Geriatric Depression is major concern for modern terms

1. Geriatric
Depression
DR.PARAG DEY
MBBS, BCS,
MD (PSYCHIATRY),
CHATTOGRAM MEDICAL
COLLEGE & HOSPITAL

2. Who?
No set age to define
≥65 years of age is often used

3. Geriatric Depression:
A persistent mental health issue occurring in older adults that
involves a persistent loss of interest and feelings of
sadness that can interfere with normal function.

4. Types:
•Major Depressive Disorder – includes symptoms lasting at least two
weeks that interfere with a person’s ability to perform daily tasks
•Persistent Depressive Disorder (Dysthymia) – a depressed mood that
lasts more than two years, but the person may still be able to perform
daily tasks, unlike someone with Major Depressive Disorder

5. Types:
•Substance/Medication-Induced Depressive Disorder – depression related to
the use of substances, like alcohol or pain medication
•Depressive Disorder Due to A Medical Condition – depression related to a
separate illness, like heart disease or multiple sclerosis.

6. Epidemiology:
According to WHO :
About 280 million
 aged 65 and over 18.4%
Annals of General Psychiatry :
aged 65 and over 31.7%
Over a third of older populations 
depression
In Bangladesh 
 In total population Depression- 6.7%
 Suicide --10-20%
 Geriatric Depression --7.9%

7. Etiology :
Genetic Personality Environment
Family
History
Psychological Biological

8. Causes:
Genetic
Neuro-progression
Neuroinflammation
Stressful life events
Chronic pain and disability
Long-term use of medications: Antihypertensive, Antipsychotics,
Anticonvulsants, corticosteroids
Physical illness: Thyroid disorders, Heart disease, Cancer, Stroke,
Dementia (such as Alzheimer’s disease), Parkinson’s disease

9. Neuroprogression :

11. Neuroinflammation:

13. Symptoms:
•Feel tired
•Have trouble sleeping
•Grumpy or irritable or crying
•Loss of concentration
•Feel confused
•Memory problems
•Somatic complaints: persistent, vague
unexplained physical symptoms like
enduring aches and pains

14. Symptoms:
•Move more slowly
•Not enjoying things used to
•Have a change in weight or appetite
•Feel hopeless, worthless, or guilty
•Have suicidal thoughts
•High degree of suspicion.

15. Geriatric Depression vs Early-onset Depression
Geriatric depression :
 more cognitive impairment
 higher rate of insomnia
 somatic symptoms
 poor insight & and more
associated with psychotic features
 more weight loss and diurnal
variation of mood ( patient might be
irritable all day but cry at night )
 linked with medical comorbidities
Early onset depression :
 cognitive impairment may be
episodic
 more anxiety symptoms
 hopelessness about future
 more chance of suicide
 feeling of guilt
 loss of sexual function
 weight gain or weight loss

16. Risk factors of
Geriatric
depression:
Previous history of depressive disorder
Previous history of anxiety disorder
Female
Recent or previous history of traumatic
life event
Isolation
Chronic disability
Lack of social support
Alcohol consumption
Smoking
Low educational status
Financial insecurity

17. Comorbid physical illness :
- Cardiovascular:
- Neurological: Stroke, Dementia, Parkinson’s disease,
Multiple sclerosis, Tumor
- Endocrine: DM , Hypothyroidism, Cushing syndrome
- Carcinoma
- Hematological
- Hearing loss
- Autoimmune diseases
Chronic use of medications: central alpha-blockers,
Ca channel blockers, opioid, Benzodiazepines,
anticonvulsants, antipsychotics, anticholinergics,
corticosteroids, interferons.

18. Why early
detection
??
Many physical problems are
associated with depression
Vulnerable to serious
consequences from self-neglect
Prevent early immobility
To overcome treatment failure
Prevent Suicide ( almost 20%)
Increase average life expectancy
Increase productivity
Preventing neuroprogression
and neuroinflammation.

19. Dementia and Depression :

20. Previous history of MDD: 2-fold increased risk for dementia
MDD > later life > prodromal sign AD
Dementia ---50%---Depression
Dementia + Depression -more cognitive decline
Long-term antidepressant treatment -lower risk of dementia,
improved cognition, slower rate of elderly dementia

21. Geriatric depression might be
misdiagnosed with:
Generalized Anxiety Disorder
Adjustment Disorder
Dementia
Personality Disorder
Thyroid Disorder
Underlying Malignancy
Bereavement
Adverse drug effect

22. • Management :
Biopsychosocial Approach by –
Proper history taking
Physical examination
Investigations
 Pharmacological management
 Non-pharmacological management
Physical treatment

23. Pharmacological management:
According to Maudsley Prescribing Guideline –
SSRI –
Escitalopram (SD: 5mg , MD : 10mg )
Sertraline ( SD : 25-50mg , MD : 100-150mg )
Fluoxetine ( SD : 20 mg , MD : 40-60mg )
Citalopram ( SD:20 mg , MD: 40 mg)
SNRI – Venlafaxine ( SD : 37.5 mg , MD : 150 mg)
Duloxetine ( SD : 30 mg, MD: 120 mg )

