Clinical Vignettes in Geriatric Depression



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Am Fam Physician. 2011 Nov 15;84(10):1149-1154.

  Patient information: See related handout on caring for older family members with depression, written by the authors of this article.

The diagnosis of depression in older patients is often complicated by comorbid conditions, such as cerebrovascular disease or dementia. Tools specific for this age group, such as the Geriatric Depression Scale or the Cornell Scale for Depression in Dementia, may assist in making the diagnosis. Treatment decisions should consider risks associated with medications, such as serotonin syndrome, hyponatremia, falls, fractures, and gastrointestinal bleeding. Older white men with depression are at high risk of suicide. Depression is common after stroke or myocardial infarction, and response to antidepressant treatment has been linked to vascular outcomes. Depression care management is an important adjunct to the use of antidepressant medications. Structured psychotherapy and exercise programs are useful treatments for select patients.

The epidemiology of geriatric major depression is similar to that of younger adults, affecting 5 to 10 percent of older patients in primary care outpatient settings and occurring more often in women.1 Depression in older persons may represent a relapse of depression from earlier in life rather than a new depressive disorder presenting late in life. Persons with late-onset depressive symptoms are more likely to have underlying cerebrovascular disease or incipient dementia. This may explain why response to psychological and pharmacologic treatment approaches is lower in older populations. Psychotic depression, which causes delusions or hallucinations, is more common in late-life depression.1 The following illustrative cases highlight challenges presented by older patients with depression.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References Comments

The Geriatric Depression Scale and the Cornell Scale for Depression in Dementia are validated tools for screening for depression in older patients with dementia.

C

7, 8

Patients with ST-segment elevation myocardial infarction should be assessed for depression during hospitalization, one month after discharge, and annually thereafter. Cognitive behavior therapy and selective serotonin reuptake inhibitors are useful for treating depression in this population.

C

28

American College of Cardiology/American Heart Association recommendation

Routine screening for depression in older patients is recommended only if depression care management is available.

A

35

U.S. Preventive Services Task Force recommendation


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.xml.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

View Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References Comments

The Geriatric Depression Scale and the Cornell Scale for Depression in Dementia are validated tools for screening for depression in older patients with dementia.

C

7, 8

Patients with ST-segment elevation myocardial infarction should be assessed for depression during hospitalization, one month after discharge, and annually thereafter. Cognitive behavior therapy and selective serotonin reuptake inhibitors are useful for treating depression in this population.

C

28

American College of Cardiology/American Heart Association recommendation

Routine screening for depression in older patients is recommended only if depression care management is available.

A

35

U.S. Preventive Services Task Force recommendation


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.xml.

Case 1. An 85-year-old nursing home patient with dementia has been withdrawn and eating poorly. The staff thinks that she may be depressed and asks you about prescribing an antidepressant.

Major depression in older patients is diagnosed using the same criteria as in younger adults. It is based on the persistence of the core symptoms of anhedonia or depressed mood for two weeks, with four or more of the following: feelings of worthlessness or guilt, decreased ability to concentrate or make decisions, fatigue, psychomotor agitation or retardation, insomnia or hypersomnia, significant changes in weight or appetite, and recurrent thoughts of suicide or death.2

The diagnosis can be more difficult in older persons, because they may have somatic symptoms related to comorbid illnesses and are less likely to report certain symptoms, such as guilt. Depressive symptoms such as fatigue and hypersomnia may be a consequence of illness.3  The diagnosis may be further obscured by dementia, limiting the patient's ability to provide a thorough history. Table 1 shows a comparison of the symptoms and signs of depression and dementia.4 Depression is more common in patients in nursing homes and is often manifested by weight loss.5

Table 1.

Comparison of the Signs and Symptoms of Depression and Dementia

Signs and symptoms Depression Dementia

Onset

Sudden

Insidious

Progression

Rapid

Slow

Patient history

Detailed

Few details

Effort on testing

May be poor

Usually good

Memory

Improves with cuing

Impaired, cuing not helpful


Information from reference 4.

