Older Adults

Abstract

Depression in the elderly is a major public health problem associated with increased morbidity, mortality, functional impairment, and a diminished quality of life. Unfortunately, late-life depression often goes unrecognized and untreated. Healthy, ambulatory elderly patients can often be treated in the same way as younger patients, whereas frail elderly patients (usually the “old” old) often need to be approached more conservatively, with special attention to physical status and concomitant illnesses. Clinicians should also consider the patient's environment (e.g., whether living at home or in a nursing home). Elderly patients may underreport psychological symptoms and overreport somatic symptoms (e.g., pain); collateral histories from families, friends, or professional caregivers are invaluable aids in diagnosis. Secondary depressions are also common in the elderly, since numerous medical disorders, medications, and life stresses can lead to depressive syndromes. Before initiating antidepressant treatment, clinicians should screen for and treat any concurrent medical condition(s), provide psychological support for the patient, identify and provide assistance with social or economic difficulties, and involve the patient's family or support network. Social and psychological supportive approaches should preferably precede pharmacologic management in mild or stable cases. Some elderly patients respond well to traditional or time-limited psychotherapies, cognitive-behavioral interventions, or spiritual support in individual or group settings. The ideal antidepressant agent for elderly patients should not cause orthostasis or cardiotoxicity and should cause little sedation or impairment of physical and cognitive abilities. Although data are inconsistent as to whether elderly patients are more likely to develop side effects than younger patients, the aged often do not tolerate side effects as well. Clinicians should take into account the heterogeneity of the elderly population in pharmacokinetic and pharmacodynamic parameters and practice individualized titration of all medications coupled with therapeutic drug monitoring. In general, the rule of “start low, go slow” applies, except when rapid symptom relief is of paramount importance. The SSRIs are important agents for the treatment of depression in the elderly, given their tolerability, wide therapeutic index and efficacy. The tricyclic antidepressants are efficacious in treating depression in the elderly. The secondary amines (e.g., desipramine, nortriptyline) are preferred over the tertiary amines (e.g., amitriptyline and imipramine) because they cause fewer serious side effects. Therapeutic drug monitoring is recommended in using TCAs in older patients, and clinicians should be alert for the risk of drug-drug interactions since many older patients are taking multiple medications. A number of other antidepressants have been shown to be effective and well tolerated in elderly depressed patients, including reboxetine, venlafaxine, and bupropion. In treating more severe depressive illness consideration should be given to ECT or prescribing a TCA or venlafaxine because of possibly increased response rates with these agents. Elderly patients who do not respond adequately to antidepressant monotherapy should be considered for antidepressant combinations or augmentation with lithium, thyroid, or hormone replacement (in perimenopausal depression). The appropriate duration of maintenance antidepressant medication will depend on the patient's history of depressive episodes.