Depression in Elderly

Key Features

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

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 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

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

• 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 ...