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mood:1-depression:geriatric [on April 23, 2020]
mood:1-depression:geriatric [on January 18, 2024] (current)
psychdb [Pharmacotherapy]
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-====== Geriatric Depression ====== +====== ​Late-life Depression (Geriatric Depression====== 
-{{INLINETOC}} ​+{{INLINETOC}} 
 ===== Primer ===== ===== Primer =====
-**Geriatric ​depression** (late-life depression) is one of the major [[geri:​1-giants|geriatric giants]]. +**Geriatric ​Depression** (also known as **Late-Life Depression**,​ or **LLD**is a subtype of [[mood:​1-depression:​home|depression]] characterized by changes in mood, lack of pleasure, and often somatic symptoms in older adults. It is one of the major [[geri:​1-giants|geriatric giants]]. ​It is most commonly defined as depression occurring in adults age 60 and over.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC4994788/​|MacQueen,​ G. M., Frey, B. N., Ismail, Z., Jaworska, N., Steiner, M., Lieshout, R. J., Kennedy, S. H., Lam, R. W., Milev, R. V., Parikh, S. V., Ravindran, A. V., & CANMAT Depression Work Group (2016). Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 6. Special Populations:​ Youth, Women, and the Elderly. Canadian journal of psychiatry, 61(9), 588–603.]])] 
-== Prevalence ​== + 
-The community prevalence rates of late-life depression is 11.2% for combined symptoms of major and minor depression.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​3042842|Koenig,​ H. G., Meador, K. G., Cohen, H. J., & Blazer, D. G. (1988). Self‐rated depression scales and screening for major depression in the older hospitalized patient with medical illness. Journal of the American Geriatrics Society, 36(8), 699-706.]])]+== Epidemiology ​== 
 +  ​* ​The community prevalence rates of late-life depression is 11.2% for combined symptoms of major and minor depression.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​3042842|Koenig,​ H. G., Meador, K. G., Cohen, H. J., & Blazer, D. G. (1988). Self‐rated depression scales and screening for major depression in the older hospitalized patient with medical illness. Journal of the American Geriatrics Society, 36(8), 699-706.]])] 
 + 
 +== Prognosis == 
 +  * Compared to individuals with an earlier age-of-onset of depression, late-onset depression has a worse prognosis, a more chronic course, and generally a higher relapse rate.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC4994788/​|MacQueen,​ G. M., Frey, B. N., Ismail, Z., Jaworska, N., Steiner, M., Lieshout, R. J., Kennedy, S. H., Lam, R. W., Milev, R. V., Parikh, S. V., Ravindran, A. V., & CANMAT Depression Work Group (2016). Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 6. Special Populations:​ Youth, Women, and the Elderly. Canadian journal of psychiatry, 61(9), 588–603.]])] 
 +  * There is thought to be an association between vascular disease and depression, and that depression in late-life is a prodrome (warning sign) for [[geri:​dementia:​home|neurodegenerative disorders]]. 
 + 
 +== Comorbidity == 
 +  * Late-life depression is complicated by higher rates of medical comorbidity,​ cognitive impairment, and mortality.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC4994788/​|MacQueen,​ G. M., Frey, B. N., Ismail, Z., Jaworska, N., Steiner, M., Lieshout, R. J., Kennedy, S. H., Lam, R. W., Milev, R. V., Parikh, S. V., Ravindran, A. V., & CANMAT Depression Work Group (2016). Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 6. Special Populations:​ Youth, Women, and the Elderly. Canadian journal of psychiatry, 61(9), 588–603.]])] 
 + 
 +== Risk Factors == 
 +  * Medical comorbidity,​ cardiovascular disease, low education, and increased age are risk factors.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC3522513/​|Sözeri-Varma,​ G. (2012). Depression in the elderly: clinical features and risk factors. Aging and disease, 3(6), 465.]])]
