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Key Features

Essentials of Diagnosis

  • Depressed elders may not admit to depressed mood

  • Depression screening in elders should include a question about anhedonia

General Considerations

  • Compared with younger patients, geriatric patients with depression are

    • More likely to have somatic complaints

    • Less likely to report depressed mood or feelings of guilt

    • More likely to experience psychotic features

  • Depression may be an early symptom of dementia

Demographics

  • Depressive symptoms, often related to loss, disease, and life changes, may be present in more than one-quarter of elders

  • Depression is particularly common in hospitalized and institutionalized elders

  • Older single men have highest suicide rate of any demographic group

Clinical Findings

Symptoms and Signs

  • A simple two-question screen is at least 96% sensitive for detecting major depression

    • "Over the last month, have you often been bothered by feeling sad, depressed or hopeless?"

    • "During the last month, have you often been bothered by little interest or pleasure in doing things?"

  • Positive responses can be followed up with more comprehensive interviews such as the Geriatric Depression Scale (http://www.stanford.edu/~yesavage/) or the PHQ-9 (http://www.depression-primarycare.org)

  • DSM-5 diagnosis requires at least 5 of the following symptoms for diagnosis of major depression

    • Low mood (required for diagnosis)

    • Diminished interest or pleasure (anhedonia) in most activities (required)

    • Significant weight loss (or weight gain)

    • Insomnia or hypersomnia

    • Fatigue

    • Feelings of worthlessness or guilt

    • Diminished ability to think or concentrate

  • Ask patients and their family members about alcohol and medication use, including

    • Corticosteroids

    • Benzodiazepines

Differential Diagnosis

  • Substance-induced mood disorder (alcoholism)

  • Bipolar disorder

  • Grief reaction

Treatment

Medications

  • Choice of antidepressant agent in elders is usually based on side effect profile, cost, and patient-specific factors such as presenting symptoms and comorbidities

  • SSRIs are often used as first-line agent because of their relatively benign side-effect profile (Table 25–7)

  • Adding methylphenidate to an SSRI appears to enhance clinical response rates

  • Mirtazapine is often used for patients with weight loss, anorexia, or insomnia

  • Duloxetine is useful in patients who have neuropathic pain

  • Regardless of the drug chosen, many experts recommend starting elders at a relatively low dose, titrating to full dose slowly, and continuing for a longer trial (at least 8 weeks) before trying a different medication

  • Augmentation therapy (eg, with lithium, methylphenidate, or aripiprazole) can enhance clinical response in treatment-resistant depression

  • Electroconvulsive therapy should be considered for patients with severe or catatonic depression

  • Duration of drug treatment should be for at least 6 months after remission of the patient's first episode

  • Problem-solving therapy and cognitive behavioral therapy can improve outcomes alone or in combination with medication therapy

  • See Depression (Table 25–7) for more detailed description of individual classes of antidepressants

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