II. Epidemiology

  1. Prevalence: 1 to 3% of older adults in general
    1. Up to one third of hospitalized elderly
  2. Major Depression is underdiagnosed or undertreated in up to 80% of older adults
  3. Untreated Major Depression is associated with poor outcomes including high mortality rates
    1. Cole (1999) Am J Psychiatry 156(8): 1182-9 [PubMed]

III. Screening

  1. See Geriatric Depression Scale
  2. See Patient Health Questionnaire (PHQ-2, PHQ-9)

IV. Signs

  1. May present with many physical complaints

V. Labs

  1. Serum Sodium
    1. Consider monitoring while on SSRI, SNRI (SIADH)

VI. Risk Factors: Depression

  1. See Depression Provoking Medications
  2. Prior history of Major Depression
  3. Loneliness
  4. Function loss
  5. New medical diagnoses
  6. Poor health status
  7. Bereavement
  8. Low self esteem
  9. Helplessness due to discrimination (racism, ageism)
  10. Muliple comorbid conditions
  11. Insomnia
  12. Chronic Pain
  13. STEMI

VII. Risk Factors: Suicide

  1. Grief
  2. Living alone and other social isolation
  3. Male gender
  4. Comorbidity and secondary Disability
  5. Poor sleep quality
  6. Substance Abuse (e.g. Alcohol Abuse)
  7. White race
  8. Turvey (2002) Am J Geriatr Psychiatry 10(4): 398-406 [PubMed]

VIII. Differential Diagnosis

  1. See Medication Causes of Depression
  2. See Organic Causes of Major Depression
  3. Dementia (contrast with depression with sudden onset, rapid progression)
    1. Insidious onset and long duration
    2. Progressive worsening
    3. Often associated with neurologic deficits
    4. Patient tries to conceal Disability
    5. Memory impaired without benefit of cuing

IX. Management

  1. See Depression Management
  2. See Depression Medical Management
  3. Non-medication management
    1. Encourage socialization and daily Exercise
    2. Psychotherapy
      1. Cognitive Behavioral Therapy
      2. Problem solving therapy
      3. Behavioral activation (via Motivational Interviewing)
    3. Collaborative care management (health care team)
      1. Depression registry to ensure follow-up
      2. Licensed care manager (similar race, cultural or ethnic background, if available, may improve communication)
      3. Mental health (RN or LICSW delivered talk therapy)
      4. Unutzer (2008) Am J Manag Care 14(2): 95-100 [PubMed]
  4. SSRI Agents (Highly responsive: 60-80% of cases)
    1. Preferred agents due to low side effect profiles, fewer Drug Interactions, less adverse effect on cognition
      1. Escitalopram (Lexapro)
      2. Citalopram (Celexa)
      3. Sertraline (Zoloft)
    2. Agents that improve appetite, maintenance of weight
      1. Mirtazapine (Remeron) promotes weight gain
    3. Agents to consider in concurrent neuropathic path (with caution, as SNRIs may be more Anticholinergic)
      1. Duloxetine
      2. Venlafaxine
    4. Agents to avoid
      1. Avoid Fluoxetine (due to Drug Interactions)
      2. Avoid Paroxetine (due to Anticholinergic effects)
      3. Avoid Tricyclic Antidepressants
    5. Monitoring
      1. Observe for Hyponatremia while on SSRI (SIADH) with periodic Serum Sodium
      2. Observe for seroronin syndrome
      3. Observe for Anticholinergic effects (e.g. confusion, Constipation, Urinary Retention, sedation)
      4. Observe for increased Fall Risk, sedation, Blurred Vision on SSRI
      5. Start dosing low (half dose)
        1. Increasing slowly every 2-4 weeks
        2. Advance until effective dose reached or maximum based on Renal Function, age
        3. Expect full effect by 12 weeks
  5. Adjunctive agents
    1. Methylphenidate (Ritalin)
      1. Consider short-term use (e.g. 3 months) while starting and titrating SSRI in severe Major Depression
      2. Avoid in severe anxiety, unstable or recent Coronary Artery Disease or Arrhythmia
      3. Example dose: Start Methylphenidate immediate release 2.5 mg in morning and afternoon
        1. Limit dose to <20 mg daily
      4. References
        1. (2016) Presc Lett 23(5):28
        2. Lavretsky (2015) Am J Psychiatry 172(6):561-9 +PMID:25677354 [PubMed]

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