Depression in Elderly

Question: Loneliness as a cause for depression?

  • Patient or Population: Elderly male patients
  • Intervention or Indicator: Comparing assessments of loneliness with assessments of depression and health
  • Comparison or Control: Comparing with elderly men who are not expressing loneliness
  • Outcome: Loneliness increases depression and poor health in elderly men

4: Aging Ment Health. 2003 May;7(3):212-6.

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Loneliness, health and depression in older males.

Alpass FM, Neville S.

School of Psychology, Massey University, New Zealand.

Loneliness and social isolation, particularly in the older adult, have been shown to influence psychosocial well-being. Loneliness has been related to chronic illness and self-rated health in older adults, and researchers suggest there is an important relationship between loneliness and psychological well-being in older adults particularly in the area of depression. This study investigated relationships between loneliness, health, and depression in 217 older men (> 65 years). Participants completed self-report measures of loneliness, social support, depression, and physical health. Regression analysis showed that a diagnosis of illness or disability was unrelated to depression, however self-reported health was associated with depression, with those reporting poorer health experiencing greater depression. Social support variables were unrelated to depression. The most significant relationship to depression was that of loneliness, with lonelier men reporting higher scores on the Geriatric Depression Scale (GDS). Although research suggests that depression is often a response to declining health and functional impairment in the older adult, the present findings suggest that social isolation may also influence the experience of depression. Age-related losses such as loss of professional identity, physical mobility and the inevitable loss of family and friends can affect a person's ability to maintain relationships and independence, which in turn may lead to a higher incidence of depressive symptoms.

PMID: 12775403 [PubMed - indexed for MEDLINE]

Question: Treatment of Depression in Elderly

  • Patient or Population: Elderly patients
  • Intervention or Indicator: Assessing how medications can treat depression in elderly patients
  • Comparison or Control: Assessing elderly patients who are depressed and treated with antidepressants
  • Outcome: Specific antidepressants help the most with depression in elderly patients

Depression in Elderly Patients

5: Postgrad Med. 2001 Oct;Spec No Pharmacotherapy:1-86.

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Library Article

The expert consensus guideline series. Pharmacotherapy of depressive disorders in older patients.

Alexopoulos GS, Katz IR, Reynolds CF 3rd, Carpenter D, Docherty JP; Expert Consensus Panel for Pharmacotherapy of Depressive Disorders in Older Patients.

OBJECTIVES: Depression in older patients contributes to personal suffering and family disruption and increases disability, medical morbidity, mortality, suicide risk, and healthcare utilization. The majority of clinical trials of antidepressant treatments are conducted in younger patients. For this reason, clinicians often have to extrapolate from studies in populations that do not present the same problems as older patients. For example, older patients often have serious coexisting medical conditions that may contribute to the depression and complicate the choice of treatment. Older patients as a rule need to be on many medications, some of which may contribute to depression and/or interact with antidepressants. Finally, older adults metabolize medications slowly and are more sensitive to side effects than younger patients. Because of these complexities, we conducted a consensus survey of expert opinion on the pharmacotherapy of depressive disorders in older patients to address clinical questions not definitively answered in the research literature. METHOD: After reviewing the literature and convening a work group of experts, we prepared a written survey with 64 questions that asked about 857 options. 618 of the options were scored using a modified version of the RAND 9-point scale for rating appropriateness of medical decisions. For the other options, the experts were asked to write in answers (e.g., average doses) or to check a box to indicate their preferred answer. We sent the survey to 50 national experts on geriatric depression, all of whom completed it. Consensus on each option was defined as a nonrandom distribution of scores by chi-square "goodness-of-fit" test. We assigned a categorical rank (first line/preferred choice, second line/alternate choice, third line/usually inappropriate) to each option based on the 95% confidence interval around the mean rating. Guideline tables indicating preferred treatment strategies were then developed for key clinical situations. RESULTS: The expert panel reached consensus on 89% of the options rated on the 9-point scale. The experts stress the importance of identifying coexisting medical conditions that may be contributing to the depression or complicate treatment. For unipolar nonpsychotic major depression, the preferred strategy is an antidepressant (selective serotonin reuptake inhibitor [SSRI] or venlafaxine XR preferred) plus psychotherapy. For unipolar psychotic major depression, the treatment of choice is an antidepressant (SSRI or venlafaxine XR) plus one of the newer atypical antipsychotics. Electroconvulsive therapy is also first line. For dysthymic disorder or persistent milder depression, the experts recommend combining an antidepressant (SSRIs preferred) and psychotherapy. If the patient has a comorbid medical condition (e.g., hypothyroidism) that is contributing to the depression, the experts recommend treating both the depression and the medical condition from the outset. The SSRIs were the top-rated antidepressants for all types of depression. Among them, the experts gave the highest ratings for efficacy and tolerability to citalopram and sertraline. Paroxetine was another first-line option, and fluoxetine was rated high second line. The preferred psychotherapy techniques for treating depression in older patients are cognitive-behavioral therapy, supportive psychotherapy, problem-solving psychotherapy, and interpersonal psychotherapy. The experts also give strong support to including appropriate psychosocial interventions (e.g., psychoeducation, family counseling, visiting nurse services) in the treatment program. The majority of experts would continue treatment with antidepressant medication for at least 1 year if a patient has had a single episode of severe unipolar major depression, for 1-3 years for a patient who has had 2 such episodes, and for longer than 3 years if there is a history of 3 or more episodes. CONCLUSIONS: The experts reached a high level of consensus on the appropriateness of including both antidepressant medication, specifically SSRIs, and nonpharmacological modalities in treatment plans for severe depression. Within the limits of expert opinion and with the expectation that future research data will take precedence, these guidelines provide direction for addressing common clinical dilemmas in older individuals. They can be used to inform clinicians and educate patients regarding the relative merits of a variety of interventions. Nonetheless, the guidelines cannot address the complexities involved in the care of each individual patient and can be most helpful in the hands of experienced clinicians.

