Tips for treating patients with late-life depression

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doi:doi: 10.12788/jfp.0539

Applied Evidence

Tips for treating patients with late-life depression

J Fam Pract. 2023 March;72(2):55-60 | doi: 10.12788/jfp.0539

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References

1. Steffens DC, Skoog I, Norton MC, et al. Prevalence of depression and its treatment in an elderly population: the Cache County study. Arch Gen Psych. 2000;57:601-607. doi: 10.1001/ archpsyc.57.6.601

2. Barry LC, Allore HG, Guo Z, et al. Higher burden of depression among older women: the effect of onset, persistence, and mortality over time. Arch Gen Psych. 2008;65:172-178. doi: 10.1001/archgenpsychiatry.2007.17

3. Katon WJ, Lin E, Russo J, et al. Increased medical costs of a population-based sample of depressed elderly patients. Arch Gen Psych. 2003;60:897-903. doi: 10.1001/archpsyc.60.9.897

4. Snow CE, Abrams RC. The indirect costs of late-life depression in the United States: a literature review and perspective. Geriatrics. 2016;1,30. doi.org/10.3390/geriatrics/1040030

5. George LK, Blazer DG, Hughes D, et al. Social support and the outcome of major depression. Br J Psych. 1989;154:478-485. doi: 10.1192/bjp.154.4.478

6. Fonda SJ, Wallace RB, Herzog AR. Changes in driving patterns and worsening depressive symptoms among older adults. J Gerontol Psychol Soc Sci. 2001;56:S343-S351. doi: 10.1093/geronb/56.6.s343

7. Cho HJ, Lavretsky H, Olmstead R, et al. Sleep disturbance and depression recurrence in community dwelling older adults—a prospective study. Am J Psych. 2008;165:1543-1550. doi: 10.1176/appi.ajp.2008.07121882

8. Golub JS, Brewster KK, Brickman AM, et al. Subclinical hearing loss is associated with depressive symptoms. Am J Geriatr Psychiatry. 2020;28:545-556. doi: 10.1016/j.jagp.2019.12.008

9. Alexopoulos GS. Mechanisms and treatment of late-life depression. Focus (Am Psychiatr Publ). 2021;19:340-354. doi: 10.1176/appi.focus.19304

10. Starkstein SE, Preziosi TJ, Bolduc PL, et al. Depression in Parkinson’s disease. J Nerv Ment Disord. 1990;178:27-31. doi: 10.1097/00005053-199001000-00005

11. Gilman SE, Abraham HE. A longitudinal study of the order of onset of alcohol dependence and major depression. Drug Alco Depend. 2001;63:277-286. doi: 10.1016/s0376-8716(00)00216-7

12. Parmelee PA, Katz IR, Lawton MP. The relation of pain to depression among institutionalized aged. J Gerontol. 1991;46:P15-P21. doi: 10.1093/geronj/46.1.p15

13. Alexopoulos GS, Meyers BS, Young RC, et al. ‘Vascular depression’ hypothesis. Arch Gen Psych. 1997;54:915-922. doi: 10.1001/archpsyc.1997.01830220033006

14. Bremmer MA, Beekman AT, Deeg DJ, et al. Inflammatory markers in late-life depression: results from a population-based study. J Affect Disord. 2008;106:249-255. doi: 10.1016/j.jad.2007.07.002

15. Taylor WD, Aizenstein HJ, Alexopoulos GS. The vascular depression hypothesis: mechanisms linking vascular disease with depression. Mol Psych. 2013;18:963-974. doi: 10.1038/mp.2013.20

16. Robinson RG, Jorge RE. Post-stroke depression: a review. Am J Psych. 2016;173:221-231. doi: 10.1176/appi.ajp.2015.15030363

17. Cai W, Mueller C, Li YJ, et al. Post stroke depression and risk of stroke recurrence and mortality: a systematic review and meta-analysis. Ageing Res Rev. 2019;50:102-109. doi: 10.1016/ j.arr.2019.01.013

18. Cole MG, Dendukuri N. Risk factors for depression among elderly community subjects: a systematic review and meta-analysis. Am J Psych. 2003;160:1147-1156. doi: 10.1176/appi.ajp.160.6.1147

19. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). 2013:160-168.

