Depression in the Elderly

Noel H. Ponce, M.D.

Definition
A disorder of mood, a syndrome that includes a
cluster of sx
Vegetative: sleep, appetite, wgt, sex
Cognitive:
attention span, frustration
tolerance, memory, negative
distortions
Impulse:
suicide, homicide
Behavior:
motivation, pleasure, interest,
fatigability
Somatic:
HA, abdl pain, muscle tension

3 Major Clinical Presentations

Associated with Depression in Older
Patients
1. Community-dwelling persons who
have recently experienced a
significant loss. The initial
presentation is one of
depressed mood
loss of pleasure
vegetative sx

2. Those recently ill whose initial

presentation is primarily a failure-tothrive or vegetative state without clear
sx of depressed mood.
Best identified by a decline in physical
and cognitive function (out of
proportion to or unexplained by recent
episode of illness)

3. Recent onset of delusions,

hallucinations or disruptive behavior
might present an initial presentation
of depressed mood and or a FTT
syndrome

Epidemiology
Prevalence of Major depressive disorder
Community: 3%
LTC facilities: 12%
Hospital: 11%

Prevalence of Depressive symptoms

Community: 15%
Nursing home: 30%

Etiology
Conglomeration of factors
Biological
Family history / prior hx
in serotonin, dopamine and noradrenaline

Physical
Chronic medical condition
Treatment

Etiology
Psychological
Low self-esteem, memory loss, childhood sexual /
physical abuse

Social
Losses of family and friends, isolation, loss
of job and income

Neurological and Medical

Causes

Parkinsons disease
Alzheimer's disease
Cerebrovascular disease
Multiple sclerosis
Hypothyroidism
SLE
Rheumatoid arthritis
Carcinoma
Vitamin deficiencies

Pharmacologic causes

Propanolol, Digitalis
Benzodiazepines
Corticosteroids
Phenytoin
Ibuprofen, indomethacin
Ampicillin, Tetracycline, Metronidazole
Meclizine
Pizotifen
Cimetidine

Significance in Medical Care

Depression promotes loss of physical, cognitive,
social function and prevents them from regaining
function after tx of acute medical illness
Despite appropriate tx of medical and surgical
diseases, undiagnosed and or untreated
depression leads to poor patient outcomes

Consequences of Failure in
Recognition

Social isolation
Reduced quality-of-life
Burden to family, society, economy
Increased M/M
Suicide risk

Symptoms
DSM-IV-TR lists the ffg sx as diagnostic
criteria for major depression in older persons
1. Depressed mood and or loss of interest
or pleasure PLUS 4 additional criteria
2. Additional criteria

Weight loss or weight gain

Insomnia or hypersomnia
Psychomotor retardation or agitation
Loss of energy
Feelings of worthlessness
Difficulty concentrating
Recurrent thoughts of death or suicide

Suicide
More frequent in the elderly than in any other
population
Up to 70% of elderly who completed suicide
visited their MD within the previous 4 weeks
Suicidal attempts and ideation decrease with
aging

Assessment
History and PE including neurologic and
mental status assessment
Review of drug use
Rating scales
Geriatric Depression Scale
Hamilton Rating Scale

Laboratory tests

Geriatric Depression Scale

1. Are you basically satisfied with your life?
2. Do you feel that your life is empty?
3. Are you afraid that something bad is going to
happen to you?
4. Do you feel happy most of the time?
Answers: 1-N, 2-Y, 3-Y, 4-N
0 - No depression
1 - Uncertain
2-4 - Probably depression present

Treatment
Treatment Issues
Any loss incurred major depressive Disorder
Unstable medical illness must be treated in
parallel with the major depression for optimal
outcome
Exacerbation or relapse are typically resistant to
Tx as a result of multiple co-morbid illness ergo
maintenance therapy should be continued
indefinitely

Treatment
Treatment issues
Common mistakes made in
pharmacotherapy
Dose too low
Treatment too short
Settling for a partial response to tx
instead of complete remission of sx.
Careful and frequent ff-up important

Treatment
Non-pharmacologic
Social support to reduce isolation
Psychotherapy
Family counseling
Substance-abuse intervention as indicated
Bereavement counseling
Health promotion and maintenance

Good nutrition
Light physical exercise
Attention to chronic medical conditions
Regular daily routine

Treatment
Pharmacologic treatment
Antidepressant

SSRI- Sertraline, Escitalopram, Paroxetine, Fluoxetine

SNRI- Venlafaxine, Duloxetine
NDRI- Bupropione
SSRI/ SNRI- Mirtazapine
TCA- Nortriptyline, Desipramine
SARI- Trazodone, Nefazodone

Psychostimulants
Methyphenidate
Modafinil

Treatment
Antipsychotics
Treats agitation, delirium, psychosis

Haloperidol
Olanzapine
Quetiapine
Risperidone

Treatment
Cognitive impairment
Cholinesterase inhibitors
Donepezil
Galantamine
Rivastigmine

NMDA receptor antagonist

Memantine

Electroconvulsive Therapy
Indications
Severely depressed patients
Those who demonstrate significant
psychotic symptoms and self-destructive
behavior
Those who do not tolerate or respond to
antidepressants