This document discusses depression in seniors. It provides information on risk factors for depression in seniors like chronic illness, bereavement, and cognitive impairment. Signs and symptoms of depression in seniors are discussed, as well as challenges in diagnosis since seniors may not report feelings of depression. Treatment options covered include antidepressant medication, psychotherapy, and electroconvulsive therapy for more severe cases. The need for careful treatment and monitoring given risks of side effects and interactions is also summarized.

1. Paula Bordelon, DO

2. Dr. Bordelon has no disclosures.

3. Increased knowledge of comorbidities
and risk factors associated with
depression in seniors
Ability to recognize signs and
symptoms of depression in seniors
Review of USPSTF recommendation as
it relates to screening adults for
depression

4. 15% of people age 65 and older suffer from
depression
Present in 25% of those with chronic illness
(e.g. CHF, DM)
Increased risk of mortality
Costly, with direct and indirect costs totaling
$43 billion/year
 Geriatric Mental Health Foundation; http://www.gmhfonline.org/gmhf/consumer/factsheets/depression_; last accessed 09/19/14

5. With less than 4000 geropsychiatrists in
U.S., primary care physicians treat
75% depressed elderly present to PCP, not
psychiatrists
Increases functional decline
Decreases quality of life
Increased mortality
Extreme burden on family and caregivers

6. Prior personal hx depression
Female
Increased stressors (e.g. moved to
assisted living)
Lower socioeconomic
Cognitive Impairment
Substance Use (e.g. alcohol)
Bereavement

7. Depression lasting > 2 years considered
chronic & has poor prognosis
Depressive symptoms or minor depression
Community 8-15%
Long-term care 30-50%
In-patient (OABH) 60-70%
Major Depression
Community 1 yr prev 2.7%
Primary Care 5.6%
Long-term care 6-25%

8. Must have depressed mood or
anhedonia (without mania or
hypomania or substance use or
another medical condition)
PLUS:
4 other “SIGECAPS”
Present at least 2 weeks
Cause significant distress
Seniors are not always aware of
their emotional feelings. May not
relay “depression”
 SIG E CAPS
 Sleep d/o
 Interest
 Guilt
 Energy
 Concentration
 Appetite/weight
 Psychomotor
agitation or
retardation
 Suicidal ideation

9. Experience anhedonia or depressive mood for at
least 2 years (think of it as long-lasting and not
lifting)
Plus at least 2 symptoms (not lifting > 2 mths):
Poor appetite or overeating
Insomnia or hypersomnia
Low energy
Low self-esteem
Poor concentration
Hopelessness

10. Rare in seniors to have its initial onset in
late life
Dysthymia frequently persists from midlife
to late life
Do not give this dx if senior ever met
criteria for bipolar D/O or cyclothymic D/O

11. Less frequent than nonpsychotic depression
when considering all age groups
Psychotic depression much more common in
elderly
Approximately 20 to 45% hospitalized
depressed seniors suffer from psychotic
depression
Symptoms associated with such include
hallucinations or delusions

12. Antidepressants alone not enough
Warrants antidepressant and
antipsychotic or
ECT
considered first-line
Effective in treatment resistant
patients

13. Symptom Description
Depressed mood or anhedonia Senior won’t state “I am depressed” but
exhibits loss of interest or anxiety
Guilt, low self-esteem, or worthlessness Not common in seniors
Somatic Complaints At risk of delayed diagnosis or
misdiagnosed
Psychomotor changes Elderly more likely to exhibit
Insomnia or hypersomnia Hypersomnia much more common in
younger adults
Weight loss, anorexia Very common for seniors
Suicidal ideation Elderly make fewer attempts; more
likely to be successful

14. 68 year-old retired nurse with no past psychiatric or
substance abuse reports a 4-week hx of hearing the
voice of her recently deceased husband telling her
that he misses her. Her husband suffered an MI while
the extended family was on a cruise celebrating their
40th wedding anniversary. The auditory hallucinations
occur at night. Ruth feels guilty, because as a RN, she
believes she should have “seen this coming.” She
reports being “down,” poor appetite and has lost 4
pounds over 45 days, difficulty concentrating
resulting in errors at work, insomnia, and fatigue.

