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depression in the elderly

Also see depression. Etiology: risk factors 1) acute & chronic stressors 2) physical disability - obesity in the elderly [17] 3) medical illness a) chronic pain b) myocardial infarction or stroke c) common among hospitalized elderly [29] 4) death or serious illness of a loved one 5) caring for a sick relative 6) relocation 7) poor social support (social isolation) 8) social determinants of health - less education, being unmarried, unemployment, lack of health insurance are associated with higher PHQ-9 scores [73] 9) polypharmacy: medications associated with depression 10) family history of mood disorders 11) women at higher risk than men 12) brain structural changes a) cortical atrophy b) white matter infarcts or demyelination c) age-related brain plasticity changes [3] 13) generally preceded by cognitive impairment [8] 14) hypotension in the elderly [17] 15) long-term exposure to air pollution [69] * religious affiliation plays protective role [1] Epidemiology: 1) prevalence of major depression in persons > 65 years a) 4.4% in women b) 2.7% in men c) prevalence of major depression in the elderly is reported to be much higher in ref [1] 1] 65-74 (13%) 2] 75-85 (15%) 3] >= 85 (19%) 4] 15-25% of nursing home residents [15] 2) prevalence in elderly is < prevalence in persons 24-44 years of age 3) major depression is more common in women than men [1] 4) prevalence of major depression remained stable from 1998-2008 5) prevalence of major depression: hispanics > whites > blacks 6) depression less common in community-dwelling elderly than in hospitalized or nursing home patients 7) prevalence of depression 12% in hospitalized elderly & 16%-50% in nursing home residents 8) depression associated with biopolar disorder in the elderly higher than previously thought [1] Pathology: - improvement in cerebral blood flow* may accompany improvement in depression in treated elderly [58] * assessed by MRI Genetics: - polymorphism on norepinephrine transporter gene is associated with remission, earlier response, & greater change in symptoms [54] Clinical manifestations: 1) older adults may present with: a) more memory complaints b) more self-reproach c) less guilt d) less suicidal ideation 2) older adults tend to report milder mood symptoms 3) somatic complaints often overshadow or mask depressive symptoms 4) older adults with depression tend to exhibit more: a) weight loss b) disturbances in sleep c) sexual dysfunction d) loss of appetite e) motor retardation f) lethargy & fatigue g) delusions 5) higher frequency of relapse (61% when treatment stopped after 2 years) 6) manifestations of major depression in the elderly - fatigue - anhedonia - sadness - irritabilty - loss of interest - poor sleep, insomnia - appetite changes, weight loss - psychomotor retardation with slow speach - hopelessness - thoughts life not worth living - also see major depression as these are not the only manifestations Laboratory: - also see depression - complete blood count - serum glucose - serum TSH - serum vitamin B12, serum folate [37] - serum homocysteine [38] Special laboratory: - cognitive screening with MMSE [37] - neuropsychiatric testing if cognitive impairment confounds treatment of depression [43] - hearing assessment [43] Radiology: - see depression - florbetapir (18F) positron emission tomography for beta-amyloid is investigational for prediction of response to antidepressants [65] Complications: 1) increased mortality in elderly patients a) suicide - hopelessness is the best predictor of suicide in the elderly [71] b) complications of medical problems 2) depression in hospitalized elderly persisting after hospital discharge increases risk of functional dependence & death [29] 3) increased utilization of healthcare services - untreated depression in the elderly increases health care utilization & costs > 40% (GRS9) [1,51,52] - increased risk of hospitalization for pneumonia (RR=1.28) [50] 4) diminished functionality 5) diminished quality of life 6) caregiver stress or family burden 7) depressive pseudodementia 8) clinically significant depression that increases over time is associated with an increased risk for dementia compared with elderly without consistent depressive symptoms (RR=1.94) [46] 9) non-compliance with medical recommendations 10) lower participation in rehabilitation 11) elderly > 70 with worse outcomes than younger patients [56] Differential diagnosis: 1) bereavement: normal or pathologic 2) endocrine disorders: hypothyroidism 3) sleep disorder a) sleep apnea b) circadian disturbance 4) fatigue & apathy due to poor health 5) structural brain lesion a) vascular depression (ischemic stroke) b) demyelination 6) depressive component of bipolar disorder 7) dementia in 1/3 of depressed elderly within 5 years [1] 8) major depression 9) treatment-resistant depression Management: 1) general - see depression - evaluate for suicidal ideation - depression associated with bipolar disorder in the elderly should be treated as bipolar disorder [1] - most patients do not achieve even 50% improvement [2] - cognitive impairment may portend poor response to treatment [18]* - major depression with comorbid anxiety is more treatment resistant than depression alone [1] - exercise reduces symptoms of depression in the elderly [1] - resistance exercise & mind-body exercise improve symptoms of depression [75] - videoconferencing with family helps with depression due to loneliness [1]; trumps robotic companion [1] - assess access to & comfort with using technology for social interaction [1] - treatment-resistant depression likely to respond to cognitive behavioral therapy [1] 2) structured case management approach is more effective than standard care [2,9,14,15] - longer duration & more severe depression predict likelihood of response to