Depression in older adults - solutions to a common disorder
One in four older people has depression which requires treatment1,2 with a prevalence of between 3 and 15 per cent in the community and even higher in the inpatient and care home population.
Depression is the leading cause of suicide in older adults, with high risk of completed suicide, especially with men living alone being at particular risk3.
Physical illness is associated with higher risk of depression and is three times as common in people with end-stage renal failure, chronic obstructive pulmonary disease and cardiovascular disease than in people who are in good physical health4.
It is important to treat depression as it is associated with increased mortality and risk of physical illness and can lead to an increase in length of hospital duration in those inpatients with untreated depression. A diagnosis of depression in those over 65 increased subsequent mortality by 70 per cent5.
In acute general hospitals, diagnosing depression is made more difficult due to various factors including effects of hospitalisation, duration of admission, coexisting physical illnesses and concurrent multiple medications. An increased length of stay can cause isolation as well as institutionalisation in older adults and can further complicate the picture.
Assessment and diagnosis
In older adults the diagnosis of depression can be missed due to ageism, delirium, or stigma associated with mental illness or the presence of cognitive impairment.
The clinical features of depression in the older people can include disturbances in sleep and appetite, low energy levels, tearfulness, anxiety and somatisation as well cognitive impairment. The degree of cognitive impairment can be severe enough to be mistaken for the start of dementia. Other causes of depression need to be considered as well (Box 1 and 2)4.
Box 1: Medications that may cause depression
Box 2: Physical disorders that may cause depression
Endocrine/metabolic eg Hypothyroidism,cushing’ syndrome,hypercalcaemia
Organic Brain disease eg Stroke,SLE,Parkinson’s disease
Occult carcinoma eg Pancreas
Chronic Infections eg Brucellosis,Herpes zoster
The management of depression in older adults includes both medication and psychological therapies – both have good evidence of effectiveness.
Antidepressants are effective with moderate to severe depression. NICE guidelines (the recommendations of which are along the same lines of prescribing as for younger adults) suggest that first line treatment should be with an SSRI (selective serotonin reuptake inhibitor). Several other antidepressants and mood stabilisers are available, such as SSRIs (Sertraline), SNRI (Venlafaxine), Mirtazapine, Tricyclic antidepressants and MAO Inhibitors.
The choice of antidepressant is guided by the patient’s previous experience of an antidepressant, and by co-morbidities and side effects. Antidepressants should be tried for at least four weeks. However in older adults it may be helpful to persist at an age appropriate dose for a minimum six weeks before adjudging the drug to be ineffective. If there is partial response, it may be sensible to persist another six weeks. Careful monitoring of side effects such as insomnia, agitation, headache, sexual dysfunction, gastrointestinal disorders (including GI bleeding) and hyponatraemia is essential. It is important to remember potential drug interactions. People with dementia may experience depression, which may be difficult to diagnose but needs treatment to improve quality of life.
Antidepressants should be continued for at least six months. Response to Antidepressants is about 40-60 per cent and long term treatment (at least 2 years) for relapse prevention should be considered in people who have had recurrent depression.
For severe depression, with or without psychotic symptoms, where response to treatments is poor, electroconvulsive therapy is considered as an effective treatment.
It is important to remember that suboptimal doses of anti-depressants used for an inadequate time period could cause limited response. There is a need for integrated approaches in terms of pharmacological, social and psychological aspects. Patient education is important, especially in terms of highlighting the importance of diet, exercise and treatment of physical illness. In older adults close working with family and giving hope is important too.
Depression occurs in 40 per cent of people living in care homes7 and often goes undetected. There is evidence to show that training care home staff to recognise possible symptoms of depression can improve detection. Using a collaborative care approach to manage depression is often effective in improving outcomes.
Referral to Old Age Psychiatry should be considered if there is diagnostic difficulty, high risk of suicide or self harm, little or no response to antidepressants and self neglect.8
Psychological therapy is the other option for management. A range of different therapies are available such as Supportive psychotherapy, CBT (Cognitive Behaviour therapy), Interpersonal therapy, Marital therapy and Psychodynamic psychotherapy. NICE favours use of CBT (Cognitive Behaviour therapy) and Interpersonal therapy. There is good evidence for the effectiveness of a number of psychosocial interventions such as Cognitive Behavioural Therapy (CBT), Behavioural Activation and Problem Solving Treatments. More research is needed in this area however psychological therapies are valued by patients and can be preferred to use of medication.
Depression is common in Older Adults and if left untreated could increase mortality, morbidity and disrupt quality of life. Mental health promotion to improve wellbeing and prevent social isolation is also important to prevent depression in older adults.
Sharmi Bhattacharyya, Consultant Psychiatrist, Wrexham, BCUHB, Honorary Senior Lecturer, University of Chester
Anitha Howard, Consultant Psychiatrist, Bensham Hospital, Gateshead