One large meta-analysis, including 51 randomized controlled trials, showed that medications led to a 48% response rate.9 This rate is almost identical to that shown in younger adult patients, at around 50%.1 However, remission is only achieved in about one-third of patients. A “meta-regression of RCTs including 34 RCTs and 3690 patients 60 years or older, found that with increasing age, antidepressant efficacy decreased. Antidepressants may be less effective in older patients because they have a greater burden of somatic disorders.”1 As Dr Baxi notes, “unfortunately, the effects of antidepressants in older adults [are] variable. The only medication that has good evidence for augmentation in older adults specifically is lithium.” 


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There are specific medications that can elicit or exacerbate depressive symptoms. Some examples include corticosteroids, angiotensin-converting enzyme inhibitors, and statins. In patients who have comorbid medical issues, it is recommended to try to eliminate these types of medications as much as possible.1 However, as Dr Baxi reminds us, “this is not always possible.” Medication management can also be complex because of these comorbid medical issues. For example, hepatic or renal impairment can limit the doses/types of medications used.1 There are other factors to consider before prescribing. These include, but are not limited to, patient preference, severity of last episode, number of treatments to achieve remission, number of years between episodes, number and severity of adverse effects, and presence of risk factors.1

Proactive Measures With Polypharmacy

It is not uncommon to have polypharmacy (defined as 5 or more medications) in this subset of the population. It is important to conduct a comprehensive review of all medications being taken by the patient. Often overlooked are over-the-counter medications and supplements.1 There are a number of tools that have been validated to assist in this process. Two such screening tools are the Screening Tool of Older Persons Prescriptions and Screening Tool to Alert Doctors to Right Treatment.6 Their goals are to “avoid potentially inappropriate medications, under-treatment, or errors of prescribing omission.”1 The reason polypharmacy is important to consider is that it can be associated with consequences from falls and adverse drug events to hospitalization and mortality.1

Other Treatments to Consider

There are depression-specific therapies that have been shown to be effective. The 3 most common ones are cognitive behavioral therapy, interpersonal therapy, and problem-solving therapy. These therapies have been compared with antidepressants in terms of efficacy in mild to moderate depression.1 Many studies do not include a specific indication for therapy in older adults, although if medication is not tolerated, therapy is a great option.1  

Exercise has long been used as an adjunctive therapy for depression. One study of almost 250 older adults looked at the relationship between moderate to vigorous physical activity and psychological distress. An increase in physical activity showed an association with quality of life. Although more studies are necessary, the results are promising.7 Another effective treatment option (60%-80% efficacy) is electroconvulsive therapy. Electroconvulsive therapy has shown to be highly useful for those who are treatment resistant. Moreover, it can be used with patients who have severe or psychotic depression and patients with severe malnutrition or a medical condition that worsens with nonadherence.8

Conclusion

Management of depression in older adults requires investigative work, attention to detail, and patience. The patient may cooperate, although some patients may not because of cognitive limitations. Getting family or other supporters involved can be very important in the treatment process. Certainly, a multidisciplinary team is a must.1

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References

  1. Kok RM, Reynolds CF. Management of depression in older adults: A ReviewJAMA. 2017;317(20):2114-2122. doi: 10.1001/jama.2017.5706
  2. Mojtabai, R. Diagnosing depression in older adults in primary care. N Engl J Med. 2014;370:1180-1182. doi: 10.1056/NEJMp1311047
  3. Snowden MB, Atkins DC, Steinman LE, et al. Longitudinal association of dementia and depression [published online September 21, 2014]. Am J Geriatr Psychiatry. doi: 10.1016/j.jagp.2014.09.002
  4. Albinski R, Kleszczewska-Albinska A, Bedynska S. Geriatric Depression Scale (GDS). Validity and reliability of different versions of the scale. A review. Psychiatr Pol. 2011;45(4):555-562.
  5. Cahoon CG. Depression in older adults. Am J Nurs. 2012;112(11):22-30. doi: 10.1097/01.NAJ.0000422251.65212.4b
  6. Patterson SM, Cadogan CA, et al. Interventions to improve the appropriate use of polypharmacy for older people [published online October 7, 2014]. Cochrane Database Syst Rev. doi: 10.1002/14651858.CD008165.pub3
  7. Awick EA, Ehlers DK, Aguinaga S, et al. Effects of a randomized exercise trial on physical activity, psychological distress and quality of life in older adults [published online June 15, 2017]. Gen Hosp Psychiatry. doi: 10.1016/j.genhosppsych.2017.06.005
  8. Kellner CH, Husain MM, Knapp RG, et al. Right unilateral ultrabrief pulse ECT in geriatric depression: Phase I of the PRIDE study. Am J Psychiatry. 173(11):1101-1109. doi: 10.1176/appi.ajp.2016.150811019. Kok RM, Nolen WA, Heeren TJ. Efficacy of treatment in older depressed patients: a systematic review and meta-analysis of double-blind randomized controlled trials with antidepressants. J Affect Disord. 2012;141(2-3):103-115. doi:10.1016/j.jad.2012.02.036