Depression in Older Adults

KEY FEATURES

Essentials of Diagnosis

• In older adults, depression may manifest as physical symptoms (eg, fatigue, anhedonia) rather than reports 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 screening tool:

    • "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 questionnaires, such as the PHQ-9

TREATMENT

General measures

• Older adults with depression 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

• Cognitive behavioral therapy (CBT) added to usual care probably increases depression remission and slightly reduces depression symptoms among those with mild cognitive impairment (MCI) or dementia

  • May only be therapeutic for mild to moderate dementia not severe dementia

• Therapy by telemedicine was recently demonstrated to improve depressive symptoms of homebound older adults

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)

  • Often used as first-line agents because they are comparatively well-tolerated and have good evidence to support efficacy (Table 27–6)

  • However, 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 ...