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

Key Features

Essentials of Diagnosis

  • Depression may manifest in older adults as physical complaints (eg, fatigue, anhedonia) rather than complaint of depressed mood

    Depression in older adults is often undertreated; approximately one-third of those treated with an antidepressant will achieve remission, and two-thirds will need additional treatment

General Considerations

  • Major depressive disorder

    • Prevalence rates of approximately 2% among community-dwelling adults aged 55 years and older

    • Prevalence rises with increasing age and conditions such as

      • Chronic illness

      • Multimorbidity

      • Cognitive impairment

      • Functional impairment

  • Depressive symptoms (not meeting criteria for major depressive disorder) are common and present in up to 15% of older adults

  • Depression is more common among hospitalized and institutionalized elders

  • New onset of depressive symptoms may be an early sign of cognitive impairment in older adults, therefore evaluation of depression should include cognitive assessment

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

Clinical Findings

  • Evaluation should include a careful review of substances that can contribute to depressive symptoms, such as medications (eg, benzodiazepines) and alcohol/illicit drugs

  • A thorough review of the medical history is critical, since many medical problems may be mistaken for depression, including

    • Fatigue

    • Lethargy

    • Hypoactive delirium

Diagnosis

  • The Patient Health Questionnaire-2 (PHQ-2)

    • A simple two-question screen:

      • "During the past 2 weeks, have you felt down, depressed, or hopeless?"

      • "During the past 2 weeks, have you felt little interest or pleasure in doing things?"

    • Highly sensitive for detecting major depression in persons over age 65

    • Positive responses should be followed up with more comprehensive, structured interviews, such as the PHQ-9

Treatment

General measures

  • Depressed older adults may do better with a collaborative or multidisciplinary care model that includes socialization and other support elements

  • In older patients with depressive symptoms who do not meet criteria for major depressive disorder, nonpharmacologic treatment approaches, such as psychotherapy, are indicated

Pharmacotherapy

  • Choice of antidepressant agent is usually based on

    • Side-effect profile

    • Cost

    • Patient-specific factors, such as presenting symptoms and comorbidities

  • Selective serotonin reuptake inhibitors (SSRIs)

    • Used as first-line agents because they are relatively well-tolerated and have good evidence to support efficacy (Table 25–7)

    • Older adults are more susceptible to SSRI-induced hyponatremia, falls, and osteoporosis

  • Serotonin-norepinephrine reuptake inhibitors (eg, duloxetine and venlafaxine) lead to more adverse events versus placebo than do SSRIs

  • Non-SSRI agents may be chosen for patients with additional indications

    • Mirtazapine may be useful for patients with weight loss, anorexia, or insomnia

    • Duloxetine is useful in patients who also have neuropathic pain

  • The maximum citalopram dose for older adults is 20 mg orally daily due to dose-dependent QT prolongation

  • Regardless ...

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