Last week’s eWeekly discussed the assessment of depression in older patients, and the intricate interplay between depression and cognitive impairment in older patients. This eWeekly addresses treatment of depression in older patients and how it might differ from treatment in younger adults.
First it is important to identify and address any medical contributions to a person’s depression, including treatment for an underlying medical condition or adjustment of a medication that could be causing problematic side effects. Prior to considering psychotropic medication for a patient’s depression, it is important to determine if therapy or increasing social engagement could play a role in the treatment. Related to this is determining if a patient retains the cognitive ability to participate effectively in therapy.
Psychotropic medication can be an important part of the treatment of depression, particularly in moderate-severe cases, but it is important to “start low and go slow”, to utilize the lowest effective dose and to monitor closely for side effects. Dementia, cardiovascular problems, diabetes, and Parkinson disease, which are commonly in older patients, can worsen with highly anticholinergic medications, like the tricyclic antidepressants. Because older patients are often on multiple medications, it is important to review relevant drug-drug interactions.
The selective serotonin reuptake inhibitors (SSRIs) are the first line agents in this population. Possible side effects that are particularly important to monitor for in older patients include bone loss and increased risk for falls and fractures. Measures to reduce the risk of bone loss, like exercise and calcium and vitamin D supplementation, are important to consider adjunctively. There can be an increased risk of developing hyponatremia secondary to a syndrome of inappropriate antidiuretic hormone secretion (SIADH), so sodium levels should be monitored regularly in older patients taking SSRIs or SNRIs. The best SSRIs to consider in older patients are citalopram, escitalopram, and sertraline. For citalopram, an appropriate starting dose would be 5-10 mg and increasing in 5mg increments, for escitalopram starting at 2.5 mg and increasing in 2.5mg increments, and for sertraline starting at 25mg and increasing in 25mg increments. Other appropriate medication options are the SNRIs, mirtazapine, and bupropion.
As a group, older patients with depression are more likely than younger patients to show signs of cognitive impairment, like poor concentration, apathy, and poor motivation, as part of their presentation. These cognitive defects often persist even when the depression is treated and can increase the risk of dementia. In addition, these cases are less likely to respond to antidepressant medications, with a less robust response overall and a less than 1/3 responding to a first medication trial. One option is augmenting an antidepressant medication with a stimulant medication. This is partially based on a practice that is commonly used in hospice care – stimulant medication as monotherapy for new-onset, end-of-life depression, given that it is often not possible to wait the length of time needed for the full positive effect of traditional antidepressant medications. There are side effects that need to be monitored carefully – appetite and sleep disturbance, increased irritability and moodiness when the medication is wearing off. Also this option should generally be avoided in patients with a history of substance abuse and/or concurrent anxiety symptoms. Stimulant medications can worsen anxiety symptoms.
It is our hope that this series on assessing for and treating depression in older patients has been helpful for working with older patients with depressions.