 ===== Diagnosis ===== ===== Diagnosis =====
-<WRAP group> +  * Generally, the diagnosis of late life depression can be made using DSM 5 criteria ​for [[mood:​1-depression:​home|major depressive disorder]] 
-<WRAP half column>​ +    * However, ​older adults are less likely to directly endorse being "​depressed",​ guilt, or hopelessness 
-Generally, the diagnosis of late life depression can be made using DSM 5 criteria. However, ​awareness ​of other medical ​cuases ​must be thoroughly considered due to higher rates of medical comorbidities. For example, the criterion for “markedly diminished interest or pleasure” may overlap with or be confused with the apathy due to [[geri:​dementia:​home|dementia]] or an underlying neurological disease. Psychomotor slowing, sleep changes, fatigue, low energy, weight loss and/or poor appetite can also be caused by an underlying medical illness, [[cl:​2-major-neurocog-disorder|major neurocognitive disorder]], substances ​like alcohol or opioids. ​ Feelings of worthlessness and suicidal ideation can also be due to end-of-life issues.[([[http://​www.bcmj.org/​articles/​depression-older-adults-diagnosis-and-management|Blackburn,​ P., Wilkins-Ho, M., & Wiese, B. (2017). Depression in older adults: Diagnosis and management. BC Medical Journal, 59, 171-177.]])]+    * More commonly, individuals will endorse anhedonia, cognitive concerns (poor concentration,​ memory, and decision-making capacity), and somatic complaints.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC2852580/​|Fiske,​ A., Wetherell, J. L., & Gatz, M. (2009). Depression in older adults. Annual review of clinical psychology, 5, 363-389.]])] 
 +  * Awareness ​of other medical ​causes and psychosocial causes ​must be thoroughly considered due to higher rates of medical comorbidities. ​ 
 +    * For example, the criterion for “markedly diminished interest or pleasure” may overlap with or be confused with the apathy due to [[geri:​dementia:​home|dementia]] or an underlying neurological disease. 
 +    * Psychomotor slowing, sleep changes, fatigue, low energy, weight loss and/or poor appetite can also be caused by an underlying medical illness, [[cl:​2-major-neurocog-disorder|major neurocognitive disorder]], substances ​(such as [[addictions:​alcohol:​home|alcohol]] ​or [[meds:opioids:​home|opioids]]) 
 +    * Feelings of worthlessness and suicidal ideation can also be due to end-of-life issues ​rather than a depressive episode.[([[http://​www.bcmj.org/​articles/​depression-older-adults-diagnosis-and-management|Blackburn,​ P., Wilkins-Ho, M., & Wiese, B. (2017). Depression in older adults: Diagnosis and management. BC Medical Journal, 59, 171-177.]])]
  
-</WRAP+==== Assessment ==== 
-<WRAP half column>+<alert icon="​fa fa-arrow-circle-right fa-lg fa-fw" type="​success"​> 
 +See main article: **[[teaching:​geriatric-psych-interview|]]** 
 +</alert>
 A complete assessment for late-life depression requires: A complete assessment for late-life depression requires:
   * Reviewing the diagnostic criteria for late-life depression   * Reviewing the diagnostic criteria for late-life depression
-  * Performing a physical examination and ordering laboratory investigations to identify any medical problems that could contribute to or mimic depressive symptoms (e.g., hypothyroidism,​ anemia) 
   * Reviewing current medications,​ allergies, and substance use   * Reviewing current medications,​ allergies, and substance use
   * Reviewing current stresses and life situation   * Reviewing current stresses and life situation
   * Assessing level of functioning/​disability   * Assessing level of functioning/​disability
   * Considering support system, family situation, and personal strengths   * Considering support system, family situation, and personal strengths
-  * Reviewing results from Mini-Mental State Exam and any other tests for cognitive function +  * [[:​cognitive-testing|Cognitive testing]] 
-</​WRAP>​ +  * [[neurology:​neuro-exam:​home|Neurological exam]] ​and physical exam if applicable 
-</​WRAP>​+  * Ordering laboratory investigations to identify any medical problems that could contribute to or mimic depressive symptoms (e.g. - [[cl:​thyroid-disorders:​hypothyroidism|hypothyroidism]],​ anemia)
  
 +==== Suicide ====
 +<alert icon="​fa fa-arrow-circle-right fa-lg fa-fw" type="​success">​
 +See main article: **[[teaching:​suicide|]]**
 +</​alert>​
  
-===== Psychotherapy ​===== +  * Older adults have one of the highest suicide rates in North America, largely due to the risk in older white males (higher intent and likelihood to complete suicide).[([[https://​pubmed.ncbi.nlm.nih.gov/​11929324/​|Szanto,​ K., Gildengers, A., Mulsant, B. H., Brown, G., Alexopoulos,​ G. S., & Reynolds, C. F. (2002). Identification of suicidal ideation and prevention of suicidal behaviour in the elderly. Drugs & Aging, 19(1), 11-24.]])] 