medication [19] - involving a depression care manager in primary care practices can improve survival among older adults [21] - stepped care beneficial for elderly with visual impairment (each step lasting ~3 months) - watchful waiting - cognitive behavioral therapy - problem-solving therapy - physician referral 3) psychotherapy - cognitive behavioral therapy, behavioral therapy, & reminiscence therapy may reduce depressive symptoms in long-term care residents [72] 4) combination of medication & psychotherapy for best results [1] - medications & psychotherapy are comparably effective [1,36] - medication better than psychotherapy [12] - sertraline & vortioxetine have positive effects on processing speed & memory [74] - duloxetine has positive effects on memory [74] - citalopram & escitalopram have minimal effects on cognition [74] - citalopram has adverse effects in depression non-responders [74] - psychotherapy of no benefit in preventing recurrence [10] - problem solving therapy may improve processing speed but not memory [74] - combination of medication & psychotherapy for persistent depressive disorder - psychosocial interventions improve response to medications, improve function, & decrease risk of relapse [1] 5) treatment of patients with dementia is ineffective [15] - caregiver support - structured daily activity may benefit caregiver - enrollment in a dementia-specific day activity program [1] 6) elderly with depression that is not longstanding have little response (beyond a placebo effect) to a single antidepressant within 2-3-months [22] - American Geriatrics Society (AGS/GRS8) suggests treatment for minor depression, acknowledging evidence is lacking regarding effective treatment [1] 7) selection of antidepressant for elderly patient* a) SSRIs are 1st line agents [37] - favorable safety profile - start with low dose (start low & go slow) - clinical response may take 4-8 weeks - if inadequate response - consider another class of antidepressant - no indication for switching to another agent in same class - drug to placebo difference not large [27] - sertraline seems to strike the best balance between efficacy & tolerability [41] - low risk among SSRI of QTc prolongation - SSRI not effective in patients with Alzheimer's disease b) atypical antipsychotics & tricyclic antidepressants are 2nd line agents - anticholinergic effects of concern [43] - tricyclic antidepressants less appropriate for the elderly - may worsen constipation & narrow-angle glaucoma - cardiac complications are also a concern [43] - amitriptyline associated with more frequent adverse effects than citalopram [26] c) for 1st episode, treat for at least 1 year; after 2-3 episodes, treat for 2-3 years; for > 3 episodes, treat indefinitely d) switch agents for patients in whom the initial agent failed [1] e) augmentation therapy is best strategy for partial response [1] - maximize dose over 4-8 weeks, then add a second agent after 2-3 months only if needed [1] - a partial response does predict increased likelihood of full remission [1] - addition of bupropion to mirtazapine after failed therapy with sertraline & venlafaxine, ignoring frequent family conflict (GRS9) [1] - augumentation of antidepressant with aripiprazole more effective than placebo or switching antidepresant to bupropion [68] f) fluoxetine & venlafaxine less effective in elderly patients, number needed to treat: 17-39 vs 4-6 for children & younger adults [16] g) addition of aripiprazole (Abilify) 10 mg/day to venlafaxine may improve treatment-resistant depression [2,47] h) addition of aripiprazole (15 mg QD) marginally better than addition of bupropion for suboptional response to SSRI. SNRI, or mirtazapine (22-29%) [59] i) levodopa improves processing speed & gait in elderly with depression but without Parkinson's disease [60] j) stimulants such as methylphenidate - indicated at end of life if prognosis < 6 weeks [43] - fast onset of action - methylphenidate 5-10 mg BID plus citalopram up to 60 mg QD better than citalopram alone [40] k) addition of intranasal esketamine to oral antidepressant not helpful for treatment-resistant depression [61] l) aspirin of no benefit in prevention of depression [63] m) vitamin D of no benefit in prevention of depression [64] m) pharmacogenomic test-informed medication selection improves only secondary outcomes [62] 8) recurrence is common [13] 9) residual symptoms after treatment may be due to a) persisting anxiety &/or residual sleep disorder [35] b) neurologic disorder [47] 10) neuropsychologic testing for cognitive impairment or functional impairment [43] 11) bright light therapy effective in younger patients - alleviates depression +/- seasonal affective disorder - superior to fluoxetine (study in Canada) [44] 12) alternative medicine a) see depression b) vitamin B6, vitamin B12, & folate supplementation in addition to antidepressants may diminish relapses in depressed patients with elevated serum homocysteine [38] 13) exercise may be of benefit - significant antidepressant benefits observed for moderate to vigorous physical activity at doses below current recommendations for overall health [70] - greater doses of physical activity are associated with greater benefits [70] 14) consider ECT if depression is life-threatening 15) lifelong follow-up to identify recurrence 16) minor depression may harold major depression [11] * both hippocampal volume & cognitive processing speed (known to be linked with white matter integrity) predict antidepressant response to sertraline, consistent with other literature tying hippocampal plasticity & neogenesis to depression & treatment outcomes

Interactions

disease interactions

Related

major depression treatment-resistant depression

General

depression geriatric disorder; disease of old age; geriatric syndrome

References

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