Table 1.   Comparison of the Signs and Symptoms of Depression and Dementia

View Table

Table 1.

Comparison of the Signs and Symptoms of Depression and Dementia

Signs and symptoms Depression Dementia

Onset

Sudden

Insidious

Progression

Rapid

Slow

Patient history

Detailed

Few details

Effort on testing

May be poor

Usually good

Memory

Improves with cuing

Impaired, cuing not helpful


Information from reference 4.

The Geriatric Depression Scale is a useful screening tool that has been validated for use in patients with dementia who have Mini-Mental State Examination scores as low as 15 (Table 26).7 The Cornell Scale for Depression in Dementia is a caregiver-based evaluation tool that can be used to diagnose depression that accompanies more severe dementia.8 It can be accessed at http://www.amda.com/resources/2005_updates_ltc_teaching_kits/dementia.pdf. Other causes of depressive symptoms should be considered, such as delirium, adverse effects from medication, or metabolic disorders (Table 39,10).

Table 2.

Geriatric Depression Scale (10-Item Shortened Form)

Question Response

1. Are you basically satisfied with your life?*

Yes/NO

2. Do you feel that your life is empty?*

YES/No

3. Are you afraid that something bad is going to happen to you?*

YES/No

4. Do you feel happy most of the time?*

Yes/NO

5. Have you dropped many of your activities and interests?

YES/No

6. Do you often feel helpless?

YES/No

7. Do you feel that you have more problems with memory than most?

YES/No

8. Do you feel full of energy?

Yes/NO

9. Do you feel that your situation is hopeless?

YES/No

10. Do you think that most people are better off than you are?

YES/No


note: One point is scored for each response in capital letters. A score of 3 or greater may indicate depression.

*—The first four questions are sometimes used as a four-item version of the scale, with one or more abnormal responses possibly indicating depression.

Adapted with permission from D'ath P, et al. Screening, detection and management of depression in elderly primary care attenders. I: The acceptability and performance of the 15 item Geriatric Depression Scale (GDS15) and the development of short versions. Fam Pract. 1994;11(3):264.

Table 2.   Geriatric Depression Scale (10-Item Shortened Form)

View Table

Table 2.

Geriatric Depression Scale (10-Item Shortened Form)

Question Response

1. Are you basically satisfied with your life?*

Yes/NO

2. Do you feel that your life is empty?*

YES/No

3. Are you afraid that something bad is going to happen to you?*

YES/No

4. Do you feel happy most of the time?*

Yes/NO

5. Have you dropped many of your activities and interests?

YES/No

6. Do you often feel helpless?

YES/No

7. Do you feel that you have more problems with memory than most?

YES/No

8. Do you feel full of energy?

Yes/NO

9. Do you feel that your situation is hopeless?

YES/No

10. Do you think that most people are better off than you are?

YES/No


note: One point is scored for each response in capital letters. A score of 3 or greater may indicate depression.

*—The first four questions are sometimes used as a four-item version of the scale, with one or more abnormal responses possibly indicating depression.

Adapted with permission from D'ath P, et al. Screening, detection and management of depression in elderly primary care attenders. I: The acceptability and performance of the 15 item Geriatric Depression Scale (GDS15) and the development of short versions. Fam Pract. 1994;11(3):264.

Table 3.

Potential Causes of Depressive Symptoms

Causes Examples

Medication class or system

Anticholinergics

Oxybutynin (Ditropan), cimetidine (Tagamet), antihistamines

Cardiac

Clonidine (Catapres), digoxin, hydralazine

Central nervous system

Levodopa, phenytoin (Dilantin), haloperidol

Hormones

Glucocorticoids, oral contraceptives, anabolic steroids

Sedatives

Benzodiazepines, ethanol, sleep aids

Illness

Cancer

Pancreas, lung, colon

Endocrine

Hypothyroidism, hypercortisolism, Addison disease

Hematologic

Vitamin B12 deficiency, iron deficiency, leukemia

Infection

Syphilis, human immunodeficiency virus, pneumonia

Metabolic

Hypercalcemia, hyperkalemia, hypokalemia, porphyria

Neurologic

Alzheimer disease, stroke, intracranial mass

Impairments

Hearing loss9

Pain10

Osteoarthritis, neuralgia

Substance abuse

Alcohol, opioids, benzodiazepines


Information from references 9 and 10.

