Depression can affect individuals of all ages and can occur throughout the lifespan. Depression may present differently in an older patient when compared with a younger individual.
In general, depression is considered to be less prevalent in the elderly population when compared to their younger counterparts; however, an estimated 15% of elderly in the community experience significant depressive symptoms, with 1-5% of those age 65 and above experiencing major depressive disorder (MDD).
Additionally, cases of MDD may be higher in specific elderly populations, including those in medical inpatient and outpatient settings, where the estimates range from 5-12%, and patients in long-term care facilities, where depression rates are cited to be 14-42%.1
How Does Depression Present in an Elderly Patient?
Depression in the elderly can present as a continuation of symptoms experienced earlier in the lifespan, known as early onset depression, or as a new onset of depressive symptoms, termed late-onset depression, and it is estimated that over half of elderly patients experiencing depression had an onset of symptoms after the age of 60.1
In general, a diagnosis of major depressive disorder is highlighted by the hallmark symptom of depressed mood, but elderly individuals are less likely to report this core affective component of depression. More commonly, elderly patients may identify a lack of emotion versus depressed mood.2
In comparison to younger patients, elderly patients may also be more likely to experience the following symptoms:1-3
- Decreased interest
- Irritability or agitation
- Sleep disturbances
- Psychomotor changes
Additionally, depression-associated cognitive deficits, including concentration difficulties and memory issues, are particularly relevant in the elderly population. Likewise, somatic symptoms, which can range from reports of aches or pain to vague complaints of not feeling well, are more notable in the geriatric population.4
Given the variability in presentation seen in the elderly, it is not uncommon that signs of depression are misattributed to advancing age or misdiagnosed as other neurologic or physical disease states.5
How Does Depression Impact the Elderly Population?
Depression has been linked with increased morbidity, mortality, and suicidality and has also been associated with decreased physical, cognitive, and social functioning, as well as decreased self-care and quality of life in elderly individuals.1,5
Additionally, depression in the elderly population is associated with increased healthcare costs, though only a small amount of these costs have been attributed to mental health care or treatment.6
Given the significance of these potential consequences, the identification and treatment of depression in this population is critical.5
How is Depression Treated in the Elderly Population?
The management of depression in the elderly population follows a similar approach to that of treatment in a younger patient population, and symptom remission should be the goal of treatment.3
Treatment may include psychotherapy, pharmacotherapy, and/or additional socialization and supportive measures such as life review, music therapy, and physical activity. Additionally, electroconvulsive therapy (ECT) is often an effective and tolerable treatment option in the elderly.1
In regards to pharmacotherapy, antidepressants are expected to be as beneficial in the geriatric population as they are in younger patients; however, it is necessary to consider specific characteristics when selecting an antidepressant for an elderly patient.
Pharmacotherapy choice should include an assessment of:3
- Past medication trials and response
- Comorbid medical conditions
- Comorbid psychiatric conditions
- Concomitant medications and drug interactions
- Medication tolerability and safety
Overall, selective serotonin reuptake inhibitors (SSRIs) are considered to be first-line treatment options, but serotonin-norepinephrine reuptake inhibitors (SNRIs), mirtazapine, bupropion, and tricyclic antidepressants may also be considered.5 It should be noted however that some of these treatments come with additional precautions. For example, the American Geriatrics Society Beers Criteria, identify tricyclic antidepressants as “potentially inappropriate in older adults.”
In addition to other patient-specific factors noted previously, clinicians should also be aware of pharmacokinetic and pharmacodynamic changes that occur with advancing age when assessing medication options for an elderly patient.
How Age-related Changes Impact Antidepressant Medications
Elderly patients may be more sensitive to any given drug dose or concentration, and starting doses of antidepressants in the elderly are often lower than those typically utilized in younger patients.
Furthermore, drug half-life may be increased in the elderly, and time to steady state, as well as time to resolution of dose-dependent adverse effects, can be longer.5
Although elderly patients may also experience common side effects of antidepressants, such as headache, gastrointestinal distress, dizziness, insomnia, or sedation, they may also be more sensitive to adverse effects such as anticholinergic side effects, increased fall risk, hyponatremia, and, rarely, gastrointestinal bleeding.3,5
It is generally accepted that time to antidepressant response may be longer in the elderly, with potentially 2-3 months’ time needed to establish full benefit of a selected medication, though moderate improvements may start to be seen within 4-8 weeks.5
Following the acute management of depressive symptoms, it has been recommended that treatment be continued for a minimum of one year, though there is an overall lack of guidance regarding how to approach duration of maintenance treatment in this population.3,5
The identification and management of depression in the elderly may present unique challenges to practitioners, though appropriate diagnosis and treatment is key in reducing significant disease-related consequences.
Knowledge of a patient’s unique presentation and symptoms, as well as a thorough assessment of treatment options can allow for a well-rounded, patient-centered approach to the management of depression in this patient population.
Predicting an individual’s likelihood of tolerating and responding to a psychotropic medication has proved challenging and has opened the door for pharmacogenetic guidance.
PGx testing can assist clinicians in the selection of safe and appropriate treatments and is intended to be used adjunctively to a complete patient assessment. Important advancements have been made in the application of PGx testing in psychiatry in recent years and the PGx knowledge base in elderly populations is emerging.
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