Geriatric Depression

Primer

Geriatric depression (late-life depression) is one of the major geriatric giants.

Prevalence

The community prevalence rates of late-life depression is 11.2% for combined symptoms of major and minor depression.[1]

Diagnosis

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 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, major neurocognitive disorder, substances like alcohol or opioids. Feelings of worthlessness and suicidal ideation can also be due to end-of-life issues.[2]

A complete assessment for late-life depression requires:

  • 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 stresses and life situation
  • Assessing level of functioning/disability
  • Considering support system, family situation, and personal strengths
  • Reviewing results from Mini-Mental State Exam and any other tests for cognitive function

Psychotherapy

Cognitive behavioral therapy (CBT), problem-solving treatment (PST), and interpersonal therapy (IPT) has strong evidence in late-life depression.[3]

Pharmacotherapy

Antidepressants

Monitor for Hyponatremia!

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.

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, tricyclic antidepressants and MAOis have been shown to be more efficacious in the treatment of geriatric depression.[4]

Tricyclics

If tricyclic antidepressants (TCAs) need to be used, nortriptyline and desipramine have the lowest anticholinergic burden, and are the most tolerated of the TCAs.[5]

Lithium

Lithium augmentation for treatment-refractory depression has some good evidence.[6]

ECT

See main article: Electroconvulsive Therapy (ECT)

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.[7]

Resources

For Providers
Guidelines
For Patients

References

1) 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.
2) Blackburn, P., Wilkins-Ho, M., & Wiese, B. (2017). Depression in older adults: Diagnosis and management. BC Medical Journal, 59, 171-177.
3) 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.
4) 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.
5) 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.
6) 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.
7) 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.