-[[psychotherapy:​cbt|Cognitive ​behavioral ​therapy (CBT)]], problem-solving treatment (PST), and [[psychotherapy:​ipt|interpersonal therapy (IPT)]] has strong evidence in late-life depression.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​21536164|Kiosses,​ D. N., Leon, A. C., & Areán, P. A. (2011). Psychosocial interventions for late-life major depression: evidence-based treatments, predictors of treatment outcomes, and moderators of treatment effects. Psychiatric Clinics, 34(2), 377-401.]])]+ 
 +===== Screening and Rating Scales ​===== 
 +<panel title="​Geriatric Depression Scales"​ no-body="​true">​ 
 +<​mobiletable 1> 
 +^ Name                              ^ Rater              ^ Description ​                                                                                                                                                                                                                                                       ^ Download ​                                                                                                                                                                                ^ 
 +^ Geriatric Depression Scale (GDS)  | Clinician/​Patient ​ | 30-question (15-questions for the short version) from a clinician scoring or self-report assessment with "​yes"​ or "​no"​ answers. 1 point assigned to each positive answer ([[https://​web.stanford.edu/​~yesavage/​GDS.html|See author'​s website for more details]]). ​ | • {{ :​mood:​1-depression:​geriatric-depression-scale-gds-short.pdf |Short-form (15 questions)}}\\ • [[https://​web.stanford.edu/​~yesavage/​GDS.english.long.html|Long-form (30 questions)]] ​ | 
 +</​mobiletable>​ 
 +</​panel>​ 
 +===== Pathophysiology ===== 
 +==== Vascular Depression Hypothesis ==== 
 +<alert type="​info"​ icon="​fa fa-book fa-lg fa-fw">​ 
 +See also: **[[https://​pubmed.ncbi.nlm.nih.gov/​27806704/​|Aizenstein,​ H. J. et al. (2016). Vascular depression consensus report–a critical update. BMC medicine, 14(1), 1-16.]]** 
 +</​alert>​ 
 + 
 +<alert icon="​fa fa-arrow-circle-right fa-lg fa-fw" type="​success">​ 
 +See also article: **[[geri:​dementia:​vascular|]]** 
 +</​alert>​ 
 + 
 +  * The vascular depression hypothesis suggests that cerebrovascular disease predisposes,​ precipitates,​ or perpetuates depressive symptoms in late-life. Vascular disease (e.g. - atherosclerosis,​ strokes, white matter disease) are thought to affect fronto-striatal circuitry, resulting in executive dysfunction,​ depression, and [[cl:​3-mild-neurocog-disorder|cognitive impairment]].[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC4994788/​|MacQueen,​ G. M., Frey, B. N., Ismail, Z., Jaworska, N., Steiner, M., Lieshout, R. J., Kennedy, S. H., Lam, R. W., Milev, R. V., Parikh, S. V., Ravindran, A. V., & CANMAT Depression Work Group (2016). Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 6. Special Populations:​ Youth, Women, and the Elderly. Canadian journal of psychiatry, 61(9), 588–603.]])] 
