Case Scenario

A 93-year-old woman has mild cognitive impairment and lives in an assisted-living facility. Before the COVID-19 pandemic, her daughter, a medical social worker, and son-in-law visited her weekly. The patient has severe sensorineural hearing loss but chooses to not wear hearing aids. Her facility prohibited visitors during the pandemic, allowing her daughter to communicate by phone, FaceTime, or standing outside her mother's window. The patient was often unable to hear what her daughter was saying. She rarely left her room because of COVID-19 protocols, lost weight, and slept poorly despite taking mirtazapine (Remeron) and sertraline (Zoloft) for chronic depression. She continued to recognize her daughter and son-in-law throughout the pandemic; however, she was often unsure why they had not visited her in person. Because of her insomnia, the patient wandered around her apartment at night, occasionally falling. She also refused to wear an alert device designed to call for help.

Clinical Commentary

Up to 88% of people 65 years and older have at least one chronic medical condition, and 25% have more than four chronic diseases.¹ Major depression occurs in 1% to 3% of older adults in the general population (8% to 16% in those with dysthymia).² However, fewer than 20% of cases are diagnosed or adequately treated because the symptoms of depression are likely to be attributed to comorbid conditions instead of sadness.² In a 2020 national survey, participants 65 years and older reported significantly lower percentages of an anxiety disorder (6.2%), depressive disorder (5.8%), or trauma-or stress-related disorder (9.2%) compared with younger participants.¹ However, family physicians need to consider or screen for depression in older adults and treat it when present.

IDENTIFICATION AND SCREENING

The U.S. Preventive Services Task Force recommends screening all adults for depression.³ Screening is important in older adults because of the likelihood of contributing risk factors, the masking of symptoms by comorbid conditions, and the tendency for depressive symptoms to compromise function and increase general health care utilization and cost. The Patient Health Questionnaire (PHQ)-2 and PHQ-9 are practical depression screening tools for adults. On a scale of 0 to 27 (nine questions representing the nine symptoms listed in the Diagnostic and Statistical Manual of Mental Disorders, 5th ed. [DSM-5], each worth 0 to 3 points, with 0 representing “not at all” and 3 representing “nearly every day”), a PHQ-9 score of 5 to 9 is consistent with mild depression, 10 to 14 moderate, 15 to 19 moderate/severe, and 20 or greater severe. An online calculator is available at https://www.mdcalc.com/calc/1725/phq-9-patient-health-questionnaire-9. Persistent depressive disorder is diagnosed only if symptoms continue longer than two years. The prognosis for patients older than 60 years with untreated depressive symptoms is poor. In a meta-analysis, 33% of patients were well, 33% were depressed, and 21% had died at 24 months.⁴

Risk factors for depression in older adults include previous depression, loneliness, loss of function, new medical diagnosis, poor health status, bereavement, poor self-perceived health, low self-esteem, helplessness because of racism or ageism, ST-segment elevation myocardial infarction, multiple chronic conditions, certain medications, insomnia, and pain.^5–7

TREATMENT

Older patients generally respond to the same treatments as other adults. A PHQ-9 score greater than 15, accompanied by the DSM-5 additional criteria, is suggestive of major depression and generally warrants treatment with medication. Close follow-up is indicated because older adults are at higher risk of adverse effects. Older adults tend to metabolize drugs more slowly (increasing the risk of serotonin syndrome) and are more sensitive to anticholinergic effects (i.e., confusion, dry mouth, blurry vision, constipation, urinary retention, decreased perspiration, and excess sedation) from tricyclics and paroxetine (Paxil).⁸ Anticholinergic medications have also been associated with an increased risk of dementia.

Selective serotonin reuptake inhibitors with a lower risk of drug interactions, such as citalopram (Celexa), escitalopram (Lexapro), and sertraline, should initially be administered at low doses because of the increased risk of drug-drug interactions due to polypharmacy (more than five daily medications).^9,10 Tricyclic antidepressants should be avoided because of the potential for overdose or medication confusion.¹¹