15. Bereavement leads to adverse mental and
physical outcomes
Associated increased mortality in the
surviving conjugal partner when compared to
married persons of the same age
Highest relative risk of mortality occurred 7 –
12 months after spousal loss

16. Also associated with anxiety, substance use,
suicide
Symptoms seen:
Marked functional impairment
Morbid preoccupation with worthlessness
Psychotic symptoms
Psychomotor retardation
Psychosis
 Rosenzweig AS, Pasternak R, et al. Bereavement-Related Depression in the Elderly. Is Drug Treatment
Justified? Drug & Aging. 1996 May; 8 (5): 323-326.

17. Functional decline
Increased use of non-mental health services1
Increased medical mortality rate in those mood d/o
Overall2: > 4x rate of death over 15 months
Cardiac3: 4x rate of death within 4 mos after MI
1. Beekman et al. Psychol Med 19997;27:1397-1409. 2. Bruce and Leaf. Am J Public Health.
1989;79:727-730. 3. Romanelli e al. J Am Geriatr Soc 2002;50:817-822.

18. Is a state of chronic stress
Risk factor for developing:
diabetes,
cognitive impairment,
coronary disease (“CAD”)
osteoporosis

19. Depression activates Hypothalamic
Pituitary Axis (HPA)
Increased levels of cortisol
Greater in those hospitalized vs outpatient
No differences between sexes
HPA hyperactivity varies but does increase
risk of diseases, including diabetes by
increasing FBS and insulin levels
 Stetler C, Miller GE. Depression and hypothalamic-pituitary adrenal activation: a quantitative
summary of four decades of research. Psychosom Med. 2011. Feb-Mar; 73(2): 14-26.

20. Depression is independent risk factor for CAD
At increased risk subclinical atherosclerosis
Hospitalized depressed patients are at
increased risk
of having a myocardial infarction (“MI”)
Death from MI
Individuals suffering MI & depression are at
increased risk of another cardiac event

21. Neurodegeneration leads to depression
Determine if it is dementia syndrome of
depression or depression causing
cognitive inabilities

22. Seniors represent 13% of the U.S. population but
18% of suicides
U.S. suicide rate 12.3/100,000 overall in 2011;
Age 85+: 16.9/100,000 (41% higher)
Among depressed elderly seen by PCP during a 12
mth period, < 10% received tx for depression before
attempted suicide or suicide
70% of suicides occur within 1 month of a visit to
PCP
 American Foundation for Prevention of Suicide: New Data Issued by CDC Releases 2011
Suicide Statistics.

23. Seniors have higher ratio of suicide
completions to attempts
Higher rates of double suicides
Higher use of firearms in seniors as
means to end life

24. White male
Bereavement (e.g. Widow or Widower)
Terminal or chronic illness, including
perceived ill health
Poor sleep
Psychiatric Disorder
Social isolation
Hx prior suicide attempt(s)

25. Less frequent in seniors
Symptoms are not typically classic (i.e.
hyperactivity, decreased sleep, flight of
ideas, grandiose delusions, hypersexual)
Several “unusual” presentations when we
think of what we learned in medical
school
Syndrome of reversible cognitive
impairment which is confused with
Alzheimer’s is seen

26. Take a psychiatric history
Speak to informant (esp. if depressed male)
Get past history (i.e. Is this the first episode
of depression?)
Suicide attempt hx
If prior hx of depression, obtain previous tx
successes and failures
ASK ABOUT SUBSTANCE ABUSE!
ASK ABOUT FIREARMS!
Investigate if hallucinations
Never assume patient is compliant with
therapy

27. In fellowship, taught to use an objective
depression scale (there are quite a few Center
for Epidemiologic Studies-Depression Scale) is
quantitative so can trend it
Review PHQ-9, GDS, Cornell

28. Have high degree of sensitivity and specificity
USPSTF states sufficiency in “asking 2 simple
questions:
1. Over the past 2 weeks, have you felt
down, depressed, or hopeless?
2. Over the past 2 weeks, have you felt
little interst in doing things?”