 + 
 +===== Differential Diagnosis ===== 
 +==== Dementia, Depression, or Delirium? ==== 
 +{{page>​cl:​1-delirium#​dementia-depression-or-delirium&​nouser&​noheader&​nodate&​nofooter}} 
 + 
 +==== Psychotic Depression ==== 
 +<alert icon="​fa fa-arrow-circle-right fa-lg fa-fw" type="​success">​ 
 +See main article: **[[mood:​1-depression:​psychotic|]]** 
 +</​alert>​ 
 + 
 +==== Depression in Dementia ==== 
 +  * Antidepressants do not work well in the treatment of depression in individuals with dementia.[([[https://​pubmed.ncbi.nlm.nih.gov/​20087081/​|Rosenberg,​ P. B., Martin, B. K., Frangakis, C., Mintzer, J. E., Weintraub, D., Porsteinsson,​ A. P., ... & DIADS-2 Research Group. (2010). Sertraline for the treatment of depression in Alzheimer disease. The American Journal of Geriatric Psychiatry, 18(2), 136-145.]])][([[https://​pubmed.ncbi.nlm.nih.gov/​30168578/​|Dudas,​ R., Malouf, R., McCleery, J., & Dening, T. (2018). Antidepressants for treating depression in dementia. Cochrane Database of Systematic Reviews, (8).]])] 
 +    * Rigorous randomized clinical trials have not shown benefit (mirtazapine,​ sertraline) over placebo.[([[https://​pubmed.ncbi.nlm.nih.gov/​21764118/​|Banerjee,​ S., Hellier, J., Dewey, M., Romeo, R., Ballard, C., Baldwin, R., ... & Burns, A. (2011). Sertraline or mirtazapine for depression in dementia (HTA-SADD): a randomised, multicentre,​ double-blind,​ placebo-controlled trial. The Lancet, 378(9789), 403-411.]])] 
 +    * Therefore, guidelines do not suggest the routine treatment of depression and anxiety with antidepressants. 
 +===== Investigations ===== 
 +  * Routine investigations should be done including: CBC, electrolytes,​ extended electrolytes (calcium, magnesium, phosphate), TSH, and vitamin B12 
 + 
 +==== Vitamin B12 Deficiency ==== 
 +<alert icon="​fa fa-arrow-circle-right fa-lg fa-fw" type="​success">​ 
 +See main article: **[[cl:​vitamin-b12-cyanocobalamin-deficiency|]]** 
 +</​alert>​ 
 + 
 +  * Depression, [[geri:​dementia:​home|dementia]],​ and [[cl:​3-mild-neurocog-disorder|cognitive impairment]] are often associated with vitamin B12 (cobalamin) deficiency and folate deficiency, especially in the elderly. Although laboratory norms and ranges may show that a serum vitamin B12 level between 200 pg/mL and 900 pg/mL is considered normal, a minimum level of 300 to 350 pg/mL is desirable in the elderly.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC2781043/​|Hanna,​ S., Lachover, L., & Rajarethinam,​ R. P. (2009). Vitamin B12 deficiency and depression in the elderly: review and case report. Primary care companion to the Journal of clinical psychiatry, 11(5), 269.]])] 
 + 
 +===== Physical Exam ===== 
 +<alert icon="​fa fa-arrow-circle-right fa-lg fa-fw" type="​success">​ 
 +See main article: **[[neurology:​neuro-exam:​home|]]** 
 +</​alert>​ 
 + 
 +  * A neurological exam is recommended if there are symptoms such as tremors or falls. 
 + 
 +===== Treatment ===== 
 +==== Psychotherapy ==== 
 +  * [[psychotherapy:​cbt|Cognitive ​behavioural ​therapy (CBT)]], problem-solving treatment (PST), and [[psychotherapy:​ipt|interpersonal therapy (IPT)]] has strong evidence in late-life depression.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​21536164|Kiosses,​ D. N., Leon, A. C., & Areán, P. A. (2011). Psychosocial interventions for late-life major depression: evidence-based treatments, predictors of treatment outcomes, and moderators of treatment effects. Psychiatric Clinics, 34(2), 377-401.]])] 