Table 3.   Potential Causes of Depressive Symptoms

View Table

Table 3.

Potential Causes of Depressive Symptoms

Causes Examples

Medication class or system

Anticholinergics

Oxybutynin (Ditropan), cimetidine (Tagamet), antihistamines

Cardiac

Clonidine (Catapres), digoxin, hydralazine

Central nervous system

Levodopa, phenytoin (Dilantin), haloperidol

Hormones

Glucocorticoids, oral contraceptives, anabolic steroids

Sedatives

Benzodiazepines, ethanol, sleep aids

Illness

Cancer

Pancreas, lung, colon

Endocrine

Hypothyroidism, hypercortisolism, Addison disease

Hematologic

Vitamin B12 deficiency, iron deficiency, leukemia

Infection

Syphilis, human immunodeficiency virus, pneumonia

Metabolic

Hypercalcemia, hyperkalemia, hypokalemia, porphyria

Neurologic

Alzheimer disease, stroke, intracranial mass

Impairments

Hearing loss9

Pain10

Osteoarthritis, neuralgia

Substance abuse

Alcohol, opioids, benzodiazepines


Information from references 9 and 10.

Treating depression in patients living in a nursing home may be problematic because polypharmacy makes medication interactions and adverse effects more likely. Compromised renal or hepatic function also may contribute to adverse reactions. Tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors, and other second-generation antidepressants have similar effectiveness. Based on their adverse effect profiles, SSRIs are the preferred medications for treating depression in older adults. Based on expert opinion, citalopram (Celexa), escitalopram (Lexapro), and sertraline (Zoloft) may be preferred because of fewer drug interactions or cognitive risks.11

Frail older patients are more likely to be taking other medications with serotonergic properties (Table 412). Therefore, care should be taken to avoid serotonin syndrome, which is manifested as autonomic (e.g., hyperthermia, hypertension, tachycardia), neuromotor (e.g., hyperreflexia, myoclonus, tremors) or cognitive/behavioral (e.g., confusion, anxiety, hallucinations) symptoms.12

Table 4.

Drugs That May Cause Serotonin Syndrome

Category Examples

Amphetamines

Methylphenidate (Ritalin)

Analgesics

Meperidine (Demerol), tramadol (Ultram)

Antispasmodics

Cyclobenzaprine (Flexeril)

Cough and cold

Dextromethorphan

Herbals

St. John's wort (Hypericum perforatum)

Migraine (triptans)

Sumatriptan (Imitrex)

Monoamine oxidase inhibitors

Phenelzine (Nardil)

Selective serotonin reuptake inhibitors

Sertraline (Zoloft)

Serotonin-norepinephrine reuptake inhibitors

Venlafaxine (Effexor), duloxetine (Cymbalta)

Other serotonergic medications

Lithium, trazodone


note: The risk of serotonin syndrome increases when agents are used in combination.

Information from reference 12.

Table 4.   Drugs That May Cause Serotonin Syndrome

View Table

Table 4.

Drugs That May Cause Serotonin Syndrome

Category Examples

Amphetamines

Methylphenidate (Ritalin)

Analgesics

Meperidine (Demerol), tramadol (Ultram)

Antispasmodics

Cyclobenzaprine (Flexeril)

Cough and cold

Dextromethorphan

Herbals

St. John's wort (Hypericum perforatum)

Migraine (triptans)

Sumatriptan (Imitrex)

Monoamine oxidase inhibitors

Phenelzine (Nardil)

Selective serotonin reuptake inhibitors

Sertraline (Zoloft)

Serotonin-norepinephrine reuptake inhibitors

Venlafaxine (Effexor), duloxetine (Cymbalta)

Other serotonergic medications

Lithium, trazodone


note: The risk of serotonin syndrome increases when agents are used in combination.

