1. Depression in older adults is clinically different to that in younger patients.
There are key differences in the prevention of depression in elderly people compared with younger age groups. Psychomotor impairment, agitation and psychosis are more likely to be part of the picture. Somatisation and hypochondriasis are also more common.
Older patients are also more likely to present with co-existent anxiety. One community-based study of people aged between 55 and 84 found 47.5% of those with major depressive disorder also met the criteria for anxiety disorders, while 26.1% of those with anxiety disorders also met criteria for major depressive disorder.1
Older people are less likely to recognise the symptoms of depression than younger people, tending to explain them away as a consequence of ageing – a tendency that is still too often seen in health professionals.
2. A suicide attempt in an older person is less likely to be a parasuicide and needs to be taken very seriously.
Suicide attempts in the elderly are a much stronger predictor of subsequent completed suicide than they are in younger people. The highest ratio of suicide attempt to completed suicide is among young women, at 200:1, but this drops down to 4:1 in older people. Older people who attempt suicide are more likely to die than younger people and the prognosis is worse for those who survive. Men who live alone are at greatest risk.
3. Aim to cover five areas in the consultation:
• Mental state assessment (see point 4)
• Suicide risk assessment
– Do you feel that life is not worth living any more?
– Do you think that you may act on this?
– Have you made any plans?
– Have you ever tried before?
• A focused neurological exam, blood pressure and pulse
• Lab tests as appropriate: FBC, U&E, LFTs, TFTs, blood glucose, B12 and folate.
4. Use a rating scale that’s been validated in older people.
PHQ-9 has been validated in a population of over-60s in the US and the Hospital Anxiety and Depression Scale (HADS) identifies similar numbers of patients regardless of their age. But I would recommend using the Geriatric Depression Scale (GDS). The original GDS was a 30-item questionnaire, but later, shorter versions contain only the most useful questions.
GDS-15 is ideal for diagnosis, evaluating the clinical severity of depression and for monitoring treatment response. It is easy to use, needs no specialist psychiatric knowledge and has been well validated in many environments including primary care.2
GDS-4 is a very short version that asks:
• Are you basically satisfied with your life?
• Do you feel that your life is empty?
• Are you afraid that something bad is going to happen to you?
• Do you feel happy most of the time?
A score of two or more indicates probable depression. This has been shown to be as effective as the longer forms of the scale in screening for depression in older people.2
5. Older people are just as likely to benefit from psychological therapy as younger adults.
The criteria for psychological therapy referral shouldn’t be any different in older patients. Psychological therapies – particularly cognitive behaviour therapy, interpersonal therapy, and problem-solving therapy – have been shown to be equally effective in older and younger adults with depression.
Combined psychological therapy and pharmacological therapy has been shown to be more effective than psychological treatment alone among older patients with depression.3
If a patient has mild depression or is showing some signs of depression, then increasing social contact and adding some structure to the day can help. This could involve visiting a day centre or accessing befriending networks. Exercise therapies have also been shown to improve depressive symptoms in older patients.
6. An SSRI – particularly sertraline, citalopram or escitalopram – is first choice in an older patient.
There is a good evidence base for SSRIs generally in older people, and citalopram, escitalopram, and sertraline are probably safest in those with coexisting physical illness as they have the lowest potential for drug interactions.
7. Remember that response to antidepressant treatment may take longer in older patients.
We’re used to telling patients they should wait at least six weeks to see a treatment effect. But a 2008 meta-analysis of newer antidepressants (venlafaxine and mirtazapine as well as SSRIs) in older adults showed that trials lasting longer than 10 weeks had a greater response rate than those that were shorter.4
8. SSRIs can increase the risk of gastrointestinal bleeding.
You should bear this in mind in patients taking NSAIDs, aspirin, warfarin, clopidogrel or heparin. You could consider an alternative antidepressant, but be realistic – especially with regard to the use of NSAIDs – and consider a proton pump inhibitor if you feel the patient could benefit from an SSRI. Alternatives can cause their own problems – for example, mirtazapine can interact with warfarin and increase the INR.
9. There are options if first-line treatments fail.
The best evidence of what to do comes from a US systematic review published earlier this year that looked at 13 studies in which older people went on to be treated with a second therapy after inadequate response to the first, usually an SSRI. There were two broad groups – those who went on to another antidepressant (such as venlafaxine, duloxetine or phenelzine) or those who had lithium or an antipsychotic added in. Overall, the response rate was 52% – although lithium was the only therapy with success replicated in more than one trial.5
10. Know when to refer.
Refer to specialist care if there is substantial risk of suicide or self-harm, poor response to two antidepressants at therapeutic doses, psychosis or cognitive impairment.
Risk factors for suicide in older patients
• Living alone
• Recent bereavement
• Social isolation
• Previous attempts
• Evidence of planning
• Chronic, painful illness
• Impaired sleep
• Vulnerable personality – hopeless or helpless, rigid, unable to sustain close relationships
• Drug or alcohol use
Dr John Lewis is a mental health GPSI in Newport, Gwent
1 Beekman AT, de BE, van Balkom AJ et al. Anxiety and depression in later life: co-occurrence and communality of risk factors. Am J Psychiatry 2000;157:89-95
2 Pomeroy IM, Clark CR and Philp I. The effectiveness of very short scales for depression screening in elderly medical patients. Int J Geriatr Psychiatr 2001;16:321-6
3 Cuijpers van Straten A, Warmerdam L and Andersson G. Psychotherapy versus the combination of psychotherapy and pharmacotherapy in the treatment of depression: a meta-analysis. Depression and Anxiety 2009;26:279-88
4 Nelson JC, Delucchi K and Schneider LS. Efficacy of second-generation antidepressants in late-life depression: a meta-analysis of the evidence. Am J Geriatr Psychiatry 2008;16:558-67
5 Cooper C, Katona C, Lyketsos K et al. A systematic review of treatments for refractory depression in older people. Am J Psychiatry 2011;168:681-8