Treating Depression in Older Patients PART 2

In last week’s eWeekly article, we discussed the features to be aware of in evaluations of depression in older patients, including the influence of depression and/or cognitive impairment in increasing the risk of the other condition. 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(s) for an underlying medical condition or adjustment of a medication that may be causing affective or cognitive changes as side effects.  Prior to considering psychotropic medication for a patient’s depression, it would be important to determine if psychotherapy or increasing social engagement with family or the community could play a role in the treatment.

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 carefully review for potentially 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, 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, 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, including poor concentration, apathy, and poor motivation, as part of their presentation. If these cognitive defects persist even when the depression is treated this may be an indicator of a potential risk of an evolving dementia process.  There are times when an elderly patient may be less likely to respond to antidepressant medications, either with a less robust response overall and with a poor response to a first medication trial (up to 1 in 3).  One option in such a situation is to consider augmenting the antidepressant with a stimulant medication. If prescribed potential side effects 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 significant histories of (recent) substance abuse and/or concurrent anxiety symptoms as stimulant medications can worsen make 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 in your practice.

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March 11, 2017

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