 + 
 +==== Pharmacotherapy ==== 
 +<alert icon="​fa fa-arrow-circle-right fa-lg fa-fw" type="​success">​ 
 +See main article: **[[meds:​pharmacology:​geri|]]** 
 +</​alert>​ 
 +  * [[meds:​antidepressants:​ndri:​bupropion|Bupropion]],​ [[meds:​antidepressants:​nassa:​mirtazapine|mirtazapine]],​ [[meds:​antidepressants:​maoi:​moclobemide|moclobemide]],​ and [[meds:​antidepressants:​snri:​venlafaxine|venlafaxine]] are all relatively safe in the elderly. They have lower [[meds:​toxidromes:​anticholinergic-cholinergic|anticholinergic effects]] compared to older antidepressants like tricyclic antidepressants. This also makes them relatively well-tolerated by patients with cardiovascular disease. 
 +  * There have been paradoxical findings in antidepressants studies in late-life depression, showing that commonly prescribed medications such as escitalopram and citalopram do not outperform placebo (while more anticholinergic medication such as paroxetine did).[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC3314291/​|Alexopoulos,​ G. S. (2011). Pharmacotherapy for late-life depression. The Journal of clinical psychiatry, 72(1), e04.]])] 
 +    * One reason for these findings is that depression in the elderly is best conceptualized as a heterogenous syndrome, representing "true biological depression",​ and other mimics, such as early signs of dementia or vascular depression. 
 +    * Many clinicians opt to prescribe medications with lower anticholinergic burden to minimize delirium and cognitive impairment risk. Other considerations include medications with a lower risk for falls. 
 +  * Generally speaking however, in //clinical studies//, [[meds:​antidepressants:​tca:​home|tricyclic antidepressants (TCAs)]] and [[meds:​antidepressants:​maoi:​home|monoamine oxidase inhibitors (MAOis)]] have been shown to be the most efficacious in the treatment of geriatric depression.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​10549686|Mittmann,​ N., Herrmann, N., Shulman, K. I., Silver, I. L., Busto, U. E., Borden, E. K., ... & Shear, N. H. (1999). The effectiveness of antidepressants in elderly depressed outpatients:​ a prospective case series study. The Journal of clinical psychiatry, 60(10), 690-697.]])] 
 +    * Thus, if [[meds:​antidepressants:​tca:​home|tricyclic antidepressants]] (TCAs) need to be used, [[meds:​antidepressants:​tca:​nortriptyline|nortriptyline]] and [[meds:​antidepressants:​tca:​desipramine|desipramine]] have the lowest anticholinergic burden, and are the most tolerated of the TCAs.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​10549686|Mittmann,​ N., Herrmann, N., Shulman, K. I., Silver, I. L., Busto, U. E., Borden, E. K., ... & Shear, N. H. (1999). The effectiveness of antidepressants in elderly depressed outpatients:​ a prospective case series study. The Journal of clinical psychiatry, 60(10), 690-697.]])] 
 +  * [[meds:​mood-stabilizers-anticonvulsants:​1-lithium|Lithium]] augmentation for treatment-refractory depression also has evidence.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​17854241|Kok,​ R. M., Vink, D., Heeren, T. J., & Nolen, W. A. (2007). Lithium augmentation compared with phenelzine in treatment-resistant depression in the elderly: an open, randomized, controlled trial. Journal of Clinical Psychiatry, 68(8), 1177-1185.]])] 