20. Pimontel MA, Rindskopf D, Rutherford BR, et al. A meta-analysis of executive dysfunction and antidepressant treatment response in late-life depression. Am J Geriatr Psych. 2016;24:31-34. doi: 10.1016/j.jagp.2015.05.010

21. Koenig HG, Cohen HJ, Blazer DG, et al. Religious coping and depression in elderly hospitalized medically ill men. Am J Psychiatry. 1992;149:1693-1700. doi: 10.1176/ajp.149.12.1693

22. Blake H, Mo P, Malik S, et al. How effective are physical activity interventions for alleviating depressive symptoms in older people? A systematic review. Clin Rehabil. 2009;10:873-887. doi: 10.1177/0269215509337449

23. Bruce ML, Ten Have TR, Reynolds CF, et al. Reducing suicidal and depressive symptoms in depressed older primary care patients: a randomized controlled trial. JAMA. 2004;291:1081-1091. doi: 10.1001/jama.291.9.1081

24. Pinquart M, Duberstein PR, Lyness JM. Treatments for later-life depressive conditions: a meta-analytic comparison of pharmacotherapy and psychotherapy. Am J Psychiatry. 2006;163:1493-1501. doi: 10.1176/ajp.2006.163.9.1493

25. Solai LK, Mulsant BH, Pollack BG. Selective serotonin reuptake inhibitors for late-life depression: a comparative review. Drugs Aging. 2001;18:355-368. doi: 10.2165/00002512-200118050-00006

26. Sanchez C, Reines EH, Montgomery SA. A comparative review of escitalopram, paroxetine, and sertraline. Are they all alike? Int Clin Psychopharmacol. 2014;29:185-196. doi: 10.1097/YIC.0000000000000023

27. Hedna K, Sundell KA, Hamidi A, et al. Antidepressants and suicidal behaviour in late life: a prospective population-based study of use patterns in new users aged 75 and above. Eur J Clin Pharmacol. 2018;74:201-208. doi: 10.1007/s00228-017-2360-x

28. Bielski RJ, Ventura D, Chang CC. A double-blind comparison of escitalopram and venlafaxine extended release in the treatment of major depressive disorder. J Clin Psychiatry. 2004;65:1190-1196. doi: 10.4088/jcp.v65n0906

29. Robinson M, Oakes TM, Raskin J, et al. Acute and long-term treatment of late-life major depressive disorder: duloxetine versus placebo. Am J Geriatr Psychiatry. 2014;22:34-45. doi: 10.1016/ j.jagp.2013.01.019

30. Holm KJ, Markham A. Mirtazapine: a review of its use in major depression. Drugs. 1999;57:607-631. doi: 10.2165/00003495-199957040-00010

31. Anttila SA, Leinonen EV. A review of the pharmacological and clinical profile of mirtazapine. CNS Drug Rev. 2001;7:249-264. doi: 10.1111/j.1527-3458.2001.tb00198.x

32. Lenze EJ, Mulsant BH, Blumberger DM, et al. Efficacy, safety and tolerability of augmentation pharmacotherapy with aripiprazole for treatment-resistant depression in late life: a randomised double-blind, placebo-controlled trial. Lancet. 2015;386:2404-2412. doi: 10.1016/S0140-6736(15)00308-6

33. Lenze EJ, Oughli HA. Antidepressant treatment for late-life depression: considering risks and benefits. J Am Geriatr Soc. 2019;67:1555-1556. doi: 10.1111/jgs.15964

34. Bondareff W, Alpert M, Friedhoff AJ, et al: Comparison of sertraline and nortriptyline in the treatment of major depressive disorder in late life. Am J Psychiatry. 2000;157:729-736. doi: 10.1176/appi.ajp.157.5.729

35. Lavretsky H, Reinlieb M, St Cyr N. Citalopram, methylphenidate, or their combination in geriatric depression: a randomized, double-blind, placebo controlled trial. Am J Psych. 2015;72:561-569. doi: 10.1176/appi.ajp.2014.14070889

36. Arthur A, Savva GM, Barnes LE, et al. Changing prevalence and treatment of depression among older people over two decades. Br J Psychiatry. 2020;21:49-54. doi: 10.1192/bjp.2019.193

37. Zuidersma M, Chua K-C, Hellier J, et al. Sertraline and mirtazapine versus placebo in subgroups of depression in dementia: findings from the HTA-SADD randomized controlled trial. Am J Geriatr Psychiatry. 2019;27:920-931. doi: 10.1016/ j.jagp.2019.03.021

38. Ochs-Ross R, Wajs E, Daly EJ, et al. Comparison of long-term efficacy and safety of esketamine nasal spray plus oral antidepressant in younger versus older patients with treatment-resistant depression: post-hoc analysis of SUSTAIN-2, a long-term open-label phase 3 safety and efficacy study. Am J Geriatr Psychiatry. 2022;30:541-556. doi: 10.1016/j.jagp.2021.09.014

