Depression in the elderly

Refers to late life depression with a major depressive disorder in adults 60 years of age or older.

Major depressive disorder occurs in up to 5% of older adults residing in the community.

Major depressive disorder rates increase with increasing medical morbidity, with rates of 5-10% in primary care, and is as high as 37% after critical care hospitalization.

As compared with older adults reporting initial depression early in life, those with late-onset depression are more likely to have neurologic abnormalities and age related changes or neuro imaging that are greater than normal, and there is also a higher risk for dementia.

Low mood may be less common in older adults with depression than in younger adults with major depressive disorder, whereas irritability, anxiety, and somatic symptoms may be more common.

Psychosocial stressors may trigger depressive episodes.

Comorbidities complicate the management of depression and this is more common with increasing age, along with the concomitant medication use.

Medical problems such as chronic pain may increase the risk for depression, and depression is associated with worse outcomes for medical conditions.

Polypharmacy associated with aging and age related decline in drug metabolism are associated with increased rates of antidepressant medication side effects.

Depression in older adults is associated with increased risk for suicide.

Screening for depression in elderly is warranted.

The presence of coexisting cognitive impairment is common in late-life depression and can involve impaired executive function, attention, and memory.

Depression is a risk factor for and a manifestation of cognitive decline.

Depression is associated with an increased long-term risk of dementia.

Cognitive deficits is related to a predisposition to, and perpetuates depression.

First line therapy includes either pharmacotherapy or psychotherapy.

Anti-depressants show efficacy in older populations, but these patients may be at increased risk for medication side effects.

Selective serotonin-reuptake inhibitors are considered the first line pharmacotherapy.

Rates of SSRI response ranges from 35-60% compared with placebo with response rates of 26 -40%.

Serotonin-norepinephrine reuptake inhibitors are commonly second line agents.

Tricyclic antidepressants have efficacy rates that are similar to SSRIs but are less commonly used due to the greater side effects in the elderly.

Bupropion has a response rate of 71% in treating late-onset depression.

Martazapine response rate in patients with late-life depression is 47%.

The addition of aripiprazole to antidepressants results in 50% response rate in resistant depression.

Maintenance antidepressants significantly benefit elderly patients with depression after remission.

Psychotherapies are affective treatments, and may be considered a first line therapy choice in late-life depression.

Problem-solving therapy and interpersonal therapy results in greater improvement in depression than usual care.

Electroconvulsive therapy is most effective for severely depressed individuals, including the elderly.

Electroconvulsive therapy is considered if patients are suicidal, have had a poor response to anti-depressants pharmacotherapy, have a deteriorating physical condition or have depression related disability threatening their ability to live independently.

Remission rates for electroconvulsive therapy in the elderly range from 30-90%.

Transcranial magnetic stimulation uses a focal electromagnetic field generated by a coil held over the scalp is positioned over the left prefrontal cortex is a newer treatment for depression.

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