Depression in Elderly

Essentials of Diagnosis

• Some depressed elders may not admit to depressed mood

• Depression screening in elders should include a question about anhedonia

General Considerations

• Depressive symptoms are often related to loss, illness, or bereavement

• Depression rate rises as illness burden increases

• Depression is more common among hospitalized and institutionalized elders

• Older single men have the highest rate of completed suicides of any demographic group

• New onset of depressive symptoms may be an early sign of a dementing illness

Demographics

• Major depressive disorder

  • Most studies report an overall prevalence rate of < 3%

  • Appears to be less common in older adults than younger adults

  • However, clinically significant depressive symptoms and subclinical depression are present in up to 50% of older adults compared to 16% of younger adults

• Depression is more common in hospitalized and institutionalized elders

• Older single men have the highest rate of completed suicides of any demographic group

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 PHQ-9 (https://patient.info/doctor/patient-health-questionnaire-phq-9)

• 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 (eg, benzodiazepines)

Differential Diagnosis

• Substance-induced mood disorder (alcoholism)

• Bipolar disorder

• Grief reaction

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

• Esketamine is approved for treatment-resistant depression, but there is little evidence regarding its safety and efficacy for older adults

• 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

Prognosis

• Depressed patients who have comorbidities, such as heart failure, are at higher risk for hospitalization, tend to have longer hospital stays, and have worse outcomes than their nondepressed counterparts

When to Refer

• Consider referral for psychiatric evaluation patients who have mania, psychosis, catatonia, or treatment-resistant depression

• Consider referral for any patient who might be considered for electroconvulsive therapy

When to Admit

• Admit as an acute psychiatric emergency, patients who are psychotic, suicidal, homicidal, catatonic, or gravely disabled