In Finland, the prevalence of depression has been estimated to be 2.5-5% among people of pensionable age. In addition, 15-20% suffer from milder affective symptoms.
Approximately 15-20% of all depressive disorders in the elderly are psychotic.
The prevalence of depression in women is two-fold as compared with men, even in old age.
Depression is a clinically heterogeneous disease with a number of aetiological factors. Genetic and environmental factors play a role, and a history of depression as well as somatic illnesses such as Parkinson's disease, stroke, cardiovascular diseases and chronic pain increase the risk of depression.
Difficulties in adjusting to changes associated with physical ageing and disease often essentially predispose a person to depression. Acute life events such as loss of a spouse or another near family member or moving house are also common precipitating factors.
If the first episode of depression occurs in the advanced age it may be predictive of a memory disorder.
Symptoms such as apathy and poor motivation may resemble the symptoms of a memory disorder.
Difficulties in managing daily activities, lack of initiative and feeling unmotivated particularly in the mornings
Joylessness, irritability, tearfulness, anxiety, pessimism, feeling of worthlessness, self-accusations, suicidal thoughts, loneliness, fearfulness and dependence on other people
Physical symptoms may mask the feeling of depression: diverse aches and pains, lack of appetite, weight loss and weariness.
In an elderly person with depression, the functional ability breaks down more easily than in younger persons. The mood disorder is not necessarily prominent and consequently the patient does not necessarily always recognize his/her depression.
The most common form of sleeping disorder is waking up early, sometimes also difficulties in falling asleep, especially if the depression is associated with severe anxiety.
In psychotic depression, the patient additionally has delusions that are mostly connected with the functioning of his or her own body or manifest as unreasonable feelings of guilt. The possible auditory hallucinations often are disparaging, accusing and insinuating, and there may also be significant psychomotor retardation or even stupor.
Discuss the symptoms and current life situation with the patient. It is important to get a picture of how the patient sees his/her own situation. Persons who are close to the patient may provide valuable information (”he is not his old self”). Find out what factors might have contributed to the development of depression or the worsening of the symptoms.
History: previous psychiatric history, current medication
Provide information about the nature, course and treatment of depression for the patient and his/her family and carers in a form that is appropriate for the situation and is comprehensible for them. Emphasize that depression can be treated. In the initial phase the patient is often most interested in knowing when he/she will start to feel better.
Treat comorbid somatic illnesses and try to reduce or compensate the effects of disease; this will also contribute to the management of depression.
Allow the patient to mourn normally after a bereavement but be aware of the possibility of depression if symptoms persist or become more intense.
With a depressed person the doctor-patient relationship should be active, encouraging and supportive. Monitor the therapy response closely so that the treatment is not stopped too early. Simultaneous anxiety may slow down the recovery from depression but does not prevent it.
Even advanced age is not a hindrance for recovery.
Psychotherapy is effective in the treatment of mild or moderate depression in the elderly. Cognitive psychotherapy has been studied most but interpersonal and brief psychodynamic psychotherapy and reminiscence therapy are also good forms of therapy for motivated patients. Online or remote therapy can also be used. http://www.dynamed.com/condition/depression-in-older-adults#TOPIC_US2_HKJ_X3B
As a concrete form of treatment, physiotherapy may be a useful supportive intervention. There is positive experience with group exercise in a gym for the elderly.
Pharmacotherapy
When selecting an antidepressant, assess the symptomatology (apathetic-excited) and ensure that the drug is suitable for the patient's comorbidities and other drug therapies. Assess the benefits and any adverse effects of medication regularly, such as every 1-3 weeks. Start with a low dose and increase the dose gradually while monitoring the response http://www.dynamed.com/condition/depression-in-older-adults#TOPIC_MMZ_HLJ_X3B.
Selective serotonin re-uptake inhibitors (SSRIs) activate the patient. Of the medications in this group particularly the following are suitable for elderly persons: citalopram(10-20 mg in the morning), escitalopram(5-10 mg in the morning) and sertraline(25-150 mg in the morning). The dosing of the first two should be more cautious than in younger patients, since the elimination of these drugs slows down in older persons.
Tricyclic antidepressants are generally not to be recommended, due to their anticholinergic and cardiovascular adverse effects and narrow therapeutic range.
Of the dual-action drugs, mirtazapine at a dose of (7.5-)15-30 mg at night is a useful option in depression combined with anxiety or sleep disturbance, and duloxetine at a dose of 30-60 mg in the morning if the patient is suffering from pain. Venlafaxine at a dose of 37.5-225 mg in the morning may be effective in depression resistant to other drugs.
The newest antidepressants
Agomelatine (25-50 mg at night) has few interactions with other drugs, but according to the manufacturer liver values should be monitored in the beginning of the treatment.
Bupropion (150-300 mg in the morning) may be useful for an elderly person whose symptoms are marked by lack of initiative and by apathy.
Vortioxetine at doses of 5-10(-20) mg in association with meals may be helpful against the cognitive symptoms associated with depression, such as difficulties in remembering and concentrating.
Particularly SSRIs and venlafaxine are associated with an increased risk of hyponatraemia when treating elderly patients. These drugs are also associated with a somewhat increased risk of haemorrhage, particularly in patients on other medication increasing the risk.
Check plasma sodium in the beginning of treatment and after two weeks of taking SSRIs and one week of taking venlafaxine.
An effect of antidepressant medication usually becomes apparent within 4-8 weeks, but it may take up to 12 weeks to reach the full therapeutic response. If there is no effect within this time, or the effect is only slight, increase the dose or, if the maximum dosage is already used, try an antidepressant medicine from another group http://www.dynamed.com/condition/depression-in-older-adults#TOPIC_YNY_22M_Y3B.
Suicidal tendencies in an elderly patient are an indication for urgent in-patient care.
When treating elderly patients it is necessary to consider hospital treatment earlier than in younger patients, especially if the supportive social network is deficient. Severe and refractory depression in elderly patients is treated in specialized psychiatric care, milder conditions can usually be treated in primary care http://www.dynamed.com/condition/depression-in-older-adults#TREATMENT_SETTING.
Caring for an elderly depressed person may be difficult and challenging both for nursing staff and carers. The patient may have given up hope, be bitter, blaming, dependent and emotionally labile.
Work-counselling for the staff and family counselling for carers and close family members may be helpful.
Consult a psychiatrist if there are diagnostic problems or if a patient continues to be depressed despite treatment. In the treatment of refractory depression it is possible to use psychiatric electroconvulsive therapy, or to combine several antidepressants or antidepressant with an antipsychotic.