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Depression in the Elderly: Risk Factors, Diagnosis and Treatment

Research Article Open Access
Gulistan Bahat1*, Timur Selcuk Akpinar2, Fatih Tufan1, Sibel Akin1, Asli Tufan1, Nilgun Erten2 and Mehmet Akif Karan3
1Fellow, Department of Internal Medicine, Division of Geriatrics, Istanbul Medical School, Istanbul University, Capa, 34390, Istanbul, Turkey
2Professor, Department of Internal Medicine, Istanbul Medical School, Istanbul University, Capa, 34390, Istanbul, Turkey
3Professor, Department of Internal Medicine, Division of Geriatrics, Istanbul Medical School, Istanbul University, Capa, 34390, Istanbul, Turkey
*Corresponding authors: Gulistan Bahat
Istanbul University, Istanbul Medical School
Department of Internal Medicine
Capa, 34390, Istanbul, Turkey
Tel: + 90 212 414 20 00-33204
Fax: + 90 212 532 42 08
E-mail: gbahatozturk@yahoo.com
 
Received March 21, 2012; Published July 28, 2012
 
Citation: Bahat G, Akpinar TS, Tufan F, Akin S, Tufan A, et al. (2012) Depression in the Elderly: Risk Factors, Diagnosis and Treatment. 1: 215. doi:10.4172/scientificreports.215
 
Copyright: © 2012 Bahat G, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
 
Abstract
 
The diagnosis and treatment of the elderly depression is the responsibility of the primary care physician. Major depression frequency is less than the younger counterparts but depressive symptoms as a whole are more prevalent. These type of depressions- named as “subsyndromal depression” or “minor depression” also affect the quality of life as much as the major depression. Screening can be performed by “two question” test or “geriatric depression scale”. When suspected for depression via these tests, further inquiry should be performed according to DSM (Diagnostic-Statistical Manual)-IV. The first choice in the medical treatment is selective serotonin reuptake inhibitors (SSRI). Citalopram, escitalopram and sertraline are especially preferred due to their low drug-drug interaction. Selective serotonin noradrenaline reuptake inhibitors (SSNRI) can be preferred due to their high anxiolytic and antidepressant effects in anxiety dominant and/or resistant depression. They may also be preferred in depression associated with pain complaint. Mirtazapine stands out with its sleep and appetite increasing effect. In cases of drug side effects limiting the use of antidepressant drugs, resistant depression and when depression presents with lifethreatening complications as severe weight loss or catatonia, electroconvulsive treatment can be used. The drugs should be started at half-dosage but increased to the “effective” dosage with close clinical follow-up. Response to the antidepressant treatment may appear in a longer period than the younger counterparts. If there is lack of response to antidepressant drugs, the dose should be increased in the therapeutic range or switched to another drug. In resistant depression, depression with suicide risk, psychotic symptoms, and in bipolar disorder, the patients should be referred to centers with geriatric psychiatry experience. In treatment responsive patients, the treatment should be continued for at least 6 months at the dose in which response was achieved. In depressions with high recurrence risk, maintenance treatment should be completed to 1 year. When it is time to stop the medication, SSRIs and SNRIs should be gradually tapered due to the risk of “discontinuation syndrome”. In frequent recurrent depression and resistant depression, treatment for 2-3 years or life-long treatment should be considered. Therefore, the depression in the elderly should be considered as a chronic condition like hypertension or diabetes mellitus, its acute and maintenance treatments should be planned accordingly and it should be followed for a long period of time.
 
Keywords
 
Elderly; Depression; Diagnosis; Risk; Treatment; SSRI; SNRI
 
The elderly become more predisposed to various diseases and symptoms due to the decrease in their physiologic spare capacities as a result of physiologic changes related to aging, to pathologies relating to numerous diseases of which frequencies increase as a result of aging, and to the use of multiple medicines which is common among elderly. In this article, depression which is one of these diseases will be handled, and depression frequency, risk factors, diagnosis and treatment options in the elderly will be examined.
 
Depression is found in approximately 10-15% of elderly population and approximately 25% of the elderly living in nursing home [1]. Although major depression frequency in elderly is less than the younger counterparts, as a whole, depressive symptoms are distinctively more than the group of young people. It is known that such depressions that are generally known as subsendromal depression or minor depression do also affect life quality negatively [2,3].
 
One of the reasons for higher frequency of depression in elderly is that risk factors for depression are more common during advanced ages. Depression risk factors especially seen in elderly people are death of spouse, lack of supporting social environment, loneliness, retirement, loss of occupation-work, loss of abilities, stressful life events, hypertension, cerebrovascular event, myocardium infract, demans, diabetes, atrial fibrillation, chronic diseases such as Parkinson’s disease, cancer, chronic pain, and use of medicines whose adverse effects may be depression (steroids, interferon, benzodiazepines, narcotics, reserpine, beta blockers, methyl dopa, L-dopa, etc.) [4-6]. The other risk factors include being female, a history of depression anamnesis, and depression in the family. On the other hand, the changes occurring in central nervous system during normal aging period (decrease in serotonin, noradrenalin, dopamine and metabolites, increase in monoamine oxidase-B enzyme activity, etc.) are similar to those in depression and make it easier to experience depression.
 
