Depression in older adults

Depression in older adults are overlooked as depressed older adults are less likely to endorse affective symptoms and more likely to display cognitive changes, somatic symptoms and loss of interest than younger adults. The common sign and symptoms of depressive disorders in older adults include reduced energy and concentration, insomnia, decreased appetite and somatic complains. In older adults, there is an increased emphasis on somatic complains so the presenting symptoms for depression go underdiagnosed and inadequately treated. According to DSM-5 criteria for depression includes at least one of the symptoms of depressed mood or loss of interest or pleasure, weight loss without trying, insomnia or hypersomnia, feelings of worthlessness, fatigue during the same 2week period APA, 2013).The symptom is not attributable to the physiological effects of substance use or to another medical condition. 

Evidence based treatments

While prescribing antidepressants to older adults it is important to be aware of other medical comorbidities with older adults such as cardiovascular problems, dementia, diabetes, Parkinson disease. Certain antidepressants can cause cardiac abnormalities and hypotension. Antidepressants is the effective treatment for depression in older adults and the selection of antidepressants should be based on the lowest side effect and drug to drug interaction.  SSRIs and SNRIs are relatively safe in the elderly compared to tricyclic antidepressants. SSRIs has lower anticholinergic effects than older antidepressants and thus well tolerated by patients with cardiovascular disease. Tricyclic antidepressants are no longer first line agents for older adults because of lethal in higher dose and can cause cardiac arrhythmia. The best SSRIs for elderly are citalopram, escitalopram, sertraline. They have low drug to drug interaction due to cytochrome P-450 interactions. Venlafaxine, Remeron and Wellbutrin are considered safe due to good safety profile in terms of drug to drug interactions. 

FDA approved drug for depression 

Bupropion is FDA approved drug for MDD for adults. Results showed that there is reduction in the risk of suicidality with bupropion in older adult age 65 and older (Stahl’s 2017). It may also improve cognitive slowing or pseudodementia. It is not sedative and weight gain is rare. Bupropion is generally well tolerated by older adults with few withdrawal symptoms and adverse events (Hewett k., et al., 2016). The risk factors associated with bupropion is the side effects that is caused by the actions of norepinephrine and dopamine in brain areas with undesired effects such as tremor, headache, dizziness and agitation.

Nonpharmacological therapy

 Bright light therapy is the effective treatment for depression in older adult. In Bright light therapy, patient suite themselves near a light box fitted with fluorescent tubes and the session typically takes place in the morning for a prescribed duration of time. The leading hypothesis of the light therapy is that it corrects phased-delayed circadian rhythms by activation suprachiasmatic nucleus through ocular receptor (Gilens D., et al., 2021). 

Off level drug for depression in elderly 

Buspirone is an anxiolytic, serotonin 1 A partial agonist, serotonin stabilizer and FDA approved for the management of anxiety disorders. It can be used off level for the depression and as adjunctive specially for the treatment resistant depression. Buspirone does not cause dependence, shows no withdrawal symptoms, safety profile and shows effect in 4 weeks (Fava M., 2017). There is rare risk of cardiac symptoms, no weight gain and minority sedation. The risk factors associated with buspirone is dizziness, headache, nausea, restlessness and sedation. 

APA Clinical guidelines

APA clinical guidelines for the treatment of depression in older adults recommends combined pharmacotherapy (second generation antidepressants, SSRIs, SNRIs or NDRIs) and interpersonal psychotherapy over psychotherapy alone (APA, 2021).In older adults, a comprehensive assessment of depression which include detailed history including assessment for the presence of physical comorbidity, physical examination and mental state examination to evaluate the risk factors , comorbidity, self-harm and level of dysfunction.

References 

American Psychological Association (2021). Decision making within evidence practice in

      psychology-using the APA clinical practice guidelines for the treatment of depression in

      older adults. Retrieved from www.apa.org.

Avasthi A., Grover S., (2018). Clinical practice guidelines for management of depression in

     elderly. Indian Journal of psychiatry. 60(3). 341-362. CINAHL plus. 

Fava M., (2017). The combination of bupropion and bupropion in the treatment of depression.

     Psychotherapy and psychosomatics. 76(5). 311-312. CINAHL Plus.

Hewett K., Chrzanowski W., Jokinen R., Felgentreff R., Shrivastava Rk., Wightman D., Modell

       J. G., (2016). Double-blind, placebo -controlled evaluation of extended -release bupropion in

       elderly patients with major depressive disorder. Journal of psychopharmacology. 24(4). 521-

        529. MEDLINE with full text.

Holvast F., Massoudi B., Voshaar R., Verhaak P, (2017). Non-pharmacological treatment for

        depressed older patients in primary care: a systematic review and meta – analysis. Plos One.

        12(9). 22-31. CINAHL plus.

Gilens D., K., Hoss M., Lyon C., (2021). Does light therapy decrease depression in older adults?

      American Family Physician. 104(4).417-418. CINAHL Plus.

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