Depression in the Elderly

Author: Renee Flores, MD & Naysia Ahmed, MD

Key Points

Depression in the older adult Mental health treatment for depressed older adults is delivered over 80% in the primary care setting.

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. 

 

Assessment

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.

 

Interventions


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
S: 5mg/10ml
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 
S: 20mg/5ml
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
10-40 mg/day
CR: 12.5-37.5 mg/day
T: 10,20,30,40
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 
S: 10mg/5ml
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.

 

References

Alexopoulos, G. (2005). Depression in the Elderly. The Lancet; 365:1961-1970. 

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Bao, Y., Post, E.P., Ten, T.R., et al. (2009). Achieving effective antidepressant pharmacotherapy in primary care: the role of depression care management in treating late-life depression. Journal of the American Geriatric Society; 57:895 

Beyer J. (2007). Managing Depression in Geriatric Populations. Annals of Clinical Psychiatry; 19(4):221-238. 

Bruce, M.L., Ten Have, T.R., Reynolds, C.F. et al. (2004). Reducing suicidal ideation and depressive symptoms in depressed older primary care patients: A randomized controlled trial. Journal of the American Medical Association; 291:1081. 

Delgado-Guay, M., Parsons, H., Li, Z., et al. (2009). The association between anxiety, depression, and physical symptoms in patients with advanced cancer. Support Care Cancer; 17:573-579. 

Hoyl, M.T., Alessi, C.A., Harker, J.O., et al. (1999). Development and testing of a five-item version of the Geriatric Depression Scale. Journal of the American Geriatric Society; 47:873. 

Licht-Strunk, E., Van Marwijk, H.W., Hoekstra, T., et al. (2009). Outcome of depression in later life in primary care: Longitudinal cohort study with three years' follow-up. British Medical Journal; 338:a3079

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Pinquart, M., Duberstein, P.R., & Lyness, J.M. (2006). Treatments for later-life depressive conditions: a meta-analytic comparison of pharmacotherapy and psychotherapy.American Journal of Psychiatry; 163:1493. 

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