Dr. Maria Chung (biography and disclosure)
What care gaps I noticed
Depression can have devastating effects on the elderly and their families. Moreover, it is often under recognized, as it can present atypically, with agitation/ anxiety, somatic symptoms, or cognitive and functional decline rather than sadness and withdrawal. (1) It has been demonstrated to be associated with increased morbidity, mortality, and decreased quality of life. (2, 3) It can cause severe hardship for caregivers because of behavioural issues and lead to premature institutionalization.
What data should be considered
By DSM IV definition (The 4th edition of “Diagnostic and Statistical Manual of Mental Disorders”), a major depression consists of depressed mood and lack of interest (anhedonia), plus four or more of the following: feelings of worthlessness or guilt, decreased concentration or ability to make decisions, decreased energy, psychomotor retardation or agitation, sleep or appetite disturbance, and preoccupation with thoughts of death, lasting more than 2 weeks.
The elderly can present atypically, often emphatically denying that they feel depressed. Instead, they may experience significant somatic symptoms, anxiety or irritability, delusional thinking involving unreasonable guilt, anxiety or fear, and marked executive impairment. This is common in patients suffering from acute (MI, CVA, hip fracture) and chronic (diabetes, osteoarthritis, incontinence, dementia) illnesses. Late onset alcohol or substance misuse may also mask an underlying depression.
What I recommend (practice tip)
Frontotemporal dementias or apathetic delirium can masquerade as a depression, as can drugs with CNS side effects, such as sedative/anxiolytics, alcohol, steroids, antihypertensives, or any drug with anticholinergic properties. Physical illnesses such as occult malignancies, chronic infections, endocrine abnormalities (hypo- or hyperthyroidism, hyperparathyroidism, diabetes), renal or hepatic impairment, anemia, Vitamin B12 deficiency, or multiple or frontal lobe strokes can also present as a depression.
History should include collateral information from a close friend or family member, a medication review and functional assessment*1. As well as a physical exam, cognitive screening*2 should also be done*3. Bloodwork could include a TSH, Vitamin B12, CBC, electrolytes, BUN, creatinine, and calcium. CT scan may be indicated by history or physical findings, to rule out frontal lobe pathology.
Antidepressants are likely no more effective than placebo in mild depression, (4) but are better than placebo for patients suffering from moderate to severe depressions. (5) All antidepressants are likely equally efficacious, but their side effect profiles differ. (6) They are likely no less effective in treating the elderly than younger patients, but reaching therapeutic dosage may be difficult because of other co-morbidities. For the elderly, a longer duration of therapy or switching regimens because of tolerability may be necessary.
Start low, go slow, and warn about potential side effects. Monitor medication compliance, and suicidal ideation. Consider limiting drug availability, especially if the patient is confused, or there is a risk of suicide. Tricyclic antidepressants are to be avoided because of side effects. Treat for 9-12 months after finding an effective drug, perhaps indefinitely if this episode represents a recurrent or severe depression. Abrupt withdrawal of an SSRI can lead to increased anxiety, irritability, dizziness and nausea.
Treatment options include serotonin reuptake inhibitors, such as citalopram, 20-30 mg/day, or escitalopram, 10-20 mg/day. Main side effects include hyponatremia, anxiety, insomnia, GI upset, and QT prolongation. The serotonin-noradrenergic reuptake inhibitor venlafaxine 75-225 mg/day in divided doses can cause the same side effects as the SSRI’s as well as hypertension, tachycardia and urinary retention. Mirtazapine 15-30 mg at hs can be useful for treating symptoms of insomnia and anxiety, and can also lead to weight gain.
It is important to recommend non-pharmacologic treatment modalities such as homemakers, nutritional assistance or supplements, exercise, caregiver support and counselling, and possibly a move to housing with increased assistance.
Cognitive Behavioural Therapy appears to be more effective than “usual care” in elderly patients with mild to moderate depression, but does not seem to add to the effectiveness of antidepressant therapy. (7)
Electroconvulsive therapy may be necessary for patients who are too fragile to wait the 2-3 months it may take for antidepressants to work, or are unable to tolerate the side effects. It should also be considered for those who are psychotically depressed, and for those for whom ECT was effective in the past. ECT can be done as an outpatient, but most frail elderly require hospitalization. If you feel that your patient may be a candidate, a Psychiatry referral is necessary, usually through the local Older Adult Mental Health Team. A Geriatric Psychiatrist may be more comfortable giving ECT to a frail, medically complex patient.
The benefits of using a neuroleptic along with an antidepressant in elderly patients likely do not outweigh the risks – (extrapyramidal side effects, excess cardiovascular death). It is better to augment therapy with another antidepressant, such as buproprion, or switch agents if not effective.
Patients should be referred to a Psychiatrist if the diagnosis is in question, the depression seems refractory to treatment, or the patient is at risk to harm themselves or others.
*1. Functional screening: The formal scales most commonly used is the Katz index of Activities of Daily Living Scale, and the Lawson Index of Instrumental Activities of Daily Living Scale. Dr. John Sloan, a family physician with special interest in care of the elderly has popularized “DEATH” (dressing, eating, ambulating, toileting and hygiene) and “SHAFT” (shopping, housework, accounting, food preparation and transportation). I would add “ability to manage medications” under the “a”. I will usually ask whether or not the patient has difficulty with bathing, as it is the most difficult ADL. If there are difficulties, I will ask about the other ADL’s. I will also ask if there is anyone assisting them with house hold chores. Collateral information is important to verify what is reported by the patient, as they may forget, confabulate, or deliberately exaggerate their capabilities out of embarrassment, or for fear of consequences.
*2. Cognitive Screening: the Folstein Minimental Status exam and the Montreal Cognitive Assessment exam are quick, easily reproducible screens for cognitive impairment. The MOCA is more useful for detecting Minimal Cognitive Impairment, or problems with frontal/executive function. Another quick screen is the clock drawing test (you get the patient to draw a clock, putting the numbers on correctly, and putting the hands of the clock to say “10 after 11”).
*3. Screening for depression can be done easily with the Geriatric Depression Scale, Short Form, which includes 15 yes or no questions. A score of greater than 5 points is suggestive of a major depression. The Patient Health Questionnaire-9 (PHQ 9) is also a self administered questionnaire that can be used to screen for depression. Both are quick to do in an office setting, and appear to be equivalent as screening tools. (8)
References (Note: Article requests might require a login ID with CPSBC or UBC)
2. Hoen PW et al. Differential associations between specific depressive symptoms and cardiovascular prognosis in patients with stable coronary heart disease. J Am Coll Cardiol Sept 7 2010; 56: 838 (View article, or view with UBC)
5. Fournier JC Antidepressant drug effect and depression severity: a patient level meta-analysis JAMA Jan 6 2010; 303 (1) : 47-53 (View article)