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For further information, see CMDT Part 4-04: Management of Common Geriatric Problems

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 ...

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