29. Recommends screening adults for depression
when staff-assisted depression care supports are
in place to assure accurate diagnosis, treatment,
and followup (Grade B
recommendation)
There may be considerations supporting screening
for depression in an individual patient
(Grade C recommendation)
Positive screen should trigger full diagnostic
interview and examination

30. Cornell Scale for Depression in Dementia –
caretaker or family member rates severity of
symptoms:
mood-related signs
Behavioral disturbances
Physical signs
Cyclic functions
Ideational disturbances
Geriatric Depression Scale – patient answers
subjective questions and validated in many studies
Looks at attitudes and cognition
Less focus on vegetative symptoms

31. Depression is a prodrome
Again: depression is linked to cognitive
impairment, especially if first episode of
depression ever
Depression leads to disturbance in
executive function; can have
“pseudodementia”
Use MMSE or Montreal Cognitive
assessment (MOCA)

32. Take a Medical History
Medication side-effects
Drug or alcohol abuse
Infection
Endocrinopathy (e.g. hypothyroidism)
Malignancy
Nutritional disorders
Sleep disorders (don’t miss sleep apnea)

33. Acyclovir
ACE-I
B Blocker
CCB
Corticosteroids
Digoxin
H2-receptor blockers
Interferon alpha
L-dopa
Methyldopa and clonidine
 Patten SB, Love EJ. Can Drugs Cause Depression: A review of the evidence. J Psychiatr
Neurosci. Vol 18. No. 3. 1993.

34. Study
MRI
Sleep Study (sleep apnea/MCI/Malaise)
UA C&S
Chemistry
LFTs
Thyroid Fxn Tests
Bun/Cr, GFR
FBS
Vitamin B-12 and folate

35. Antidepressant medications are the
foundation for treatment of moderate and
severe late life depression
When considering an antidepressant, is
based on
Efficacy
Side effects
Drug interactions
Cost

36. Diagnosis Treatment/therapy
Nonpsychotic MDD SSRI (SNRI) or venlafaxine XR +
psychotherapy
Psychotic MDD SSRI (SNRI) or venlafaxine XR +
Atypical Antipsychotic OR
ECT
Dysthymia SSRI (SNRI) + psychotherapy + tx
concurrent medical conditions
MDD + insomnia Sedating antidepressant
Expert Consensus Guideline Series: Pharmacotherapy of Depressive Disorders in Older
Patients. Postgrad. Med Sp Report 2001 (Oct.): 1-86. PMID: 17205639

37. FDA-indicated antidepressants are effective in
treating late-life depression; don’t choose “off label”
medication if unnecessary
Response rate (defined as 50% decrease in symptoms)
Remission rate (defined as > 90% symptom decrease)
Typically only achieved in 30 -40% with medication
versus 15% for placebo
NNT for remission (drug vs placebo): 4

38. Avoid TCAs in seniors unless refractory depression
because of side effects
Discontinuation 2d to SE is frequent in tx studies
TCA 24%
SSRI 17%
Side effect TCA (%) SSRI (%)
Dry mouth 28 7
N/V 7.5 17
Drowsiness 15.3 6.5
Vertigo 12.2 7.8
Sleep disturbance 4 2.6

39. SIADH – most likely as result of SSRI
Easy bruising – SSRIs reduce platelet
aggregation
GI bleed -
Bowel Dysfunction (i.e. constipation)
Weight Gain (e.g. with TCAs)
Decreased libido (not unique to elderly)

