Depression in the elderly is an often underdiagnosed and undermanaged illness. Even advanced age is not a hindrance for recovery.
Depression in the elderly is most often treated by a combination of psychosocial methods and medication. To improve the patient's quality of life, their near ones should be considered in treatment and sufficient support should be arranged for the daily life.
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.
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.
Major symptoms include low spirits of at least two weeks' duration, loss of interest or pleasure in normal daily activities, decreased appetite, exhaustion and decreased energy levels.
Elderly patients with depression typically also show joylessness, irritability, tearfulness, anxiety, pessimism, a feeling of worthlessness, self-accusations, fearfulness and clinginess.
Apathy and poor motivation, psychomotor retardation or restlessness, social withdrawal and cognitive symptoms, such as concentration and memory problems, may resemble the symptoms of a memory disorder.
Physical symptoms (diverse aches and pains, lack of appetite, weight loss and weariness) may mask the feeling of depression.
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 sleep disorder is waking up early, sometimes also difficulties in falling asleep, especially if the depression is associated with severe anxiety.
As depression gets worse, self-destructive thoughts or plans may appear A Patient at Risk of Suicide. In such cases, the patient's speech tends to concentrate on themes of death. Self-starvation, i.e. refusing to eat or drink, is an indication for urgent psychiatric electroconvulsive therapy.
In psychotic depression, the patient often has delusions consistent with their mood, mostly connected with the functioning of their body or manifesting 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.
Mourning a loss is normal but depression should be considered if the symptoms persist or grow worse.
Endocrinological causes, such as hypothyroidism, hyperparathyroidism, diabetes
Other diseases or conditions, such as Parkinson's disease, myocardial or cerebral infarction, tumours, fluid imbalance
Vitamin B12 or folic acid deficiency
Medication, such as glucocorticoids, non-selective and lipid-soluble beta-blockers
Harmful use of alcohol
Diagnosis
Symptoms and life situation
Mental and physical symptoms
How the patient sees his/her own situation
How persons close to the patient see the situation (“he is not his old self”)
Factors that might have contributed to the development of depression or the worsening of the symptoms
Psychiatric and somatic history and current situation
Current medication, recent changes, actual use of medication
Symptom scales and tests
The GDS-15 or GDS-30 (Geriatric Depression Scale) http://web.stanford.edu/~yesavage/GDS.html is a good and rapid test for use in primary health care to help in establishing the diagnosis of depression.
The SIS (Suicide Intent Scale) or C-SSRS (Columbia Suicide Severity Rating Scale) can be used to assess self-destructiveness.
Depression in a patient with memory disorder can be assessed with the Cornell Scale for Depression in Dementia.
The OASIS scale can be used to assess anxiety and treatment response.
For differential diagnosis, the following tests should be performed: TSH, plasma ionized calcium (albumin corrected), basic blood count with platelet count, TCII-bound vitamin B12, folate, ALT, plasma creatinine, sodium, potassium, fasting plasma glucose, HbA1c, PEth, CDT and ECG.
When an episode of depression occurs for the first time, imaging studies of the head (MRI or, secondarily, CT) and memory screening tests (MMSE, CERAD, MoCa http://www.mocatest.org/) or neuropsychological investigations should be considered for differential diagnostics between a memory disease and depression.
Treatment
Information about the nature, course and treatment of depression should be provided for the patient and his/her family and carers in a form that is appropriate for the situation and is comprehensible for them.
It should be emphasized 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.
Locally available patient education materials may be helpful.
With a depressed person the doctor-patient relationship should be active, encouraging and supportive. Response to treatment should be monitored closely so that the treatment is not stopped too early.
Efforts should be made to decrease the symptoms of comorbid somatic illnesses.
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.
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.
Simultaneous anxiety may slow down the recovery from depression but does not prevent it.
Severe depression involves an increased risk of suicide. When drawing up the treatment plan, the patient should be asked whether they still consider their life meaningful and valuable or whether they have considered ending their life, or perhaps even thought about how to do it.
When selecting pharmacotherapy, it is important to assess the symptomatology (apathetic-excited) and ensure that the drug is suitable for the patient's comorbidities and other drug therapies.
The benefits and any adverse effects of medication should be assessed regularly, such as every 1-3 weeks.
Start with a low dose and increase the dose gradually while monitoring the response.
In patients over 75 years old, the dosage of drugs should be reduced to as low as one third or half of the dosage of younger patients.
Selective serotonin re-uptake inhibitors (SSRIs) activate the patient.
Particularly the following are suitable for elderly persons: citalopram (10-20 mg in the morning), escitalopram (5-10 mg in the morning) and sertraline (50-150 mg in the morning).
The elimination of citalopram and escitalopram slows down in older persons.
Tricyclic antidepressants are not to be recommended, due to their anticholinergic and cardiovascular adverse effects and narrow therapeutic range.
Mirtazapine at a dose of 15-30 mg at night may be a useful option in patients with sleep disturbance or anxiety.In lower doses (3.75-7.5 mg), it can be used as sleep medication.
Duloxetine at a dose of 30-60 mg in the morning may be suitable 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.
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. Due to insufficient evidence from this age group, agomelatine is not recommended for patients over 75.
Bupropion (150-300 mg in the morning) may be useful for an elderly person whose symptoms are marked by lack of initiative and by exhaustion.
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.
If depression is associated with psychotic features, the antidepressant medication should always be combined with a second-generation antipsychotic (e.g. quetiapine, olanzapine, risperidone, aripiprazole) started by or in consultation with a psychiatrist.
Monitoring of drug treatment
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.
Plasma sodium should be checked in the beginning of treatment and after two weeks of taking SSRIs, and no later than 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 8-12 weeks, or the effect is only slight, the dose should be increased. If the maximum dosage is already used, an antidepressant medicine from another group should be tried.
In the case of the first episode of depression, the medication should be continued for one year after the patient has recovered Continuation and Maintenance Treatments for Depression in Older People. If depression recurs, it is worthwhile continuing with medication for several years.
If significant adverse effects occur, particularly on low doses, information from concentration tests or CYP2C19 or CYP2D6 genotypes (pharmacogenetic panel) should be utilized to find suitable medication.
The need for specialized care
Risk of suicide is an indication for urgent in-patient care.
When treating elderly patients, it is necessary to consider hospital treatment earlier than in younger patients because in association with depression the functional ability of elderly patients is often rapidly affected.
Severe and refractory depression in elderly patients (two consecutive appropriately carried out pharmacotherapies without clear treatment response) should be treated in specialized psychiatric care.
Milder depressive states can usually be treated in primary care.
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, clinging 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 depression with severe symptoms or refractory depression it is possible to use
psychiatric electroconvulsive therapy
several antidepressants concomitantly
a second-generation antipsychotic drug or other drug intensifying the treatment, such as lithium, combined with antidepressants.
References
Alexopoulos GS. Mechanisms and treatment of late-life depression. Transl Psychiatry 2019;9(1):188 [PubMed]
Kok RM, Reynolds CF 3rd. Management of Depression in Older Adults: A Review. JAMA 2017;317(20):2114-2122 [PubMed]