Depression In The Elderly

From Anvita Health Wiki

Contents 1 Introduction 2 Etiology 3 Epidemiology 4 Clinical-manifestations 5 Laboratory 6 Radiology 7 Complications 8 Differential-diagnosis 9 Management 10 More General Terms 11 References

Introduction

• Also see depression.

Etiology

• risk factors

• acute & chronic stressors
• physical disability
• medical illness including chronic pain
• death or serious illness of a loved one
• relocation
• caring for a sick relative
• poor social support ( social isolation)
• polypharmacy: medications associated with depression
• family history of mood disorders
• women at higher risk than men
• brain structural changes

• cortical atrophy
• white matter infarcts or demyelination
• age-related brain plasticity changes [3]

• generally preceded by cognitive impairment [8]
• myocardial infarction or stroke

Epidemiology

• prevalence of major depression in persons > 65 years

• 4.4% in women
• 2.7% in men
• prevalence of major depression in the elderly is reported to be much higher in ref [1]

• 65-74 (13%)
• 75-85 (15%)
• >= 85 (19%)

• prevalence in elderly is < prevalence in persons 24-44 years of age
• major depression is more common in women than men [1]
• prevalence of major depression remained stable from 1998-2008
• prevalence of major depression: hispanics > whites > blacks
• depression less common in community-dwelling elderly than in hospitalized or nursing home patients
• prevalence of depression 12% in hospitalized elderly & 16%-50% in nursing home residents

Clinical-manifestations

• older adults may present with:

• more memory complaints
• more self-reproach
• less guilt
• less suicidal ideation

• older adults tend to report milder mood symptoms
• somatic complaints often overshadow or mask depressive symptoms
• older adults with depression tend to exhibit more:

• weight loss
• disturbances in sleep
• sexual dysfunction
• loss of appetite
• motor retardation
• lethargy & fatigue
• delusions

• higher frequency of relapse (61% when treatment stopped after 2 years)

Laboratory

• see depression

Radiology

• see depression

Complications

• increased mortality in elderly patients

• suicide
• complications of medical problems

• increased utilization of healthcare services
• diminished functionality
• diminished quality of life
• caregiver stress or family burden
• depressive pseudodementia
• non-compliance with medical recommendations
• lower participation in rehabilitation
  
• disease interaction(s) of depression with anxiety
• disease interaction(s) of ischemic heart disease with depression

Differential-diagnosis

• bereavement: normal or pathologic
• endocrine disorders: hypothyroidism
• sleep disorder

• sleep apnea
• circadian disturbance

• fatigue & apathy due to poor health
• structural brain lesion

• vascular depression ( ischemic stroke)
• demyelination

• depressive component of bipolar disorder
• dementia in 1/3 of depressed elderly within 5 years [1]

Management

• see depression
• structured case management approach is more effective than standard care [2,9,14]
• most patients do not achieve even 50% improvement [2]
• medication better than psychotherapy [12]

• psychotherapy of no benefit in preventing recurrence [10]
• psychosocial interventions improve response to medications, improve function, & decrease risk of relapse [1]

• selection of antidepressant for elderly patient

• SSRIs are 1st line agents

• favorable safety profile
• start with low dose (start low & go slow)
• clinical response may take 4-8 weeks
• if inadequate response

• consider another class of antidepressant

• no indication for switching to another agent in same class

• atypical antipsychotics & tricyclic antidepressants are second line agents
• for 1st episode, treat for at least 1 year after 2-3 episodes, treat for 2-3 years for > 3 episodes, treat indefinitely
• switch agents for patients in whom the initial agent failed [1]
• increase dose for partial response [1]
• fluoxetine & venlafaxine less effective in elderly patients, number needed to treat: 17-39 vs 4-6 for children & younger adults [16]

• recurrence is common [13]
• consider ECT if depression is life-threatening
• lifelong follow-up to identify recurrence
• minor depression may harold major depression [11]