Depression causes an increase in “loss of ability” and “mortality” in all age groups and worsens prognosis of the accompanying medical diseases. Depression cause loss of ability and function more than the diseases such as diabetes and hypertension. It was shown that mortality increases in patients experiencing depression after myocardium infarct and palsy, and that 1-year mortality of geriatric patients in whom depression is detected at the time of accepting to nursing home is higher [7-9].
 
Diagnosis
 
Diagnosis and treatment of depression in elderly is the duty of primary health care doctors. All doctors who encounter an geriatric patient and take over his/her treatment in any way are expected to have knowledge about diagnosis and treatment of geriatric depression. However, although geriatric depression is common, it is not sufficiently known as is stated above. Insufficient recognition of geriatric depression is related to the attitudes of elderly, patient companions and doctors and clinical features of the geriatric depression. As is seen in other geriatric problems, the depressive symptoms such as anhedonia, loss of interest-desire are sometimes accepted as a natural result of aging by the patient himself/herself, patient companions and the related doctors; and so, quest for resolution does not become a current issue. Sometimes, depression is recognized by the patient and his/her companion but it is not considered to apply to a doctor as it is thought that depression cannot be treated. Another reason for insufficient diagnosis of depression is that the doctors of other branches do not feel themselves responsible to question depressive symptomatology in the existence of other numerous geriatric symptoms. However, the groups such as ACOVE (Assessing Care of Vulnerable Elderly) and USPSTF (United States Preventive Services Task Force) which are preparing guidelines for diagnosis and treatment of morbidities in elderly people recommend depression scanning in all adults. Scanning of geriatric depression can simply be applied using two questions or "Geriatric Depression Scale". When these measures are applied, advanced questioning should be done conforming to DSM (Diagnostic-Statistical Manual)-IV for diagnosis of depression in case of suspecting depression.
 
Another reason for insufficient recognition of depression by doctors is the clinic signs of geriatric depression which are different from those of young people. Because, old people do not talk about depressive symptoms contrary to the young people. Instead of this, somatic signs such as widespread pain, constipation, sleep disorders, appetite disorders and amnesia compose depression signs in geriatric depression. For this reason, some writers title geriatric depression as “hypochondriac depression”. In a study, 50% of elderly people having signs which are thought to be related to physical diseases or use of medicines by internal disease doctors, are diagnosed to experience depression by psychiatrists [10]. So, the doctors dealing with elderly should make examination taking different clinic symptomatology of olds into consideration and consider geriatric depression when organic reasons that may cause the symptoms listed above are excluded. Each patient diagnosed as experiencing depression should be questioned about thought of suicide. Questioning the thought of suicide does not facilitate suicide attempt by bringing suicide into the mind; on the contrary, it will be a malpractice not to ask any question about it. It should be remembered that the risk of suicide resulting in death is higher in elderly than young people; it is especially the highest in males aged over 85.
 
At the stage of diagnosis of geriatric depression, in order to determine secondary factors and accompanying co morbidities if any, it is convenient to request for blood count, serum glucose, creatinine levels, thyroid function, vitamin B12 and folate levels, liver function tests and electrocardiography [11].
 
Difficulties in diagnosis of geriatric depression are unfortunately accompanied by lower treatment rate. This rate is very low for a disease that may result in serious consequences.
 
Treatment
 
Treatment of geriatric depression is composed of psychotherapy and medical approach as is for young patients. Psychotherapy is a valid method in treatment of mild and moderate depression; however, it has some limitations about prevalence and application. For this reason, treatment of geriatric depression is generally composed of only medical treatment. Nevertheless, even increasing physical activity performed with a family member or a friend may increase social support simply and effectively, and provide improvements in general well-being [12].
 
The first option in medical treatment is Selective Serotonin Reuptake Inhibitors (SSRI). They are generally well tolerated, easily usable and reliable medicines even in high doses. In this group, sertraline, citalopram, escitalopram, paroxetine and fluoxetine are the antidepressants which are effective in elderly. Especially citalopram, escitalopram and sertraline citokrom p450 are the prominent medicines as their interaction with medicine system is low. On the other hand, paroxetine may be a reason for choice in some events due to its strong anxiolytic feature, but it should be remembered that it is the agent which has the most anticolinergic effect among SSRs [12]. Fluoxetine has a long half life and inhibits cytochrome p450 system, and so it is not preferred as its adverse effects will continue even after the medicine is discontinued in the event of a possible adverse effect taking possible medicine interaction into consideration [12]. The most frequently seen adverse effects are nausea, insomnia, diarrhea, headache, sexual dysfunction and anxiety. Extrapyramidal system adverse affects (achatisia, tremor, parkinsonism, etc.) and the adverse affects such as inappropriate ADH syndrome are not seen frequently; however, if these affects occur, they limit the use thereof.
 