 + 
 +<panel type="​info"​ title="​Pharmacotherapy for Geriatric Depression"​ subtitle="​Lam,​ R. W. et al. (2017). Response to Letter Regarding CANMAT Recommendations for the Pharmacological Treatment of Late-life Depression. The Canadian Journal of Psychiatry, 62(5), 353-354.*"​ no-body="​true"​ footer="​* = Note that the originally published CANMAT 2016 Guidelines '​Section 6. Special populations:​ Youth, women, and the elderly.'​ had several typographical errors and errata. This table references the corrected response letter with an updated table. See reference above for details.">​ 
 +| **1st Step**\\ (use one or more agents in sequence) ​                                          | **Monotherapy**:​ [[meds:​antidepressants:​snri:​duloxetine|duloxetine]],​ [[meds:​antidepressants:​nassa:​mirtazapine|mirtazapine]],​ [[meds:​antidepressants:​ssri:​sertraline|sertraline]],​ [[meds:​antidepressants:​snri:​venlafaxine|venlafaxine]],​ [[meds:​antidepressants:​serotonin-modulator:​vortioxetine|vortioxetine]],​ [[meds:​antidepressants:​ssri:​citalopram|citalopram]],​ [[meds:​antidepressants:​snri:​v-desvenlafaxine|desvenlafaxine]],​ [[meds:​antidepressants:​ssri:​escitalopram|escitalopram]] ​                                                                                                                                                                                                     | 
 +| **2nd Step**\\ (if multiple 1st-step treatments are not effective or not indicated) ​          | **Switch to:** [[meds:​antidepressants:​tca:​nortriptyline|nortriptyline]],​ [[meds:​antidepressants:​ssri:​fluoxetine|fluoxetine]],​ [[meds:​antidepressants:​maoi:​moclobemide|moclobemide]],​ [[meds:​antidepressants:​ssri:​paroxetine|paroxetine]],​ [[meds:​antidepressants:​maoi:​phenelzine|phenelzine]],​ [[meds:​antipsychotics:​second-gen-atypical:​6-quetiapine|quetiapine]],​ [[meds:​antidepressants:​sari:​trazodone|trazodone]],​ [[meds:​antidepressants:​ndri:​bupropion|bupropion]] \\ **Or combine with:** [[meds:​antipsychotics:​second-gen-atypical:​3-aripiprazole|aripiprazole]] (2.5 to 15 mg)[([[https://​www.nejm.org/​doi/​full/​10.1056/​NEJMoa2204462|Lenze,​ E. J., Mulsant, B. H., Roose, S. P., Lavretsky, H., Reynolds III, C. F., Blumberger, D. M., ... & Karp, J. F. (2023). Antidepressant Augmentation versus Switch in Treatment-Resistant Geriatric Depression. New England Journal of Medicine.]])],​ [[meds:​stimulants:​2-methylphenidate:​home|methylphenidate]],​ [[meds:​mood-stabilizers-anticonvulsants:​1-lithium|lithium]] ​ | 
 +| **3rd Step**\\ (if multiple 1st- and 2nd-step treatments are not effective or not indicated) ​ | **Switch to:** [[meds:​antidepressants:​tca:​amitriptyline|amitriptyline]],​ [[meds:​antidepressants:​tca:​imipramine|imipramine]]\\ **Or combine with:** an [[meds:​antidepressants:​ssri:​home|SSRI]] or [[meds:​antidepressants:​snri:​home|SNRI]] with [[meds:​antidepressants:​ndri:​bupropion|bupropion]] ​                                                                                                                                                                                                                                                                                                                                                                                                   | 
 +</​panel>​ 
 + 
 +==== Pharmacotherapy Initiation and Monitoring ==== 
 +<WRAP group> 
 +<WRAP half column>​ 
 +  * A "start low, go slow, but keeping going" approach to medications is recommended.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC4994788/​|MacQueen,​ G. M., Frey, B. N., Ismail, Z., Jaworska, N., Steiner, M., Lieshout, R. J., Kennedy, S. H., Lam, R. W., Milev, R. V., Parikh, S. V., Ravindran, A. V., & CANMAT Depression Work Group (2016). Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 6. Special Populations:​ Youth, Women, and the Elderly. Canadian journal of psychiatry, 61(9), 588–603.]])] 
 +    * It appears that older adults require longer periods of antidepressant trials (between 10 to 12 weeks) compared to younger adults 
 +  * Prescribers need to be especially aware of the [[geri:​1-giants|geriatric giants]], [[meds:​pharmacology:​geri|pharmacokinetic and pharmacodynamic changes in old age]], increased risk for drug-drug interactions,​ and adverse drug events. 
 +    * For example, older adults will have greater retention of lipid-soluble drugs due to increased body fat, have slower metabolism and excretion, and lower rates of absorption. 
 +    * Common side effects and adverse events in the elderly include [[cl:​hyponatremia|hyponatremia]],​ [[meds:​qtc|QTc prolongation]],​ [[meds:​toxidromes:​anticholinergic-cholinergic|anticholinergic burden]], falls, and gastrointestinal bleeding).[([[https://​pubmed.ncbi.nlm.nih.gov/​31140587/​|Sobieraj,​ D. M., Martinez, B. K., Hernandez, A. V., Coleman, C. I., Ross, J. S., Berg, K. M., ... & Baker, W. L. (2019). Adverse effects of pharmacologic treatments of major depression in older adults. Journal of the American Geriatrics Society, 67(8), 1571-1581.]])] 