More General Terms

• geriatrics
• depression

References

1. Geriatrics Review Syllabus, American Geriatrics Society, 5th edition, 2002-2004; 7th edition 2010
2. Journal Watch 23(3):25, 2003 Unutzer J, Katon W, Callahan CM, Williams JW Jr, Hunkeler E, Harpole L, Hoffing M, Della Penna RD, Noel PH, Lin EH, Arean PA, Hegel MT, Tang L, Belin TR, Oishi S, Langston C; IMPACT Investigators. Improving Mood-Promoting Access to Collaborative Treatment. Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA. 2002 Dec 11;288(22):2836-45. PMID: [1]
3. Yerevanian BI. In: Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 29-Oct 2, 2004
4. Thompson LW, Cognitive-behavioral therapy and treatment of late life depression, J. Clin. Psychiatry 57(suppl 5):29-37, 1996
5. Alexopoulous GS et al, ECT in the high risk geriatric patient, Convuls Ther 5:75, 1989
6. NIH Consensus Development Panel on Depression in Late Life, JAMA 268:1018, 1992
7. Rothchild AJ, The diagnosis and treatment of late life depression, J Clin Psychiatry 57(suppl 5):29, 1996
8. Journal Watch 24(24):184, 2004 Vinkers DJ, Gussekloo J, Stek ML, Westendorp RG, van der Mast RC. Temporal relation between depression and cognitive impairment in old age: prospective population based study. BMJ. 2004 Oct 16;329(7471):881. Epub 2004 Sep 02. <PubMed> PMID: [2] <Internet> [3]
9. Hunkeler EM et al, Long-term outcomes from the IMPACT randomised trial for depressed elderly patients for primary care BMJ 2006; 332:259 PMID: [4]
10. Reynolds CF III et al, Maintenance treatment of major depression in old age N Engl J Med 2006; 354:1130 PMID: [5]
    - Reifler BV Play it again, Sam - Depression is recurring N Engl J Med 2006; 354:1189 PMID: [6]
11. Lyness JM, Heo M, Datto CJ, Ten Have TR, Katz IR, Drayer R, Reynolds CF 3rd, Alexopoulos GS, Bruce ML. Outcomes of minor and subsyndromal depression among elderly patients in primary care settings. Ann Intern Med. 2006 Apr 4;144(7):496-504. PMID: [7]
    - Kroenke K. Minor depression: midway between major depression and euthymia. Ann Intern Med. 2006 Apr 4;144(7):528-30. No abstract available. PMID: [8]
12. Dombrovski AY, Lenze EJ, Dew MA, Mulsant BH, Pollock BG, Houck PR, Reynolds CF 3rd. Maintenance Treatment for Old-Age Depression Preserves Health-Related Quality of Life: A Randomized, Controlled Trial of Paroxetine and Interpersonal Psychotherapy. J Am Geriatr Soc. 2007 Sep;55(9):1325-1332. PMID: [9]
13. Luidendijk HJ et al, Incidence and recurrence of late-life depression. Arch Gen Psychiatry 2008, 65:1394 PMID: [10]
14. Bruce ML et al. Reducing suicidal ideation and depressive symptoms in depressed older primary care patients: A randomized controlled trial. JAMA 2004 Mar 3; 291:1081-91. PMID: [11]
15. Alexopoulos GS et al Reducing suicidal ideation and depression in older primary care patients: 24-month outcomes of the PROSPECT study. Am J Psychiatry 2009 Jun 15; [e-pub ahead of print] <PubMed> PMID: [12] <Internet> [13]
16. Journal Watch March 13, 2012, Massachusetts Medical Society Gibbons RD et al. Benefits from antidepressants: Synthesis of 6-week patient- level outcomes from double-blind placebo-controlled randomized trials of fluoxetine and venlafaxine. Arch Gen Psychiatry 2012 March 5; PMID: [14]
17. Older Adults: Depression and Suicide Facts [15]
18. National Guideline Clearinghouse
    - (1) Caregiving strategies for older adults with delirium, dementia and depression. (2) Caregiving strategies for older adults with delirium, dementia and depression 2010 supplement. Registered Nurses' Association of Ontario (RNAO) ngc-guideline: [16]
    - Depression. In: Evidence-based geriatric nursing protocols for best practice. Hartford Institute for Geriatric Nursing ngc-guideline: [17]
    - Detection of depression in the cognitively intact older adult. (University of Iowa Gerontological Nursing Interventions Research Center, Research Dissemination Core) ngc-guideline: [18]

depression in the elderly