Another antidepressant group is Selective serotonin noradrenaline re-uptake inhibitors (SNRI) and composed of velafaxine, duloxetine and milnaciprane. Mirtazapine can also be included in this group [11]. Venlafaxine and duloxetine in this group have similar affect and adverse affect profiles. They are preferred for dominant and/or resistant depression due to their strong anxiolytic and antidepressant affects. They have activating features. Due to their analgesic features in the depressions accompanied by pain complaints including neuropathic pain, it is convenient to use them. In addition to nausea, insomnia, also diastolic hypertension is one of the possible important adverse effects. Milnaciprane is an antidepressant medicine that can be used in hepatic impairment events [13]. Mirtazapine steps forward with its appetizing and sleeping feature. As it can be found in solution form, it can be used in the events that cannot tolerate tablets and capsules. Parkinsonism with the depressions which are developing especially with insomnia and/or anorexia is preferred in the events such as essential tremor. Agranulocytosis is its rarely seen adverse affect but it limits its use. It may increase liver enzymes mildly and reversibly.
 
Atypical antidepressant group includes trazodone and bupropion –a selective nonadrenaline and dopamin reuptake inhibitor. Trazodone is not used in geriatric patient in antidepressant doses due to its feature of causing intense sedation and orthostatic hypotension; however, it can be preferred in the depressions continuing with insomnia as an aid to treatment due to its sedative effect. It should be known that its adverse effects are priapism and hyponatremia. Bupropion is generally an effective and a reliable antidepressant which is studied in geriatric patient [14,15]. Its adverse effects include hypertension, convulsions and insomnia. It can be preferred in asleep depressions. As it does not cause sexual dysfunctions, it can be preferred in some events.
 
Tricyclic antidepressants compose the group which should not be used in elderly due to their wide adverse effects profiles. Their adverse effects include the problems which cause serious disorders in geriatric patient such as arrhythmia, orthostatic hypotension, sedation, falls, and regression in cognitive functions, delirium, narrow angled glaucoma, urinary retention, dry mouth and constipation.
 
Electroconvulsive treatment is a treatment modality which is used in geriatric patients gradually at higher rates. In the event that adverse effects of the medicines limit the use of antidepressants, in resistant depression, it is used when the depression is presented with the lifethreatening complications such as serious weight loss and catatonia. It is generally accepted as a reliable process in old people. It may cause short-term hypertension, tachycardia and delirium and this limits usage in ischemic cardiac patients and those with dementia [11].
 
For all groups of medicines, it is suggested that half-dose be used in young people but it be increased to effective dose gradually with a close clinic follow-up. It should be remembered that response to the antidepressant may occur in a longer time than young people. During the clinic evaluation after 6-8 weeks, it is followed quarterly if the response to the medicine is meaningful. If no response is given to the medicine, therapeutic dose should be increased or another medicine should be used. In resistant depressions, in the depressions with a risk of suicide, in case of accompanying symptoms and in bipolar diseases, the cases should be transferred to the centers having experience in geropsychiatry. In the cases giving response to the treatment, the treatment should be continued at least 6 months in the doses giving response. However, recurrence possibility of many geriatric depressions is high and maintenance treatment should be completed to 1 year in the depressions having higher possibility to recur. Risk factors for depression recurrence are frequent depressive episodes, presence of dysthimia anamnesis, presence of medical co-morbidities, presence of severe clinical symptoms and signs, symptoms lasting more than 2 years and late onset of depression. In frequent depressions and resistant depressions, 2-3 year or life-long treatment should be considered. Even if it is the first major depression attack of the patient, some writers recommend life-long treatment if the depression is serious and related to the life changes which are not expected to recover [12]. In resistant depressions, it has been shown that remission did not develop in 50% of the patients using antidepressant treatment at the beginning, and even after 2 years, 20% of the patients remained symptomatic significantly. After remission is obtained, relapse and recurrence are widely seen problems. For this reason, geriatric depression should be handled as a chronic process such as hypertension and diabetes; acute and maintenance treatments should be planned appropriately, and the treatments should be followed for a relatively longer time. When it comes to withdrawal the drug after depression treatment, immediate withdrawal of drugs in SSRI and SNRI group results in “Withdrawal Syndrome” characterized with anxiety, paresteshia, vertigo and tinnitus. This group of drugs should be discontinued gradually.
 
 
References