Treatment of Depression in the Elderly



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Treatment of Depression in the Elderly






Arash Mirabzadeh, MD;
University of Social Welfare and Rehabilitation Sciences,
Social Determinants Of Health Research Center, Tehran, Iran

Mohammad Reza Khodaei1, MD;

University of Social Welfare and Rehabilitation Sciences, Tehran, Iran



Abstract

Depression is a common symptom and a major public health problem in the elderly. Despite its prevalence and seriousness, depressive disorder in older people remains under-treated. The optimal treatment of depression in later life is crucial, and requires appreciation of several age-related factors such as comorbidity, polypharmacy, altered drug kinetics, variable treatment response and increased predisposition to side effects. Although sometimes difficult to diagnose because of concurrent stressors medical illness, or dementia, depression in elderly patients responds readily to appropriate therapy. When untreated, this disorder may result in increased morbidity and mortality or suicide. Effective therapeutic options for late-life depression, as in younger patients, include psychotherapy and pharmacotherapy. Because of their favorable adverse effect profiles and safety in cases of overdose, the selective serotonin reuptake inhibitors have, in most cases, replaced tricyclic antidepressants as first-line therapy when antidepressants are indicated. SSRIs considered to have the best safety profile in the elderly are citalopram, escitalopram, and sertraline. Finally, electroconvulsive therapy offers a safe and effective alternative for patients refractory to or unable to tolerate antidepressant medication.



Keywords: Polypharmacy, depressive disorder, older people

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Introduction

Depression as a symptom is common in the elderly and is a major public health problem (1). Major depressive disorder (MDD) is common in the elderly too, with an estimated prevalence of 2% to 3% in the general population and 15% to 25% among nursing home residents (2). Approximately 15% of the community dwelling elderly have clinically significant depressive symptoms, and such symptoms are present in 25% of elderly patients with a chronic medical illness (3). Despite the high prevalence of depressive illness in this population, it is estimated that clinically significant depression goes untreated in 60% of cases (4-5).

Depression in the elderly can be divided into early-life onset, which recurs in old age, and late-life onset, which begins in old age (6).

Depression in late life is associated with significant morbidity including deficits in a range of cognitive functions and considerable influence on functional impairment and disability (1-2-7). In elders who have co-existing chronic medical conditions, the presence of depressive symptoms increases role impairment, utilization of medical services and treatment costs decreases patients' compliance with their medical treatments and alters the course of disease that leads to higher mortality and disability (1-4-5-8).

Evidence regarding outcome and treatment response in relation to age is even less consistent (9-10). Old age has been associated with a slower improvement during treatment and an overall poorer prognosis (9-11-12-13). However, opposite findings have also been reported (9-14). Elderly patients with late onset of depressive disorder have been characterized by less personality abnormalities and a low incidence of family history of psychiatric illness (9-16), but severity and symptomatology have been observed to be quite similar in early and late onset elderly patients (9-16). Old age at onset has been linked to both better and poorer outcome. Thus, the impact of age and age at onset of depressive disorder in symptomatology and outcome is still a debated issue. It has been suggested that potential biases may have confounded the above-mentioned studies (17), For example, severity of depression may be influenced by concurrent medical problems and time to remission may be longer. Medical comorbidity more likely occurs in people with late-onset depression without a past psychiatric history (18). The importance of assessing factors related to patient age and not just to age itself in evaluations of risk factors for poor prognosis has been emphasized (9-17).




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