Publication Types:

  • Practice Guideline
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

PMID: 17205639 [PubMed - indexed for MEDLINE]

Question: Depression: Drug-Induced

  • Patient or Population: Elderly patients
  • Intervention or Indicator: Assessing how medications can contribute to depression in the elderly
  • Comparison or Control: Assessing elderly patients who are on one or multiple medications and have depression
  • Outcome: Medications can lead to depression in elderly patients

6: Am J Geriatr Pharmacother. 2005 Dec;3(4):288-300.

Update on drug-induced depression in the elderly.

Kotlyar M, Dysken M, Adson DE.

Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Twin Cities, Minneapolis, Minnesota 55455, USA.

BACKGROUND: Depression is a common disorder in the elderly. Use of certain medications may be a potentially preventable cause of new-onset depression or worsening of established depression. OBJECTIVE: This paper reviews recent publications evaluating medications commonly used in the elderly as potential causes of depressive symptoms. METHODS: Relevant articles examining the association between medication use and symptoms of depression were identified through searches of MEDLINE (1996-March 2005) and International Pharmaceutical Abstracts (1996-March 2005) using the MeSH heading depression and the subheading chemically induced. Included articles were limited to those that discussed medications commonly used in the elderly and that employed a rigorous study design. RESULTS: A wide variety of medications have been implicated as potential causes of depressive symptoms in numerous reports, although many of these reports relied on data obtained from observational rather than experimental studies. The most extensively studied agents include anti hypertensives, lipid-lowering drugs, and selective estrogen-receptor modulators. The data on antihypertensive agents were contradictory; however, most studies found no association between use of the newer lipid-lowering drugs (statins) or selective estrogen-receptor modulators and the emergence of depressive symptoms. Corticosteroids, although not studied recently, generally have been associated with depressive symptoms in the older literature. CONCLUSIONS: The recent data evaluating whether medications can induce or worsen symptoms of depression are largely contradictory. This reflects a relative lack of controlled studies of this association and the difficulties in determining whether depressive symptoms are caused by a particular medication or by other factors. Nonetheless, when new or worsening symptoms of depression occur, medications should be considered a potential cause and withdrawn as appropriate. Nonpharmacologic and/or pharmacologic treatment is indicated for those whose depressive symptoms do not resolve.

Publication Types:

  • Meta-Analysis
  • Review

PMID: 16503326 [PubMed - indexed for MEDLINE]

Question: Depression: Medical Conditions

  • Patient or Population: Elderly patients
  • Intervention or Indicator: Assessing if depression can be due to a lack of vitamin B12 in elderly patients
  • Comparison or Control: Assessing elderly patients who have vitamin B12 depletion for depression
  • Outcome: Finding of various poor health measures including depression in elderly patients with low vitamin B12

7: Prev Med. 2004 Dec;39(6):1256-66.

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Library Article

Cobalamin: a critical vitamin in the elderly.

Wolters M, Ströhle A, Hahn A.

Nutrition Physiology and Human Nutrition Unit, Department of Food Science, Centre of Applied Chemistry, University of Hanover, D-30453 Hannover, Germany.

Vitamin B(12) deficiency is a common problem in elderly subjects. If a serum cobalamin level of about 150 pmol/L (200 pg/mL) is considered normal, 10-15% of the elderly are deficient. Today, however, a threshold of 220-258 pmol/L (300-350 pg/mL) is recognized as desirable in the elderly, or else sensitive markers like the blood concentration of homocysteine or methylmalonic acid (MMA) are used. Then the prevalence of cobalamin deficiency rises to up to 43%. In the elderly, this high prevalence of poor cobalamin status is predominantly caused by atrophic gastritis type B. Atrophic gastritis results in declining gastric acid and pepsinogen secretion, and hence decreasing intestinal absorption of the cobalamin protein complexes from food. About 20-50% of the elderly are affected. Furthermore, the reduced acid secretion leads to an alkalinization of the small intestine, which may result in bacterial overgrowth and thus to a further decrease of the bioavailability of the vitamin. In addition, some drugs such as proton pump inhibitors or H2 receptor antagonists inhibit the intestinal absorption of vitamin B(12). An already moderately reduced vitamin B(12) level is associated with vascular disease and neurocognitive disorders such as depression and impaired cognitive performance. Furthermore, a poor vitamin B(12) status is assumed to be involved in the development and progression of dementia (e.g., Alzheimer's dementia). This is especially observable if the folic acid status is reduced as well. Due to the insecure supply, the cobalamin status of elderly persons (>/=60 years) should be regularly controlled and a general supplementation with vitamin B(12) (>50 microg/day) should be considered.

Publication Types:

  • Review

    PMID: 15539065 [PubMed - indexed for MEDLINE]