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Depression, Geriatric

Basics

  • Primary mood disorder with depressed mood and/or anhedonia β‰₯2 weeks causing significant distress or functional impairment.
  • Elderly often present with variable symptoms and multiple comorbidities complicating diagnosis.
  • Suicide rates highest in males >85 years.

Epidemiology

  • Incidence: 2–10% community dwelling; 5–10% primary care; 10–37% hospitalized elderly; 12–27% nursing home residents.
  • Prevalence: 4–6% males, 5–8% females >60 years (2015 data).

Etiology and Pathophysiology

  • Complex interplay of genetic, biologic, psychological, and environmental factors.
  • Neurotrophin, neurogenesis, neuroimmune, and neuroendocrine dysregulation implicated.
  • Possible genetic influences on monoamine transmission and protein dysregulation.

Risk Factors

  • Female sex, low socioeconomic status
  • Widowhood, divorce, or separation
  • Chronic physical illness and pain
  • Prior mental health history
  • Family history of depression
  • Bereavement
  • Caregiving role
  • Functional or cognitive impairment
  • Social isolation, loss of independence
  • Sleep disturbances

Prevention

  • Diets rich in omega-3 fatty acids (Mediterranean, Japanese)
  • Regular physical activity
  • Social and group activity participation for elderly

Commonly Associated Conditions

  • Coronary artery disease, cerebrovascular disease, cancer, Parkinson disease

Diagnosis

History

  • Depressed mood or anhedonia β‰₯2 weeks
  • Additional symptoms: hopelessness, insomnia/hypersomnia, appetite changes, fatigue, somatic complaints, psychomotor changes, impaired concentration, suicidality
  • Use β€œSIGECAPS” mnemonic for screening

Physical Exam

  • Focused mental status and neurologic exam to exclude other causes

Differential Diagnosis

  • Medical conditions: hypothyroidism, B12/folate deficiency, liver/renal failure, cancers, stroke, sleep disorders, Cushing disease
  • Cognitive disorders: dementia, delirium
  • Medications: interferon-Ξ±, beta blockers, isotretinoin, benzodiazepines, glucocorticoids, others
  • Other psychiatric disorders

Diagnostic Tests

  • Labs: TSH, CBC, B12, folate, urinalysis, metabolic panel, urine toxicology, 24-hr urine cortisol
  • Consider sleep studies or other tests if indicated
  • Screening tools (validated):
  • Geriatric Depression Scale (GDS) 15- or 30-point
  • PHQ-2, PHQ-9
  • Hamilton Depression Rating Scale (HDRS)
  • Beck Depression Inventory (BDI)
  • Cornell Scale for Depression in Dementia

Treatment

General Measures

  • Lifestyle: nutrition, socialization, exercise
  • Psychotherapy: cognitive-behavioral therapy, psychodynamic therapy

Medications

  • Start at half usual dose, titrate slowly every 2–4 weeks.
  • First line: SSRIs (no clear superior agent; choose based on side effects/familiarity)
  • Citalopram 10–20 mg/day
  • Sertraline 25–200 mg/day
  • Escitalopram 5–20 mg/day
  • Fluoxetine 10–60 mg/day
  • Paroxetine 10–40 mg/day
  • Avoid SSRI + MAOI combination
  • Side effects: falls, nausea, diarrhea, sexual dysfunction
  • Second line: atypical antidepressants
  • Bupropion, venlafaxine, duloxetine, mirtazapine, desvenlafaxine
  • TCAs effective but limited by side effects and overdose risk
  • MAOIs effective but rarely used (diet restrictions, side effects)
  • Off-label augmentation: buspirone, lithium, triiodothyronine
  • Antidepressant use in dementia equivocal; trial with close monitoring if severe symptoms
  • ECT for severe/psychotic depression

Complementary & Alternative Medicine

  • St. John’s wort: minimal benefit, many interactions
  • Tryptophan/5-HTP: possible efficacy

Inpatient Care

  • Indicated for imminent safety risk or inability to self-care

Ongoing Care

  • Educate on delayed onset of antidepressant effect and adherence
  • Monitor suicidality and anxiety, especially first weeks after starting/changing meds

Diet

  • Avoid tyramine-rich foods with MAOIs

Patient Education

  • Depression treatable but requires time for improvement
  • National Suicide Prevention Lifeline: 1-800-273-TALK (8255)

Prognosis

  • Clinical response/remission rates 30–70%

Complications

  • Impaired functioning and self-care
  • Increased healthcare utilization
  • Suicide risk

ICD10 Codes:
- F32.9 Major depressive disorder, single episode, unspecified
- F03 Unspecified dementia
- F43.21 Adjustment disorder with depressed mood

Clinical Pearls:
- Late-life depression is not normal aging.
- Diagnosis complicated by comorbidities.
- Depression may present as cognitive dysfunction which improves with treatment.
- SSRIs are first-line; remission may take up to 12 weeks.
- Multidisciplinary approach yields best outcomes.