24. MASSA : Agomelatine ( SD : 25mg , MD : 50 mg )
TCA : - Clomipramine ( SD ; 10mg , MD : 75 mg )
- Lofepramine ( SD : 35 mg , MD : 140 mg )
NASSA : Mirtazapine ( SD : 7.5 mg , MD : 45 mg )
SARI: Trazodone ( SD: 100mg , MD: 300 mg or 150 mg divided dose )
For multimodal action : Vortioxetin ( SD : 5-10 mg ,MD : 20mg)

25. NICE Guideline :
Choice of treatment based on :
•The severity of the problem
•Past experiences of treatment
•Person’s preference
 1st line: SSRI
Depression with personality disorder:
Both Antidepressants & CBT, IPT
(try to extend treatment up to≥ 1 year )
 Psychotic depression:
antidepressant + antipsychotic
 Chronic depression: SSRIs, SNRIs, TCAs
 If no response: consider TCAs, moclobemide, MAOIs, low-dose amisulpride

26. According to BAP Guideline –
1st line : Escitalopram
Sertraline
Fluoxetine
2nd line : Nortriptyline
Duloxetine
Agomelatine

27. Why SSRIs is superior ??
Well tolerated
because of less
adverse drug
reactions
No weight gain No sedation
No effect on QT
prolongation
(except
citalopram )
No cognitive
impairment
Less
antiadrenergic
effects
Less
anticholinergic
effects
Relatively easy
to give an
effective dose

28. Possible adverse effects of SSRIs:
GIT disturbance
Sexual dysfunction
Initial Anxiety
Insomnia
Headache
Dizziness
Tremor
Hyponatraemia

29. When to avoid SSRI :
Hyponatremia
Hemorrhagic
stroke
Patients using
warfarin, NSAIDS,
and other oral
anti-coagulant
Peptic ulcer
Patient with
alcohol misuse and
smoking
History of major
bleeding

30. Alternative of SSRIs :
Agomelatine Mirtazapine Trazodone

31. Psychotic depression :
Psychotic Depression is a serious form of depression
 1st Line: TCAs (with caution )
 2nd Line: If TCA is poorly tolerated or has
contraindications give SSRIs (sertraline ) or SNRIs
 Augmentation : Olanzapine or Quetiapine
 ECT can be helpful

32. Comorbid medical conditions and geriatric depression:
•Post Stroke depression:
Depression itself is a risk factor for stroke. In
addition, depression is seen in 30-40% of stroke
survivors.
 Recommended drugs: SSRI or Nortriptyline (but
caution is needed)
•Parkinson ‘s Disease: SSRIs

33. •Ischemic heart disease: SSRI or Mirtazapine
Post MI: Sertraline
avoid TCA
•Antidepressant induced hyponatremia:
Stop SSRI
Switch to Agomelatine, Mirtazapine,
Trazodone
•Diabetes Mellitus: SSRI – escitalopram,
sertraline, fluoxetine
Agomelatine can also be an alternative

34. •Dementia:
-SSRI ( but can worsen some symptoms of
Parkinson’s disease like restless leg syndrome, periodic
limb movements, and rem sleep behavior disorders)
- Trazodone can be helpful ( by blocking
serotonin 2A, 2C, H1, alpha 1)
also improves sleep and behavioral symptoms
-Vortioxetine: has precognitive effects and can
be used for treatment-resistant depression.

35. Physical treatment :
ECT :
Severe depression with refusal of food and medications
Suicidal ideation
Psychotic Depression

36. Non-pharmacological management :
oCBT
oInterpersonal psychotherapy
oMindfulness
oProblem-solving counseling
oRelaxation therapy
oSocial support and psychoeducation of carer
oPromoting sleep hygiene , exercise and physical activities
oEating a well-balanced diet

37. Why is it difficult to
treat dementia and
GD together :

38.  Follow up :
Assess efficacy  2 weeks
If no response  assess further 1-2 weeks
If no response switch
Continue  6-9 months
High relapse rate  2 years
Maintenance treatment  Recurrent episodes  ≥ 2 years
Discontinuation  Tapper dose gradually
Ensure remission
Process takes- 3 months to 2 years

39. Take home messages :
SSRIs are 1st line for GD
Elderly dementia can be delayed by treating depression
For treatment response early detection of GD
Early detection can protect against neuro progression and
neuroinflammation

40. References :
https://annals-general-psychiatry.biomedcentral.com
https://www.who.int/news-room/fact-sheets/detail/depression
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10387770/
https://www.healthline.com/health/depression/elderly
https://www.frontiersin.org/articles/10.3389/fpubh.2023.1180446/full
https://pubmed.ncbi.nlm.nih.gov/36822724/#
BAP guideline for depressive disorders
The Maudsley prescribing guideline
Stahl’s essential psychopharmacology
Shorter Oxford Textbook of Psychiatry

41. Thank YOU