Elderly depression

Depression. Like delirium, depression is an illness that is common among the elderly and that can occur either apart from or concurrently with dementia. Elderly depressed patients often have poor concentration and poor motivation and appear... 

Clearly the major advantage of all the recently introduced antidepressants lies in their relative safety in overdosage and reduced side effects. These factors are particularly important when considering the need for optimal patient compliance and in the treatment of the elderly depressed patient who is more likely to experience severe side effects from antidepressants. 

Gaillard JM, Blois R, Couto L, et al Modifications of paradoxical sleep by desipramine in elderly depressed patients. Advances in Biological Psychiatry 13 224-228, 1983... 

Executive tasks, e.g. tests of verbal fluency and attentional set-shifting (such as card sorting tasks), are significantly impaired in patients with more severe depression and in elderly depressed patients. 

With regard to its effects on cognitive performance in the target population, the SSRI sertraline appears to be the most thoroughly studied newer antidepressant. Lane and O Hanlon (1999) listed three controlled clinical studies with fluoxetine and three with sertraline however, all three trials with fluoxetine and one of the trials with sertraline were not sufficiently powered to demonstrate reliable differences between treatments. One of the two adequately powered studies, a comparison between nortriptyline and sertraline in elderly depressed patients (Bondareff et al., 2000 see Box 7.3), supports the notion that antidepressants with anticholinergic action (such as nortriptyline) are similarly... 

Kitanaka I, Ross RJ, Cutler NR, et al. Altered hydroxydesipramine concentration in elderly depressed patients. Clin Pharmacol Ther 1982 31 51-55. 

Georgotas A, McCue RE, Cooper TB. A placebo controlled comparison of nortriptyline and phenelzine in maintenance therapy of elderly depressed patients. Arch Gen Psychiatry 1989 46 783-786. 

Although ECT is a relatively costly form of treatment, one study in elderly depressed patients who responded to an acute course demonstrated that maintenance ECT reduced the overall cost of medical care and the relapse rate as compared with patients on maintenance medication after ECT ( 87). The reduced costs were evident at the 12-month follow-up, primarily through decreased hospital use. In addition, this strategy was also associated with improvements in functional status and cognition. 

Kelsey MC, Grossberg GT. Safety and efficacy of caffeine-augmented ECT in elderly depressives a retrospective study. J Geriatr Psychiatry Neurol 1995 8 168-172. 

Rondanelli, M., Giacosa, A., Opizzi, A., Pelucchi, C., La Vecchia, C., Montorfano, G., Negroni, M., Berra, B., Politi, P., and Rizzo, A. (2011). Long chain omega 3 polyunsaturated fatty acids supplementation in the treatment of elderly depression Effects on depressive symptoms, on phospholipids fatty acids profile and on health-related quality of life. J. Nutr. Health Aging 15, 37-44. 

The side effects and cardiotoxicity of the tricyclic antidepressants have been discussed in detail elsewhere in this volume and, while there is ample evidence of their therapeutic efficacy, it seems difficult to justify their use, particularly in a group of patients who are most vulnerable to their detrimental side effects. Of the newer antidepressants, the reversible inhibitors of monoamine oxidase type A such as moclobemide may also be of value in the elderly depressed patient, particularly in those patients who fail to respond to the amine uptake inhibitor type of antidepressant. 

The safety of antidepressants should be the first priority for the elderly. For this reason, the second-generation antidepressants, or the atypical tricyclic antidepressant lofepramine, should be the drugs of choice. Undoubtedly the SSRI antidepressants have a major role to play and of these, citalopram and fluvoxamine have been extensively studied in the elderly depressed patient. 

Altamura, A. C., De Novalis, F., Guercetti, G. et al. Fluoxetine compared with amitriptyline in elderly depression a controlled clinical trial. Int. ]. Clin. Pharmacol. Res. 9 (1989) 391-396. 

There is growing interest in using stimulants, particularly methylphenidate, in the management of elderly depressed patients, either alone (44) or in combination with antidepressants such as citalopram (45). In a preUminary trial in 10 elderly patients a combination of methylphenidate and citalopram was well tolerated. 

Lavretsky H, Kumar A. Methylphenidate augmentation of citalopram in elderly depressed patients. Am J Geriatr Psychiatry 2001 9(3) 298-303. 

Depression in the elderly is a major public health problem. Many elderly depressed patients are often inadequately treated, or depression is missed or mistaken for another disorder, such as dementia. In the elderly, depressed mood, the typical signature symptom of depression, may be less prominent than other depressive symptoms such as loss of appetite, cognitive impairment, sleeplessness, anergia, and loss of interest in and enjoyment of the normal pursuits of life. Somatic (physical) complaints are quite frequently the presenting symptoms in elderly depressed patients. The increased suicidal attempts present in the depressed elderly may be due to access to firearms, diminished cognitive functions, sleep disruptions, poor social interactions, and inattention among primary caregivers. Approximately every 95 minutes an elderly person commits suicide. ... 

I Useful in the elderly, depression with anxiety/OCD, suicidal patients (safer in overdose than tricyclics). 

Lorazepam may be useful for anxiety or insomnia in elderly depressed patients without impairing the response to treatment with nortriptyline. Studies on the effects of alprazolam, chlordiazepoxide, diazepam, nitrazepam and oxazepam on the steady-state plasma levels of nortriptyline found no interaetions. 

Lucassen PJ, Stumpel MW, Wang Q et al (2010) Decreased numbers of progenitor cells but no response to antidepressant drugs in the hippocampus of elderly depressed patients. Neuropharmacology 58 940-949... 

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