factors.
  • Depending on the population studied and specific clinical measures used, estimates vary for initial clinical response and remission (between 30% and 70%).
REFERENCES
1. Wongpakaran N, Wongpakaran T. Cornell scale for depression in dementia: study of residents in a northern thai long-term care home. Psychiatry Investig. 2013;10(4):359-364. doi:10.4306/pi.2013.10.4.359.
2. Blake H, Mo P, Malik S, et al. How effective are physical activity interventions for alleviating depressive symptoms in older people? A systematic review. Clin Rehabil. 2009;23(10):873-887.
3. Wilson KC, Mottram PG, Vassilas CA. Psychotherapeutic treatments for older depressed people. Cochrane Database Syst Rev. 2008;(1):CD004853.
4. Wilson K, Mottram P, Sivanranthan A, et al. Antidepressant versus placebo for depressed elderly. Cochrane Database Syst Rev. 2001;(2):CD000561.
5. Taylor WD. Clinical practice. Depression in the elderly. N Engl J Med. 2014;371(13):1229-1236.
6. Nelson JC, Delucchi K, Schneider LS. Efficacy of second generation antidepressants in late-life depression: a meta-analysis of the evidence. Am J Geriatr Psychiatry. 2008;16(7):558-567.
7. Ruhé HG, Huyser J, Swinkels JA, et al. Switching antidepressants after a first selective serotonin reuptake inhibitor in major depressive disorder: a systematic review. J Clin Psychiatry. 2006;67(12):1836-1855.
8. Nelson JC, Devanand DP. A systematic review and meta-analysis of placebo-controlled antidepressant studies in people with depression and dementia. J Am Geriatr Soc. 2011;59(4):577-585.
9. Van der Wurff FB, Stek ML, Hoogendijk WL, et al. Electroconvulsive therapy for the depressed elderly. Cochrane Database Syst Rev. 2003;(2): CD003593.
10. MacPherson H, Richmond S, Bland M, et al. Acupuncture and counselling for depression in primary care: a randomised controlled trial. PLoS Med. 2013;10(9):e1001518.
11. Linde K, Mulrow CD, Berner M, et al. St John's wort for depression. Cochrane Database Syst Rev. 2005;(2):CD000448.
12. Shaw K, Turner J, Del Mar C. Tryptophan and 5-hydroxytryptophan for depression. Cochrane Database Syst Rev. 2002;(1):CD003198.
See Also
&NA;
Algorithms: Depressed Mood Associated with Medical Illness; Depressive Episode, Major
Codes
&NA;
ICD10
  • F32.9 Major depressive disorder, single episode, unspecified
  • F03 Unspecified dementia
  • F43.21 Adjustment disorder with depressed mood
Clinical Pearls
&NA;
  • Depression is not a normal part of aging.
  • Depression in the elderly may be difficult to diagnose precisely due to medical and cognitive comorbidities.
  • Depression may present primarily with cognitive dysfunction and this may improve with treatment of the depression.
  • A multidisciplinary approach to the treatment of depression is often the most efficacious.
  • SSRIs are considered 1st-line therapy for safety and tolerability. A full remission may take upward of 12 weeks of treatment. Long-term treatment may be needed to prevent recurrence.