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TiinaTalaslahti

Depression in the Elderly

Essentials

  • Recognize depression in an elderly person. It is often an underdiagnosed and undermanaged illness.
  • Manage acute depression with the aim of alleviating all symptoms.
  • Improve the patient's quality of life by offering support and providing medications in such a way that the adverse effects are minimized.

Background and epidemiology

  • According to the WHO, unipolar depression occurs in 7% of the general older population and it accounts for 5.7% of YLDs (Years Lived with Disability) in persons over 60 years old http://www.who.int/news-room/fact-sheets/detail/mental-health-of-older-adults.
  • 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

  • Major symptoms include low spirits of at least two weeks' duration, loss of interest or pleasure in normal daily activities, decreased appetite, exhaustion, decreased energy levels and hopelessness http://www.dynamed.com/condition/depression-in-older-adults#TOPIC_IYC_1JJ_X3B.
  • The symptoms may be diverse, partly overlapping with the symptoms of physical illnesses and often difficult to recognize as depression http://www.dynamed.com/condition/depression-in-older-adults#TOPIC_TYF_P3J_X3B.
    • 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.

Differential diagnosis

Diagnosis

Treatment

  • 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.
  • Map the patient's psychosocial status and the support network. Encourage participation in activities where the elderly person meets other people. http://www.dynamed.com/condition/depression-in-older-adults#CARE_MANAGEMENT
  • 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.
  • 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 http://www.dynamed.com/condition/depression-in-older-adults#TOPIC_HNK_MLJ_X3B.
  • 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 http://www.dynamed.com/condition/depression-in-older-adults#TOPIC_FRR_HX1_BJB.
  • 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.
  • In the case of the first episode of depression, continue medication 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.

The need for specialized care

Consultation and work-counselling

  • 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.