It is important to have some kind of knowledge about it in the ED because it affects 5% of older adults from the community, 10% in primary care and up to 37% after critical care hospitalizations (1). Plus, in older age, depression can manifest by an impressive variety of symptoms and is difficult to diagnose. Interestingly, the primary feature could be something else than low mood or sadness.
Here is what I learn this week about depression.
The first thing that stroke me was that elderly has an increased risk of suicide (especially men). The thing is, we rarely see in the emergency department an old patient with the primary complaint of depressed mood, and then we rarely screen for suicidal ideation. Right?
Depressions symptoms are subtle and may not correspond to the DSM-5 criteria. It can be manifested by irritability, anxiety, somatic symptoms, and also cognitive impairment.
When proxies brings their old loved one for memory problems, it is very important to screen for depression. Although results of the cognitive testing are altered, it still can be a manifestation of depression, called pseudo-dementia.
Risk factors and etiology
Depression has a bidirectional relation with pretty much every thing in late life. It can be triggered by a major disease (particularly stroke and heart disease) but also is a risk factor for it. A symptom of depression can be cognitive disorder, but is also a risk factor for future dementia.
When you get older and older, you are going to experience a lot of loss, especially loved ones. Although it is a “normal” pathway of life, it can be very difficult to bear.
Poly-pharmacy is another risk factor. For example, beta-blockers can trigger depressive symptoms.
Do not forget folate, vit B12 deficiency, and hypothyroidism as a metabolic cause of depression.
But how do you treat depression in an old person?
Although lifestyle change is always good like moderate physical activity, in the bottom tank of depression, it is a difficult sale.
Pharmacotherapy should be initiated. I heard that, comparatively to adults in general, there is a phenomenon of more severe neurotransmitter depletion in older adults. Therefore, pharmacotherapy works better.
The choice of anti-depressant depends on these things:
- Previous good results with a particular agent
- Adverse events and side effects
- Interaction with other medication
- Major symptoms profile of depression
First line: selective serotonin-reuptake inhibitors (SSRIs). Sertraline and escitalopram have a very safe adverse-events profile. Although, paroxetine works well also, it is the most anti-cholinergic agent of this class, therefore not highly recommended in older adults.
Second-line: serotonin-norepinephrine reuptake inhibitors (SNRIs) like venlafaxine and duloxetine. They can increase risk of falls.
Others: mirtazapine can be used if one of the primary features of depression is lack of sleep or decrease appetite. Nortriptyline (TCA) and aripiprazole (psychotic agent) are other alternatives but have more undesirable side effects and interaction.
I won’t go over all the different psychotherapy offered, but the thing to remember is that it works for older adults as well.
Interestingly, electroconvulsive therapy (ECT) is the most effective treatment for severely depressed patients, including older adults. It should be offered if the pharmacotherapy does not work, severe suicidal ideation, or other symptoms causing deterioration in the physical condition. Others may argue that ECT is more effective than medication and it is true!
I know that for most part, in the ED, we won’t probably start a depression treatment in an older patient. Neither prescribe ECT. Although, we do prescribe medication for other acute medical conditions, should we start doing it?
But the point I was trying to make with this post is that depression in the elderly is more common than we think, it can have an atypical presentation (like most disease in the elderly), and treatment is usually effective.
Think about it more, screen for suicidal ideation and consider it in the differential of cognitive impairment.
This way, we can save lives and increase quality of life. Isn’t what we are there for?!
- Taylor WD. Clinical practice. Depression in the elderly. The New England journal of medicine. 2014 Sep 25;371(13):1228-36. PubMed PMID: 25251617.