 +</​WRAP>​ 
 +<WRAP half column>​ 
 +<alert type="​info"​ icon="​fa fa-book fa-lg fa-fw">​ 
 +See also: **[[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC4122285/​|Mulsant,​ B. H. et al. (2014). A systematic approach to pharmacotherapy for geriatric major depression. Clinics in geriatric medicine, 30(3), 517-534.]]** 
 +</​alert>​
  
-===== Pharmacotherapy ===== 
-==== Antidepressants ==== 
 <callout type="​warning"​ title="​Monitor for Hyponatremia!"​ icon="​true">​ <callout type="​warning"​ title="​Monitor for Hyponatremia!"​ icon="​true">​
-Monitor for electrolytes ​(in particular sodium) ​within one month of starting an SSRI. This is especially important in individuals taking other medications,​ such as diuretics, which can cause hyponatremia.+Monitor for electrolytes within one month of starting an SSRI. This is especially important in individuals taking other medications,​ such as diuretics, which can cause [[cl:​hyponatremia|hyponatremia]].
 </​callout>​ </​callout>​
-Buproprion, mirtazapine,​ moclobemide,​ and venlafaxine are all relatively safe in the elderly. They have lower anticholinergic effects compared to older generation antidepressants. This makes them well tolerated by patients with cardiovascular disease. ​ However in clinical studies, [[meds:antidepressants:​tca:​home|tricyclic antidepressants]] and [[meds:antidepressants:​maoi:​home|MAOis]] have been shown to be more efficacious in the treatment of geriatric depression.[([[https:​//​www.ncbi.nlm.nih.gov/​pubmed/​10549686|Mittmann,​ N., Herrmann, N., Shulman, K. I., Silver, I. L., Busto, U. E., Borden, E. K., ... & Shear, N. H. (1999). The effectiveness of antidepressants in elderly depressed outpatients:​ a prospective case series study. The Journal of clinical psychiatry, 60(10), 690-697.]])]+</​WRAP>​ 
 +</​WRAP>​ 
 +==== ECT ==== 
 +<alert icon="​fa fa-arrow-circle-right fa-lg fa-fw" type="​success">​ 
 +See main article**[[brain-stimulation:ect|]]** 
 +</alert>
  
-==== Tricyclics ==== +  * ECT is a safe and effective treatment for depression in older adults. 
-If [[meds:antidepressants:​tca:​home|tricyclic antidepressants]] ​(TCAsneed to be used, [[meds:antidepressants:​tca:​nortriptyline|nortriptyline]] and desipramine have the lowest anticholinergic burdenand are the most tolerated ​of the TCAs.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​10549686|MittmannN., HerrmannN., ShulmanKI., SilverIL., BustoU. E., BordenEK., ... & ShearN. H. (1999). The effectiveness of antidepressants ​in elderly depressed outpatientsa prospective case series ​study. ​The Journal of clinical psychiatry60(10), 690-697.]])]+  * Older adults who receive ECT have a lower mortality rate compared to other depression treatments (i.e. - antidepressants)[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC4000084/​|Kerner, N., & Prudic, J. (2014). Current electroconvulsive therapy practice and research in the geriatric population. Neuropsychiatry4(1), 33–54.]])][([[https://​pubmed.ncbi.nlm.nih.gov/​962487/​|Avery, D., & Winokur, G. (1976). Mortality in depressed patients treated with electroconvulsive therapy and antidepressants. Archives of general psychiatry, 33(9), 1029-1037.]])] 
