Despite its impact on individuals and public health, depression in older persons is inadequately diagnosed and treated. Even when depression is diagnosed, only one-third of persons older than 65 receive treatment.1 Reasons for this include:
- lack of physician awareness that depression presents differently in older than in younger adults
- patient denial of depressive symptoms
- patients’ and physicians’ mistaken belief that feeling depressed is a normal part of aging.
The good news is that when geriatric depression is recognized, it usually responds favorably to treatment, although aggressive intervention may be required.2 In this article, we describe our approach to diagnosis and discuss use of selective serotonin reuptake inhibitors (SSRIs) as first-line antidepressants for older patients.
Late-life depression risk factors
Depression is common in older persons, especially in those who have experienced psychosocial or medical losses, including chronic illness. Although its presentation often does not meet criteria for major depression, the more common subsyndromal depression is debilitating and can lead to suicide.
CASE REPORT: DEPRESSED, AT RISK FOR SUICIDE
A 72-year-old man presents with trouble concentrating, decreased appetite, anergy, and anhedonia. He says he frequently awakes at 3 AM, and it takes him 2 hours to return to sleep. Lately, he has thought of shooting himself with his hunting rifle. The patient’s wife died of cancer 1 year ago, and he has developed several medical illnesses within the past 10 years: chronic obstructive pulmonary disease, worsening arthritis, mild ischemic heart disease, and worsening hearing loss.
The patient denies feeling depressed and instead attributes his symptoms to his medical illnesses. He has become progressively isolated in the past year, with less social contact with his friends at the local parish. His older brother, with whom he was close, died recently. Until now, he says his “pride” has made him resist his primary care physician’s recommendation that he see a psychiatrist.
Late-life depressive syndromes commonly present with somatic complaints. Typically, patients deny having a mental illness and perceive that their symptoms are organic in origin (Box).1
Losses. Psychosocial and medical losses are major risk factors for late-life adjustment disorders, subsyndromal depressive disorders, and major depression. Medical losses may include loss of mobility or independent function, chronic pain, or sensory losses that limit one’s ability to read or hear. Psychosocial losses may include the death of a spouse, sibling, or peer or moving from one’s longtime home to a more structured environment (assisted living, nursing home, or living with relatives).
Medical causes to rule out before starting antidepressant therapy include:
- hypothyroidism
- medication side effects
- bipolar disorder, which may require the use of a mood-stabilizing agent to prevent manic symptoms.3
History. Often a history of mood disorder in the individual or a family member can help the clinician determine that mental illness accounts for the patient’s symptoms. In older patients, it is not uncommon for psychotic symptoms to accompany a primary mood disturbance.
Suicide risk is high in depressed older persons, so detection and quick treatment of depression is paramount. Older white men are at particularly high risk for completed suicide using firearms.3
Alcohol abuse may contribute to depressive symptoms in older persons. A second peak of alcoholism occurs in the eighth decade of life and can confound diagnosis of depression in patients of this age.
Making the diagnosis. In patients who present with symptoms and risk factors for late-life depression, depression rating scales can help confirm the diagnosis. Commonly used scales include the Beck Depression Inventory, the Hamilton Depression Rating Scale, and the Zung Self-Rating Depression Scale. Specialized scales for use in older patients include the Geriatric Depression Scale and the Cornell Scale; the latter scale is designed for patients with comorbid depression and dementia.3,4
Treatment
Antidepressant treatment in combination with psychotherapy usually is warranted when treating nonpsychotic late-life depression. In patients with psychosis, electroconvulsive therapy can help achieve remission.
Cognitive-behavioral therapy and interpersonal and insight-oriented psychotherapy have been shown to be effective in late-life depression. Social interventions aimed at preventing isolation also can work. In milder cases of depression, psychotherapy alone may be sufficient.3
Starting dosages. When antidepressant therapy is indicated in an older patient, start low and go slow.5 Older patients generally require prolonged titration rates and a longer course of treatment than do younger patients. Physiologic changes that occur with aging include:
- altered drug metabolism rate, including slower demethylation
- increased body fat-to-water ratio, which increases the volume of distribution for lipophilic psychotropic drugs
- decreased glomerular filtration rate, which may account for higher serum concentrations of drugs and their metabolites
- increased sensitivity of the older brain to the effects of medications.6