Information from reference 12.

Because hyponatremia has been linked to the use of SSRIs, serum sodium levels should be checked if a patient exhibits lethargy or delirium after starting therapy.13 SSRI use also increases the risk of falls, fractures, gastrointestinal bleeding, and sleep disturbances.1417 The duration of therapy required to maintain remission is uncertain.18,19 Based on principles of geriatric pharmacotherapy, patients should have periodic assessments for continuing medication or tapering to a minimal effective dose.

Case 2. Three weeks ago, a 75-year-old man presented with a viral-sounding illness. The patient seemed apathetic, but commented that he needed to recover in time for hunting season. He later died of a self-inflicted gunshot wound.

White men older than 65 years account for a disproportionate number of completed suicides.1  Depression is a major risk factor for suicidal ideation (Table 5).20 Suicidal patients may present to their physician with seemingly unrelated symptoms shortly before making an attempt. A mood change, especially when means for self-harm (e.g., firearms) are readily available, should prompt a careful evaluation for suicidal ideation. Suicidal intent, the presence of a plan, and the means available to carry out the plan should be addressed directly in the interview.

Table 5.

Risk Factors for Suicide

Bereavement

Depression

Living alone, social isolation

Male sex

Poor health status, development of disability

Poor sleep quality

Substance abuse (e.g., alcohol, sedatives, pain medications)

White race


Information from reference 20.

Table 5.   Risk Factors for Suicide

View Table

Table 5.

Risk Factors for Suicide

Bereavement

Depression

Living alone, social isolation

Male sex

Poor health status, development of disability

Poor sleep quality

Substance abuse (e.g., alcohol, sedatives, pain medications)

White race


Information from reference 20.

Management of suicidal ideation in older patients requires hospitalization, unless there is a reliable source of psychosocial support, and good follow-up is assured. Although SSRI therapy has been shown to reduce suicidal ideation, it has been difficult to demonstrate that it reduces the rate of suicide attempts.21,22 Medications more likely to be lethal in overdose (e.g., tricyclic antidepressants) should be avoided. Persisting suicidal ideation is one of the indications for electroconvulsive therapy, which may be safely administered to older patients. Other indications for electroconvulsive therapy are lack of response to medication, psychosis, and previous good response to this modality.23

Case 3. A 72-year-old woman had a myocardial infarction and underwent coronary artery bypass grafting four weeks ago. She has been participating in an outpatient cardiac rehabilitation program. Her therapist is concerned about her lack of progress and apparent apathy. The patient's son comments that she seems uninterested in participating in family activities and looks depressed.

About 20 percent of patients who have a stroke or myocardial infarction develop major depression.24,25 Depression persisting after an acute coronary event increases the risk of future cardiovascular events and death.26 In one study, response to treatment for depression was associated with a 7.4 percent risk of recurrent cardiac events, compared with a 25.6 percent risk in those whose depression did not respond to treatment.27

The American College of Cardiology and the American Heart Association recommend screening for and treating depression for secondary prevention in patients with ST-segment elevation myocardial infarction. Assessment is recommended during hospitalization, one month after discharge, and annually thereafter.28 Cognitive behavior therapy (CBT) or antidepressant medication is recommended for treatment. SSRIs are generally well tolerated by patients with cardiac conditions. Whether treatment of depression prevents future cardiovascular events is uncertain. A study of patients with acute coronary syndrome showed treatment of depression to be associated with greater patient satisfaction and a reduction of depressive symptoms, with a trend toward improved cardiac prognosis.29

Case 4. An 82-year-old woman comes to the office for a checkup three months after the death of her husband. The patient says her daughter asked her to make the appointment because she had not seemed like herself lately. The patient expresses anhedonia, and her 10-item Geriatric Depression Scale score is 7 out of 10. Her physical examination and laboratory tests are otherwise unremarkable. You prescribe a 30-day supply of an SSRI with three refills. Six weeks later, she says she discontinued the medication after the 30-day supply ran out and did not understand that she needed to get a refill. She is uncertain whether the medication was helpful.

