II. Epidemiology
-
Prevalence: 1 to 3% of older adults in general
- Up to one third of hospitalized elderly
- Major Depression is underdiagnosed or undertreated in up to 80% of older adults
- Untreated Major Depression is associated with poor outcomes including high mortality rates
III. Screening
- See Geriatric Depression Scale
- See Patient Health Questionnaire (PHQ-2, PHQ-9)
IV. Signs
- May present with many physical complaints
V. Labs
VI. Risk Factors: Depression
- See Depression Provoking Medications
- Prior history of Major Depression
- Loneliness
- Function loss
- New medical diagnoses
- Poor health status
- Bereavement
- Low self esteem
- Helplessness due to discrimination (racism, ageism)
- Muliple comorbid conditions
- Insomnia
- Chronic Pain
- STEMI
VII. Risk Factors: Suicide
- Grief
- Living alone and other social isolation
- Male gender
- Comorbidity and secondary Disability
- Poor sleep quality
- Substance Abuse (e.g. Alcohol Abuse)
- White race
- Turvey (2002) Am J Geriatr Psychiatry 10(4): 398-406 [PubMed]
VIII. Differential Diagnosis
- See Medication Causes of Depression
- See Organic Causes of Major Depression
-
Dementia (contrast with depression with sudden onset, rapid progression)
- Insidious onset and long duration
- Progressive worsening
- Often associated with neurologic deficits
- Patient tries to conceal Disability
- Memory impaired without benefit of cuing
IX. Management
- See Depression Management
- See Depression Medical Management
- Non-medication management
- Encourage socialization
- Encourage daily Exercise
- Psychotherapy
- Cognitive Behavioral Therapy
- Problem solving therapy
- Behavioral activation (via Motivational Interviewing)
- Collaborative care management (health care team)
- Depression registry to ensure follow-up
- Licensed care manager (similar race, cultural or ethnic background, if available, may improve communication)
- Mental health (RN or LICSW delivered talk therapy)
- Unutzer (2008) Am J Manag Care 14(2): 95-100 [PubMed]
-
SSRI Agents (Highly responsive: 60-80% of cases)
- Preferred agents due to low side effect profiles, fewer Drug Interactions, less adverse effect on cognition
- Agents that improve appetite, maintenance of weight
- Mirtazapine (Remeron) promotes weight gain
- Agents to consider in concurrent neuropathic path (with caution, as SNRIs may be more Anticholinergic)
- Agents to avoid
- Avoid Fluoxetine (due to Drug Interactions, and risk of Agitation)
- Avoid Paroxetine (due to Anticholinergic effects)
- Avoid Tricyclic Antidepressants
- Monitoring
- Observe for Hyponatremia while on SSRI (SIADH) with periodic Serum Sodium
- Observe for seroronin syndrome
- Observe for Anticholinergic effects (e.g. confusion, Constipation, Urinary Retention, sedation)
- Observe for increased Fall Risk, sedation, Blurred Vision on SSRI
- Start dosing low (half dose)
- Increasing slowly every 2-4 weeks
- Advance until effective dose reached or maximum based on Renal Function, age
- Expect full effect by 12 weeks
- Adjunctive agents
- Methylphenidate (Ritalin)
- Consider short-term use (e.g. 3 months) while starting and titrating SSRI in severe Major Depression
- Avoid in severe anxiety, unstable or recent Coronary Artery Disease or Arrhythmia
- Example dose: Start Methylphenidate immediate release 2.5 mg in morning and afternoon
- Limit dose to <20 mg daily
- References
- (2016) Presc Lett 23(5):28
- Lavretsky (2015) Am J Psychiatry 172(6):561-9 +PMID:25677354 [PubMed]
- Methylphenidate (Ritalin)
X. References
- (2018) Presc Lett 25(12): 71
- Glaseroff (2022) Am Fam Physician 106(3): 318-20 [PubMed]
- Morley (2010) J Am Med Dir Assoc 11(5):301-3 [PubMed]
- Reynolds (2006) N Engl J Med 354(11): 1130-8 [PubMed]
- Spoelhof (2011) Am Fam Physician 84(10): 1149-54 [PubMed]
- Thakur (2008) J Am Med Dir Assoc 9(2): 82-7 [PubMed]
- Unutzer (2007) N Engl J Med 357(22): 2269-76 [PubMed]