39. Devanand DP, Pelton GH, D’Antonio K, et al. Donepezil treatment in patients with depression and cognitive impairment on stable antidepressant treatment: a randomized controlled trial. Am J Geriatr Psychiatry. 2018;26:1050-1060. doi: 10.1016/ j.jagp.2018.05.008

40. Obbels J, Vansteelandt K, Verwijk E, et al. MMSE changes during and after ECT in late life depression: a prospective study. Am J Geriatr Psychiatry. 2019;27:934-944. doi: 10.1016/ j.jagp.2019.04.006

41. Wagenmakers MJ, Vansteelandt K, van Exel E, et al. Transient cognitive impairment and white matter hyperintensities in severely depressed older patients treated with electroconvulsive therapy. Am J Geriatr Psychiatry. 2021:29:1117-1128. doi: 10.1016/j.jagp.2020.12.028

42. Trevizol AP, Goldberger KW, Mulsant BH, et al. Unilateral and bilateral repetitive transcranial magnetic stimulation for treatment-resistant late-life depression. Int J Ger Psychiatry. 2019;34:822-827. doi: 10.1002/gps.5091

43. Aben I, Verhey F, Stik J, et al. A comparative study into the one year cumulative incidence of depression after stroke and myocardial infarction. J Neurol Neurosurg Psychiatry. 2003;74:581-585. doi: 10.1136/jnnp.74.5.581

44. Gallo JJ, Bogner HR, Morales KH, et al. The effect of a primary care practice-based depression intervention on mortality in older adults: a randomized trial. Ann Intern Med. 2007;146:689-698. doi: 10.7326/0003-4819-146-10-200705150-00002

45. Lee J, Jang SN, Cho SL. Gender differences in the trajectories and the risk factors of depressive symptoms in later life. Int Psychogeriatr. 2017;29:1495-1505. doi: 10.1017/S1041610217000709

46. Lee E, Cho HJ, Olmstead R, et al. Persistent sleep disturbance: a risk factor for recurrent depression in community-dwelling older adults. Sleep. 2013;36:1685-1691. doi: 10.5665/sleep.3128

47. Berk M, Woods RL, Nelson MR, et al. Effect of aspirin vs placebo on the prevention of depression in older people: a randomized clinical trial. J Am Med A Psych. 2020;77:1012-1020. doi: 10.1001/jamapsychiatry.2020.1214

48. Okereke OI, Reynolds CF, Mischoulon D, et al. Effect of long-term vitamin D3 supplementation vs placebo on risk of depression or clinically relevant depressive symptoms and on change in mood scores: a randomized clinical trial. JAMA. 2020;324:471-480. doi: 10.1001/jama.2020.10224

When drug-related interventions fail, therapy ought to be more psychologically focused.³⁷ Psychotherapy is usually helpful and is particularly indicated when recovery is suboptimal. Counseling might come from the treating physician or referral to a psychotherapist.

Nasal esketamine can be efficacious when supplementing antidepressant pharmacotherapy among older patients with treatment-resistant depression.³⁸ Elderly individuals responding to antidepressants do not benefit from adjunctive donepezil to correct mild cognitive impairment.³⁹ There is no advantage to off-label cholinesterase inhibitor prescribing for patients with both depression and dementia.

Other options. Electroconvulsive therapy (ECT) does not cause long-term cognitive problems and is reserved for treatment-resistant cases.⁴⁰ Patients with depression who also have had previous cognitive impairment often improve in mental ability following ECT.⁴¹

A promising new option. Transcranial magnetic stimulation (TMS) is a promising, relatively new therapeutic option for treating refractory cases of depressive mood disorders. In TMS, an electromagnetic coil that creates a magnetic field is placed over the left dorsolateral prefrontal cortex (which is responsible for mood regulation). Referral for TMS administration may offer new hope for older patients with treatment-resistant depression.⁴²

Keep comorbidities in mind as you address depression

Coexisting psychiatric illnesses worsen emotions. Geriatric patients are susceptible to psychiatric comorbidities that include substance abuse, obsessive-compulsive characteristics, dysfunctional eating, and panic disorder.¹⁹ Myocardial and cerebral infarctions are detrimental to mental health, especially soon after such events.⁴³ Poststroke depression magnifies the risk for disability and mortality,^16,17 yet antidepressant pharmacotherapy often enhances prognoses. Along with early intervention algorithm-based plans and inclusion of a depression care manager, antidepressants often diminish poststroke depression severity.⁴⁴ Even when cancer is present, depression care reduces mortality.⁴⁴ So with this in mind, persist with antidepressant treatment, which will often benefit an elderly individual with depression.

Continue to: When possible, get ahead of depression before it sets in