Depressive symptoms may be a normal part of bereavement. Symptoms causing functional impairment and persisting without improvement for more than two months after the loss of a loved one should result in consideration for treatment.30  After a diagnosis of depression is established, pharmacotherapy is one of several treatment options (Table 6).11

Table 6.

Medications for Geriatric Depression

Medication Initial dosage Maximal dosage Risk of drug interaction Adverse effects*

Selective serotonin reuptake inhibitors

Citalopram (Celexa)

10 to 20 mg once per morning

40 mg once per day

Low

Hyponatremia, GI symptoms, sexual dysfunction, weight gain, extrapyramidal symptoms

Escitalopram (Lexapro)

10 mg once per day

20 mg once per day

Low

GI symptoms, sexual dysfunction, weight gain

Fluoxetine (Prozac)

10 to 20 mg once per day

40 mg once per day

High

Insomnia, GI symptoms, sexual dysfunction, weight gain

Paroxetine (Paxil)

10 mg once per day

40 mg once per day

Moderate

GI symptoms, sedation, weight gain, withdrawal symptoms

Sertraline (Zoloft)

25 to 50 mg once per day

200 mg once per day

Low

Sexual dysfunction, weight gain

Serotonin-norepinephrine reuptake inhibitors

Duloxetine (Cymbalta)

20 mg once or twice per day

60 mg once per day or 30 mg twice per day

Low

GI symptoms, xerostomia, urinary hesitancy

Venlafaxine (Effexor)

25 to 50 mg twice per day

75 to 225 mg total twice per day

High

GI symptoms, headaches, hyponatremia, withdrawal symptoms, hypertension, extrapyramidal symptoms

Other serotonergic agents

Bupropion (Wellbutrin)†

37.5 to 50 mg twice per day

75 to 150 mg twice per day

Moderate

GI symptoms, sexual dysfunction, seizures, psychosis

Mirtazapine (Remeron)

7.5 to 15 mg at bedtime

45 mg once per day

Low

Sedation, sexual dysfunction, weight gain

Tricyclic agents

Desipramine (Norpramin)

10 to 25 mg once at bedtime

50 to 150 mg once per day

High

Hypotension, sedation, GI symptoms, weight gain

Nortriptyline (Pamelor)

10 to 25 mg once at bedtime

75 to 150 mg once per day

High

Hypotension, sedation, weight gain


GI = gastrointestinal.

*—Adverse effects are similar within each class; more prominent symptoms listed for individual agents.

†—These agents are available in extended-release formulations at different dosages.

Adapted with permission from Pollock BG, Semla TP, Forsyth CE. Psychoactive drug therapy. In: Halter JB, et al., eds. Hazzard's Geriatric Medicine and Gerontology. 6th ed. New York, NY: McGraw-Hill Medical; 2009:769.

Table 6.   Medications for Geriatric Depression

View Table

Table 6.

Medications for Geriatric Depression

Medication Initial dosage Maximal dosage Risk of drug interaction Adverse effects*

Selective serotonin reuptake inhibitors

Citalopram (Celexa)

10 to 20 mg once per morning

40 mg once per day

Low

Hyponatremia, GI symptoms, sexual dysfunction, weight gain, extrapyramidal symptoms

Escitalopram (Lexapro)

10 mg once per day

20 mg once per day

Low

GI symptoms, sexual dysfunction, weight gain

Fluoxetine (Prozac)

10 to 20 mg once per day

40 mg once per day

High

Insomnia, GI symptoms, sexual dysfunction, weight gain

Paroxetine (Paxil)

10 mg once per day

40 mg once per day

Moderate

GI symptoms, sedation, weight gain, withdrawal symptoms

Sertraline (Zoloft)

25 to 50 mg once per day

200 mg once per day

Low

Sexual dysfunction, weight gain

Serotonin-norepinephrine reuptake inhibitors

Duloxetine (Cymbalta)