 +  * Right unilateralultrabrief pulse ECT (average ​of 7 treatments of ECT), when combined with venlafaxine,​ can be a rapidly acting and effective treatment in depressed geriatric patients. There very good safety and tolerability when this combination therapy is used.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​27418379|KellnerC. H., HusainM. M., KnappRG., McCallWV., PetridesG., RudorferMV., ... & PrudicJ. (2016). Right unilateral ultrabrief pulse ECT in geriatric depressionphase 1 of the PRIDE study. ​American ​Journal of Psychiatry173(11), 1101-1109.]])]
  
-==== Lithium ​==== +===== Guidelines ​===== 
-Lithium augmentation for treatment-refractory depression has some good evidence.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​17854241|Kok,​ R. M., Vink, D., Heeren, T. J., & Nolen, W. A. (2007). Lithium augmentation compared with phenelzine in treatment-resistant depression in the elderly: an open, randomized, controlled trial. Journal of Clinical Psychiatry, 68(8), 1177-1185.]])] +<alert icon="​fa ​fa-arrow-circle-right ​fa-lg fa-fw" type="​success">​ 
-===== ECT ===== +See also: **[[teaching:​clinical-practice-guidelines-cpg|]]** 
-<callout type="success">​{{fa>arrow-circle-right?color=green}} ​See main article: **[[brain-stimulation:​ect|]]**</callout> +</alert>
- +
-Right unilateral, ultrabrief pulse ECT (average of seven treatments of ECT), when combined with venlafaxine,​ has been shown to be a rapidly acting and effective treatment in depressed geriatric patients. There very good safety and tolerability when this combination therapy is used.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​27418379|Kellner,​ C. H., Husain, M. M., Knapp, R. G., McCall, W. V., Petrides, G., Rudorfer, M. V., ... & Prudic, J. (2016). Right unilateral ultrabrief pulse ECT in geriatric depression: phase 1 of the PRIDE study. American Journal of Psychiatry, 173(11), 1101-1109.]])]+
  
 +{{page>​teaching:​clinical-practice-guidelines-cpg#​geriatric-depression&​nouser&​noheader&​nodate&​nofooter}}
 ===== Resources ===== ===== Resources =====
 +
 <WRAP group> <WRAP group>
-<​WRAP ​third column>+<​WRAP ​quarter column>​ 
 +== For Patients == 
 + 
 +</​WRAP>​ 
 + 
 +<WRAP quarter ​column>
 == For Providers == == For Providers ==
   * [[https://​www.psychiatrictimes.com/​geriatric-psychiatry/​psychotherapy-late-life-depression|Psychiatric Times: Psychotherapy for Late-Life Depression]]   * [[https://​www.psychiatrictimes.com/​geriatric-psychiatry/​psychotherapy-late-life-depression|Psychiatric Times: Psychotherapy for Late-Life Depression]]
  
 </​WRAP>​ </​WRAP>​
-<​WRAP ​third column>​ +<​WRAP ​quarter ​column>​ 
-== Guidelines ​== +== Articles ​==
-  * [[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC3922554/​|Frank,​ Christopher. "​Pharmacologic treatment of depression in the elderly."​ Canadian Family Physician 60.2 (2014): 121-126.]] +
-  * [[http://​journals.sagepub.com/​doi/​abs/​10.1177/​0706743716659276|MacQueen,​ Glenda M., et al. "​Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 clinical guidelines for the management of adults with major depressive disorder: section 6. special populations:​ youth, women, and the elderly."​ The Canadian Journal of Psychiatry 61.9 (2016): 588-603.]] +
-  * [[http://​www.bcmj.org/​articles/​geriatric-depression-use-antidepressants-elderly|Wiese,​ B. S. (2011). Geriatric depression: The use of antidepressants in the elderly. BCMJ, 53(7), 341-7.]] +
-  * [[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC3147175/​|Gellis,​ Z. D., McClive-Reed,​ K. P., & Brown, E. (2009). Treatments for depression in older persons with dementia. The annals of long-term care: the official journal of the American Medical Directors Association,​ 17(2), 29.]]+
  
 </​WRAP>​ </​WRAP>​
-<​WRAP ​third column>​ +<​WRAP ​quarter ​column>​ 
-== For Patients ​==+== Research ​== 
 </​WRAP>​ </​WRAP>​
 </​WRAP>​ </​WRAP>​