Older Patients With Inadequately Treated Depression Have Poorer Prognosis Overall

Importance of Addressing Depression in Older Adults

Depression is a common mental health concern that is pervasive across all ages. Contrary to common belief, the prevalence of depression in older adults does not decrease with age. Studies have shown that 2% of adults older than 55 years suffer from major depressive disorder.¹ This number increases with age, especially in those older than 85 years, in those who are hospitalized, and in those who are in nursing homes.¹ Almost 15% of older adults have clinically depressive symptoms. ¹

Diagnosis of depression in older patients needs improvement.² Depression often goes unnoticed; other times, the patient is inadequately treated, receiving no treatment or a lower dose than necessary, or discontinuing the medication prematurely.¹ Shreyas Baxi, MD, a psychiatrist in private practice and at Campbell Hall Nursing Home in Warwick, New York, notes that “these challenges negatively impact these patients’ quality of life as their medical symptoms suffer. There is a direct impact, and inadequate treatment of depression often leads to poorer prognosis of medical conditions.”

Diagnosis by DSM-V

Diagnosis of older adults is exactly the same as in younger adults. The Diagnostic and Statistical Manual of Mental Health Disorders, Fifth Edition (DSM V), criteria for major depressive disorder are not specific to one’s age. The DSM V states that a patient should have 5 or more symptoms during the same 2-week period, 1 of which must be depressed mood or anhedonia. The other symptoms include significant weight loss or weight gain, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue, worthlessness, decreased concentration, and recurrent thoughts of dying. The symptoms are a change from baseline and cause significant distress.

Older adults present with varying symptoms when depression is the root cause. For example, some present with a chief complaint of fatigue or weight loss. Others complain of pain, memory issues, substance issues, or social withdrawal.¹ Diagnosis can be difficult in this population. Medical comorbidities and cognitive impairment contribute to this challenge.¹

Risk Factors

Some older adults are at greater risk of suffering from depression than their peers. Women are more likely than men to have depression, and patients with chronic somatic illness or functional impairment also have an increased likelihood.¹ Older adults with cognitive impairment also seem to be at a higher risk.³ Lack of social contacts, life stressors, and history of depression are other risk factors. ¹ These risk factors should be taken into careful consideration during the evaluation.

Evaluation

A comprehensive psychiatric evaluation is a necessity in diagnosing depression in older adults. Rating scales can be helpful in this evaluation, as they can help differentiate between similar disorders (ie, depression and dementia). One such rating scale is the Geriatric Depression Scale. This 30-item scale is self-rated. It has many different versions, although the original version has the most data in terms of validity, reliability, sensitivity, and specificity.⁴ This scale can also be performed serially and help monitor effectiveness of treatments.

The Patient Health Questionnaire 9 can also be used in the same way.¹ In addition to a full psychiatric evaluation, complete blood count, glucose level, thyroid-stimulating hormone level, vitamin B12 level, and folate level also should be checked. Many older adults also have comorbid cognitive impairment. The most common screening tool used for a cognitive evaluation is the Mini-Mental State Examination.¹

Treatments: Medications

Medications are an important treatment modality for older adults with depression. The first-line medications are antidepressants.⁵ Selective serotonin reuptake inhibitors (SSRIs) are the most prescribed antidepressants and have almost completely replaced tricyclic antidepressants. SSRIs have shown to be equally effective, with fewer adverse effects, especially cardiac effects, which leads to a lower likelihood of fatal overdose.¹ SSRIs are usually prescribed at the same doses, except to those who are very old and frail or are receiving a multitude of medications. However, some studies have shown that SSRIs can be associated with falls and osteoporosis.¹