20 mg once or twice per day

60 mg once per day or 30 mg twice per day

Low

GI symptoms, xerostomia, urinary hesitancy

Venlafaxine (Effexor)

25 to 50 mg twice per day

75 to 225 mg total twice per day

High

GI symptoms, headaches, hyponatremia, withdrawal symptoms, hypertension, extrapyramidal symptoms

Other serotonergic agents

Bupropion (Wellbutrin)†

37.5 to 50 mg twice per day

75 to 150 mg twice per day

Moderate

GI symptoms, sexual dysfunction, seizures, psychosis

Mirtazapine (Remeron)

7.5 to 15 mg at bedtime

45 mg once per day

Low

Sedation, sexual dysfunction, weight gain

Tricyclic agents

Desipramine (Norpramin)

10 to 25 mg once at bedtime

50 to 150 mg once per day

High

Hypotension, sedation, GI symptoms, weight gain

Nortriptyline (Pamelor)

10 to 25 mg once at bedtime

75 to 150 mg once per day

High

Hypotension, sedation, weight gain


GI = gastrointestinal.

*—Adverse effects are similar within each class; more prominent symptoms listed for individual agents.

†—These agents are available in extended-release formulations at different dosages.

Adapted with permission from Pollock BG, Semla TP, Forsyth CE. Psychoactive drug therapy. In: Halter JB, et al., eds. Hazzard's Geriatric Medicine and Gerontology. 6th ed. New York, NY: McGraw-Hill Medical; 2009:769.

If medication is chosen, there is increasing evidence that a prescription with office-based follow-up is inferior to an organized program of depression care management or collaborative care.31,32 Depression care management involves the designation of an allied health professional to assist treatment by providing education and close follow-up, and monitoring response to treatment.33 A randomized study compared usual care with pharmacotherapy augmented by depression care management. It found improved remission rates and medication adherence over the 12-month intervention (number needed to treat = 4), and the results were sustained for another 12 months after intervention had ended (number needed to treat = 9).34 The evidence in favor of depression care management is strong enough that the U.S. Preventive Services Task Force (USPSTF) recommends screening for depression in adults (including older adults) only when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up. The USPSTF notes that the evidence demonstrating a benefit of screening in the absence of depression care support is small.35

Structured psychotherapy yields depression remission rates similar to medication, and may be preferred in patients at higher risk of adverse drug reactions.36 CBT is the most widely studied form of psychotherapy and has been shown to be effective in geriatric depression, particularly in mild to moderately severe cases. CBT involves replacing negative distortions of events and situations with more positive and rational cognitive responses.37,38 There is some evidence that the effects of CBT may be longer lasting than drug therapy following discontinuation of treatment. Older persons do well with CBT, but need special attention because of memory impairment and sensory deficits, primarily hearing loss.39

There is some evidence that aerobic and anaerobic exercise programs are helpful for treating depression. A meta-analysis specific to older patients found evidence of benefit for major depression but the effects were not sustained unless the exercise program continued.40 A Cochrane review on exercise for adult depression found evidence of benefit comparable to cognitive therapy.41 Both reviews noted inconsistencies in the quality of the studies and the need for further research.

The Authors

G. DAVID SPOELHOF, MD, is a physician at St. Luke's Hospital of Duluth, Minn., and is an adjunct clinical associate professor in the Department of Family Medicine and Community Health at the University of Minnesota Medical School in Duluth.

GARY L. DAVIS, PhD, is regional campus dean, associate professor in the Department of Behavioral Sciences, and associate director of the Center for Rural Mental Health Studies at the University of Minnesota Medical School in Duluth.

ADDIE LICARI, MD, is a practicing physician at P.S. Rudie Medical Clinic in Duluth. At the time this article was written, Dr. Licardi was a resident at the University of Minnesota's Duluth Family Medicine Residency Program.

Address correspondence to G. David Spoelhof, MD, Miller Creek Medical Clinic, 4884 Miller Trunk Highway, Hermantown, MN 55811 (e-mail: dspoelho@d.umn. edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations to disclose.

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