Janimine

The National Institutes of Health recently convened a consensus development conference to examine the data on the epidemiology, pathogenesis, pathophysiology, prevention and treatment of depression in the elderly. The following information is from a draft of the statement developed at the conference. A copy of the complete statement, "Diagnosis and Treatment of Depression Late in Life," can be obtained by calling 301-496-1143.

Diagnosis of Depression

The recognition of depression may be more difficult in the elderly population. Both physicians and patients may incorrectly attribute depressive symptoms to the aging process. They may not fully appreciate the degree of impairment because of lower functional expectations in this age group. Symptoms of depression may differ because elderly persons may more readily report somatic symptoms than depressed mood. Both the patient and the physician are often more concerned about concurrent medical conditions, and depressive symptoms may be overlooked. In addition, the presence of dementia may compromise accurate recognition and reporting of symptoms.

No specific diagnostic test can be recommended for clinical practice. Impaired dexamethasone suppression of the hypothalamicpituitary-adrenal axis is observed in elderly patients with depression but is not sufficiently specific to have diagnostic use. Similarly, response to thyroid-stimulating hormone, platelet monoamine oxidase activity (MOA), and platelet imipramine and [alpha.sub.2] binding may be altered nonspecifically in a subset of patients. Further research is clearly needed to refine diagnosis. Presently, an attentive and focused clinical interview remains the mainstay for the diagnosis of depression.

Epidemiology

The major social and demographic risk factors for depression in the elderly are generally similar to those of younger persons. Women, the unmarried, particularly the widowed, those with stressful life events and those who lack a supportive social network are at increased risk of depression.

In the elderly, the coexistence of physical conditions (e.g., stroke, cancer, dementia) and depression has been confirmed in numerous studies. Although depression may be an effect of such disorders, it might also enhance vulnerability to certain disorders, particularly of the immune system.

The course of depression in elderly persons is similar to that in younger persons. Recurrence s a serious problem; up to 40 percent of people continue to experience depression over time.

Pharmacologic Treatment

Evidence from more than 25 randomized, double-blind trials indicates that antidepressants are more effective than placebo in the treatment of acute depression. Approximately 60 percent of patients clinically improve with antidepressant therapy, but many of them retain significant residual symptoms.

Most of the antidepressants are thought to be equally effective in the elderly. The most commonly used and studied antidepressants have been nortriptyline (Aventyl, Pamelor) and desipramine (Norpramin) because they have a more favorable side effect spectrum than traditional antidepressants, such as amitriptyline (Elavil, Endep) and imipramine (Janimine, Tofranil). Most clinicians avoid these latter two medications because they cause significant orthostatic hypotension, and because elderly patients are especially sensitive to their anticholinergic, cardiovascular and sedative side effects.

Based primarily on clinical experience, many clinicians favor the newer antidepressants trazodone (Desyrel), bupropion (Wellbutrin) and fluoxetine (Prozac) because they are associated with fewer anticholinergic and cardiovascular side effects. Contrary to widespread clinical opinion, the use of MAO inhibitors, especially phenelzine, has been generally found to be safe and effective, but they remain underused for the treatment of geriatic depression.

Little is known about the factors that predict response, including clinical symptoms, demographics, subtype, comorbidity or radiologic findings. However, considerable evidence indicates that response depends on adequate length of treatment, dose and blood level of the medication.

Full clinical response is primarily dependent on administering therapeutic doses that achieve adequate blood levels. Measurement of plasma drug levels in elderly patients is even more important than in younger patients because of the increased importance of attaining appropriate therapeutic levels and avoiding toxicity. Significant response to antidepressant therapy often occurs later in elderly patients than in younger patients. Six to 12 weeks of therapy are often required.

Medication compliance by elderly people is an especially important and difficult issue. According to one estimate, 70 percent of patients fail to take 25 to 50 percent of their medication. Lack of compliance, producting wide fluctuations in plasma levels, has been shown to be predictive of poor outcome.

Maintenance Therapy

Because of the increasing recognition that the majority of patients with major depressions have recurrence, the central issue in treatment is the prevention of recurrence. Continuation of antideprassants has been shown to confer significantly greater protection against recurrence than placebo. Although physicians often reduce doses during the maintenance phase, preliminary evidence suggests that continuation of the dose and plasma level that was effective in the acute treatment phase offers increased protection against recurrence.

Evidence suggests that treatment should be maintained for six months after remission from a first episode of major depression and 12 months f longer after a second or third episode. Remission over extended follow-up continues in approximately 80 percent of patients maintained on doses that led to their recovery.

Electroconvulsive Therapy

Electroconvulsive therapy (ECT) has an important role in the treatment of depression in the elderly. Evidence for the short-term efficacy of ECT is strong. Relapse after effective ECT is frequent, and alternative treatment strategies, including maintenance ECT or maintenance antidepressants following ECT, require further study.

ECT is often stated to be safer than antidepressants, although this has not been documented in controlled trials. Limited data suggest that advancing age heightens the probability of transient post-ECT confusion, especially in the very old. Additional risk factors include use of psychotropic medication during ECT, concurrent major medical illness and preexisting cognitive deficits.

Psychosocial Treatment

Psychosocial treatment is important because of the broad range of functional and social consequences of depression in elderly people. Biologic treatment, including pharmacologic therapy or ECT, will not resolve all of the problems associated with depression in the elderly. For example, psychosocial support and new coping skills may be needed to help patients deal with significant and continuing life events, altered life roles, lack of social support and chronic medical illnesses. Moreover, some patients will strongly prefer nonbiologic intervention, and others will not be suitable for biologic treatment because of side effects, interactins between drugs and comorbid medical conditions.

A number of problems in the use of psychosicial treatment require study. Many elderly people do not see themselves as depressed and/or will not admit to being depressed and will reject referral to mental health professionals. Special effort might be needed to engage these individuals in treatment. Patients with significant physical illness and disabilities (e.g., visual and hearing impairment) and cognitive impairment may require special approaches.

Comorbidity

Depression in the elderly frequently coexists with multiple chronic diseases and disabilities (e.g., cancer, cardiovascular deases, neurologic disorders, various metabolic disturbances, arthritis and sensory loss). These conditions create psychosocial concerns, medical and physiologic burdens, and functional disabilities that may directly contribute to the development of depressive symptoms as well as complicate treatment. However, current data indicate that depresive symptoms respond to treatment in most patients.

The evidence is contradictory concerning whether concurrent medical illness has an adverse effect on response to treatment. Although medical comorbidity may result in increased vulnerability to side effects, vigorous but careful treatment is still indicated.

Very few controlled trials have been performed to assess treatment of secondary depression after the medical condition is stabilized. Also, patients with known brain lesions should be treated with the same guidelines and does as patients without known brain lesions, except as specifically contraindicated. Based on the limited data available, these patients can be expected to respond as well as patients with primary depression.

COPYRIGHT 1992 American Academy of Family Physicians
COPYRIGHT 2004 Gale Group