40. Polypharmacy: avg adult > age 65 is on 5 or more
medications
Age exacerbates potential for side effects
Renal elimination of drugs decreases
Hepatic inactivation of drugs decreases
Anticholinergic vunerability increases

41. Careful treatment initiation can reduce side
effects and PREMATURE withdrawal! Dosing
initiation rule: ½ adult dose
Start low and go slow
Treatment takes more time:
Acute treatment: 8 weeks
Increase dose: after 6 weeks
Remission: Months
Continuation: 6-12 Months
Maintenance: 1-5 years vs lifetime

42. Even with maintenance, there is a high
recurrence rate
Maintenance pharmacotherapy reduces
recurrence risk (Maintenance means beyond 12
months)
Slower initial responders may do better with
combined therapy in maintenance 1
1. Dew et al. J Affect Disord 2001;65:155-166

43. Psychotherapy is under-prescribed (avoid
in the demented because of lack of
efficacy)
Effective for non-psychotic MDD and in
dysthymia
Several approaches are evidence-based
Cognitive Behavior Therapy (CBT)
Problem Solving Therapy (PST)
Interpersonal Therapy (IPT)

44. Adequacy of treatment
Duration of treatment
Dosage of medication
Solo therapy versus dual therapy
Behavioral factors
Personality disorder
Psychosocial stressors
Compliance
Education provided
Diagnosis
Missed medical conditions

45. Nonadherence (33-81%) facilitated by:
Preference for different treatment (e.g. no
medications)
Complexity of medication regimen
Cost (e.g. too expensive so skip doses)
Side effects (e.g. too severe)
Cognitive impairment (i.e. noncompliance)
Patterns: underuse, overuse, altered use

46. Recognition and treatment is poor-missed in 50% of
the ambulatory population
Among those treated, treated “inappropriately”:
Inappropriate use of medications
Too low doses for fear of side effects
Too short duration
Inadequate followup (don’t see often enough)

47. Delusional depression is more prevalent in older
depressives vs younger depressives
Associated with:
Hypochondriasis
Delusional relapses
Worse response to monotherapy
Longer hospitalizations
Higher relapse rates

48. Optimize current therapy
Switch therapy to new agent
Augment with additional medication or co-prescribe
ECT

49. Slower
Simpler, less costly
Avoids drug-drug
interaction
Reduces SE
Introduce “different
mechanism”
Augmentation
Quicker
More complex, costly
Risks drug-drug
interaction
Can increase SE
Avoids loss of earlier
partial response

50. Venlafaxine when ANXIETY is prominent
Bupropion when APATHY is prominent
Mirtazapine when INSOMNIA/ANXIETY are
prominent
Aripiprazole is atypical antipsychotic
approved for major depressive disorder and
bipolar disorder

51. Challenging in treating depressed older adults who
have not responded to multiple trials of
antidepressant medications
Elderly with psychotic symptoms who failed
antidepressant therapy often do respond to ECT
Some studies suggest that ECT is in fact the
SUPERIOR treatment in late life compared to midlife

52. Underused!
Some indications:
Antidepressant intolerance and/or
nonresponse
Prior positive response to ECT
Psychosis
Catatonia
Mania
Profound weight loss

53. Relative contraindications:
Cardiac: Recent MI, unstable angina,
uncompensated CHF, arrhythmias, severe
valvular disease
Neurologic: intracranial lesions “increase”
risk, recent CVA

54. Major concern of patients (transient retrograde
amnesia)
ECT may improve depression-impaired cognition
but exacerbate impaired cognition of dementia
Preparation:
Education
Pre-screen to establish baseline
Monitor memory throughout treatment
Decrease treatment frequency when
pronounced

55. The diagnosis of late-life depression is as valid as
any other significant medical disorder.
MDD in seniors is associated with psychiatric and
medical morbidity, increased utilization of health
care, and increased mortality.
Late-life depression is treatable but may be
refractory to a single intervention.
Late-life depression often coexists with cognitive
impairment.