Author: Renee Flores, MD & Nasiya Ahmed, MD
Key PointsDepression in the older adult
It is estimated that 10-15 percent of older adults with intact cognitive functioning have depression. Health care providers should screen all hospitalized geriatric patients for depression.
Greater than 50% of nursing home residents are depressed.
Dementia syndrome of depression is defined as a cognitive impairment present in an elderly patient with major depression that may have cognitive deficits that develop after the onset of mood symptom.
All older adult patients should be screened for depression.Assessment of the older adult suspected of being depressed includes:
Use the Geriatric Depression Scale (GDS) to screen for depression (Hoyt et al., 1999):
|Are you basically satisfied with your life?||Yes||No|
|Do you often get bored?||Yes||No|
|Do you often feel helpless?||Yes||No|
|Do you prefer to stay at home, rather than going out and doing new things?||Yes||No|
|Do you feel pretty worthless the way you are now?||Yes||No|
|Two out of five depressive responses ("no" to question 1 or "yes" to questions 2 through 5) suggests the diagnosis of depression.|
The table below provides basic information regarding medications for the treatment of depression:
|Class Medication||Initial Dosage||Usual Dosage||Formulation||Comments|
|SSRIs||Class Adverse Events: EPS, hyponatremia, increased risk of upper GI bleeding, suicide (early in treatment), lower BMD and fragility fractures, risk of toxicity if methylene bile or linezolid co administration. Avoid if history of falls or fractures; caution if history of SIADH|
|Citalopram (Celera)||10-20 mg po qam||20 mg/day||T: 20,40,60
|20 mg/day is max dose in age >60; concerns about dose-dependent QT interval prolongation that can lead to arrhythmias|
|Escitalopram (Lexapro)||10 mg po qam||10 mg/day||T: 10,20||10 mg/day is max dose in age>60|
|Fluoxetine (Prozac)||5 mg po qam||5-60 mg/day||T: 10 C: 10,20, 40; C SR90
|Long half-lives of parent and active metabolite; may cause more insomnia than other SSRI|
|Paroxetine (Paxil)||5 mg po qam
CR: 12.5mg po qam
CR: 12.5-37.5 mg/day
CR: T: ER 12.5, 25, 37.5
CR: S: 10mg/ml
CR: Increase by 12.5 mg no faster than once/week
|Helpful with anxiety symptoms; increased risk for withdrawal symptoms (dizziness); anticholinergic events|
|SNRIs||Caution with history SIADH. Most common adverse events: nausea, dry mouth, constipation, diarrhea, urinary hesitance; reduce dosage if CrCl 30-60 ml/min; contraindicated if CrCl < 30 ml/min|
|Duloxetine (Cymbalta)||20 mg po qam, then 20 mg po q12h||40-60 mg q24h or 30 mg q12h||C: 20,30,60||Useful in patients with depression and neuropathic pain|
|Venlafaxine (Effexor)||25-50 mg po q12h
XR: 75 mg po qam
|75-225 mg/day in divided doses
XR: 75-225 mg/day
|T: 25, 37.5, 50, 75, 100
XR: 37.5, 75, 150
|Low anticholinergic activity; minimal sedation and hypotension; may increase BP and QTC; may be useful when somatic pain present; EPS, withdrawal symptoms, hyponatremia|
|Desvenlafaxine (Pristiq)||60 mg po qam||50-400 mg/day||SR T: 50,100||Active metabolite of venlafaxine; adjust for CrCl <30ml/min|
|TCAs||Caution in the elderly due to significant arrhythmic side effects, anticholinergic effects causing urinary retention, orthostasis, and possible exacerbation of dementia.|
|Desipramine (Norpramin)||10-25 mg po qhs||50-150 mg/day||T: 10,25,50,75, 100, 125||Therapeutic serum level >115 ng/ml|
|Nortriptyline||10-25 mg po qhs||75-150 mg/day||C: 10,25,50,75, 100,150
|Therapeutic window 50-150 ng/ml|
|Additional Options||Consider for SSRI, TCA nonresponders; safe in HR; may be stimulating; can lower seizure threshold.|
|Buproprion (Wellbutrin)||37.5-50 mg po q12h||75-50 mg q12h||T: 75,100|
|Wellbutrin SR (Zyban)||SR: 100 mg po q12h or q24h||100-150 mg q12h||T: 100,150,200|
|Wellbutrin XL||150 mg po qday||300 mg/day||T: 150,300|
|Methylphenidate (Ritalin)||2.5-5 mg po q7am and q12pm||5-10 mg at 7am and 12p||T: 5,10,20||Short term treatment of depression or apathy in physically ill older adults; avoid if insomnia; used as adjunct|
|Mirtazapine (Remeron)||15 mg po qhs||15-45 mg/day||T: 15,30,45; ODT (SolTab available)||Useful for patients with insomnia, agitation, restlessness, or anorexia and weight loss; sedating|
ECT may be effective for the older patient who is unable to tolerate medications or who is not responding to medications. ECT causes transient memory loss.
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