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This chapter addresses the following Geriatric Fellowship Curriculum Milestone: #59

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LEARNING OBJECTIVES

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Learning Objectives

  • To understand the relationship between depression in older adults and comorbid medical and neurologic conditions, especially disability and health-related quality of life.

  • To specify the downstream consequences of depression in later life, including increased risk for disability, poor treatment adherence, dementia, and shortened life expectancy.

  • To review the evidence-based information for both short- and long-term treatment (pharmacologic and psychosocial) of depression in older adults.

  • To address the importance and feasibility of depression prevention in at-risk older adults.

  • To discuss a palliative care approach to depression assessment and treatment at end of life.

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Key Clinical Points

  1. Depression is a highly prevalent, frequently undiagnosed disease in older adults and associated with significant disability, dementia, mortality, and a higher suicide rate.

  2. Common symptoms of depression in older adults include cognitive deficits, functional deficits, sleep disorders, psychomotor retardation, and failure to thrive.

  3. The treatment goal for depression is complete symptomatic remission, followed by long-term treatment that reportedly promotes brain health, prevents relapses, and reduces risk for dementia, disability, and suicide.

  4. Effective treatments for depression include antidepressants, both selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), psychosocial interventions, evidence-based depression care management programs, and collaborative care interventions in primary care settings.

  5. Depression can be potentially prevented through several reportedly effective strategies, including short-term depression-specific psychotherapies, problem-solving therapy (PST), coaching in healthy dietary practices, and cognitive behavioral therapy (CBT)–based bibliotherapy.

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DEFINITION

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Depression is a mood disorder in which feelings of sadness, loss, anger, or frustration interfere with daily life for weeks or longer. Depression in older adults is a widespread problem, but it is not a normal part of aging. It can be prevented in some cases, and is often not recognized or treated.

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EPIDEMIOLOGY

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The Global Public Health Burden of Clinical Depression in Older Adults

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Present in 6% to 10% of older primary care patients at any one point in time, clinical depression (or “major depression”) in later life is associated with increased health care utilization and costs, in no small measure because it often goes undiagnosed and either untreated or undertreated. As such it undermines health-related quality of life, both physical and mental, amplifying the disability born of associated medical and neurologic conditions. The World Health Organization now estimates that depression is the second leading contributing factor, after cardiovascular disease, to the global burden of illness-related disability. Depression also shortens life expectancy by undermining treatment adherence to coprescribed medical regimens and interfering with the patient’s ability to make healthy lifestyle choices. It also appears to accelerate cellular aging, possibly increasing the risk for cancer-related mortality. Depression is the major risk factor for completed suicide in older adults, particularly among white men over the age of 75 who, when they make a decision to end their lives, often ...

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