Learning Objectives

After the webinar, you should be able to:

1. Recognize the importance of treating depression in older adults.
2. Identify common risk factors and triggers for depression in older adults.
3. Differentiate between depression and normal aging.
4. Understand treatment modalities for depression in older adults

Transcript edited for clarity

Welcome to the Carlat Psychiatry webinar on treating depression in older adults. I'm Stephanie Collier, the Editor in Chief of The Carlat Geriatric Psychiatry Report. I have no financial disclosures related to this material.

Today we're going to learn about the importance of treating depression in older adults, the risk factors and triggers for depression in older adults, how to differentiate depression from normal aging, and how to treat depression.

Case Study

Mr. A is a 70-year-old retired teacher with recurrent major depressive disorder, a history of hypertension, and recent bereavement. He comes to you reporting sadness, a loss of interest, and insomnia, but he denies feeling depressed. You think about whether this is a major depressive episode or something else.

First, you need to rule out medical causes of depression. In this webinar, we'll discuss not only how to treat depression but how to know your treatment's working and how to personalize your treatment to your patient.

Late life depression

What's different about late life depression? First, let's define it.

• More likely to be accompanied by cognitive changes, somatic symptoms, and loss of interest
• Risks going undetected (half of cases) or being mismanaged
• Often comorbid with cognitive impairment or physical diseases
• Significant source of caregiver burden
• Heightened risk for dementia and suicide

Late life depression, which is often abbreviated LLD, is a major depressive disorder occurring in adults aged 60 years or older.

Older adults with depression are less likely to say they're feeling sad or depressed. Rather, they're more likely to tell you about a loss of interest in activities or to report memory problems. Older adults with late life depression are also more likely to report physical complaints like fatigue, weight loss, or pain.

Or they may have multiple unexplained medical conditions. Also, look for social withdrawal, a refusal to eat or drink, or new problems with self-care. Depression presents differently in old age. More cognitive complaints, more physical complaints, and oftentimes a lack of depressed mood. But older adults usually meet the anhedonia criteria.

Because of the overlap of depressive symptoms with medical illness, late life depression is not picked up in about half of cases. You can see how it's missed in an older patient who reports disturbed sleep, low energy, poor concentration, and changes in appetite or activity level, as these symptoms could also be due to medical disorders or aging, especially if the patient tells you they're not feeling depressed.

Older adults from racially minoritized populations are less likely than white older adults to have their depression recognized, to receive prescriptions for antidepressants, and to receive specialty mental health care in general.

Although clinicians miss about half of depression cases in older adults, depression can also be over- diagnosed. This occurs in patients with conditions like cancer that can cause fatigue and weight loss. But you probably recall that in the DSM-5, you can't diagnose major depressive disorder when symptoms are the direct physiological result of a medical condition. This is why we don't rely on positive screening tools like the PHQ 9 alone, especially in older adults with medical complexity.

Still, late life depression commonly co-occurs with medical illness, and it's often associated with cognitive impairment. Think about using a cognitive screening tool in patients with late life depression, even if it's just to establish a cognitive baseline. Especially when late life depression is accompanied by comorbid dementia, it can be a significant source of caregiver burden. Late life depression increases the risk of dementia, but it might also be a prodrome of dementia.

Finally, late life depression increases the risk of suicide. The highest suicide rates are among older men, with suicides closely associated with depression.

Understanding depression in older adults 

How common is depression in older adults? Like all disorders in psychiatry, it depends on the context. It's estimated that about 1-4% of older adults in community samples meet major depressive disorder criteria. But about 10-15% of older adults have clinically significant depressive symptoms without meeting full criteria. The prevalence of MDD increases substantially with increasing age, particularly among adults older than 85 years and those who are hospitalized or living in nursing homes.

About 30-50% of older adults living in long-term care settings experience depressive symptoms. Prevalence rates are likely to be higher in racially minoritized populations. and those of lower socioeconomic status, with the social inequalities of risk widening with age. There are a lot of risk factors and triggers for depression in older adults, but let's look at a few in more detail.

As you can see, many of the risk factors start in midlife, like cerebrovascular burden, which predicts increased depression severity over time. The most frequent chronic health conditions associated with late life depression are cardiopulmonary disorders, cerebrovascular disease, endocrine conditions, autoimmune disorders, cancer, and neurological conditions.

The best studied are hypertension, diabetes, and obesity. It's thought that the effects on late life depression are mediated through immune system activation and inflammation. Vascular and hormonal changes also influence a person's risk. For example, longer exposure to endogenous estrogens, so an older age at menopause, is associated with a lower risk of depression, whereas the post-menopausal loss of estradiol cycling increases depressive symptoms.

Another important cause of depression in older adults is post stroke depression, which occurs in about a third of people following stroke. In contrast to vascular depression, post stroke depression involves the larger blood vessels. It develops in the weeks and months following a stroke and can continue for many years. Although the correlation of post stroke depression with the stroke lesion is controversial, it's thought that a left hemispheric location or proximity to the frontal pole are likely post stroke depression risk factors. Bilateral basal ganglia damage appears to be associated with apathetic depression.

An additional risk factor for late life depression, which spans many health conditions, is insomnia. Persistent insomnia increases the risk for patients to develop a chronic relapsing course. It warrants its own attention. Insomnia also increases suicidal ideation and behavior, and it may be a modifiable risk factor for suicide.

Changes to mobility and cognition are other risk factors for late life. Depression and dementia have a bidirectional relationship. Depression in mid to late life increases a person's risk for dementia with the highest risk in patients who have persistent or worsening depressive symptoms over time. However, depression can also be a precursor or a symptom of dementia, and it can occur in all stages of dementia.

Another risk factor to think about is a patient's medications. Here you're thinking about medications like steroids that can affect a patient's mood pretty quickly.

Loss and bereavement are additional risk factors. Following the loss of a spouse, a patient's greatest relative mortality risk is between 7 and 12 months after the event. As bereavement increases a patient's suicide risk, make sure to ask about suicidal thoughts in bereaved patients.

Another important risk factor in late life is social isolation and loneliness. Up to 24% of community dwelling older adults experience social isolation, and over 40% of older adults report feeling lonely. You may have heard that loneliness and social isolation are as dangerous to health as smoking and obesity. And loneliness is an important risk factor for not just depression, but also Alzheimer's disease and generalized anxiety disorder, as well as for cardiovascular and metabolic diseases. More Americans die from loneliness and social isolation related conditions than from stroke or lung cancer.

Additional risk factors for late life depression include psychosocial factors common in later life, like financial stress or changes in a person's living situation.

Challenges in Diagnosis

Key points:

You've assessed your patient's risk factors for depression, but as we talked about earlier, symptoms of depression overlap with other medical and psychiatric conditions, as well as distress related to normal aging and life circumstances.

As older adults with depression often express their distress through somatization, you may also get a false positive for depression when asking about sleep, energy, concentration, appetite, and activity, which is a lot of the SIG E CAPS criteria, and they can all be affected by medical disorders. Sleep as a symptom is particularly challenging, as problems with sleep may be due to normal aging. Difficulty initiating and maintaining sleep, especially after age 50, is a normal part of the aging process. It's more that when a patient is experiencing apathy and anhedonia, in addition to problems with sleep, then we start thinking about depression. In normal aging, patients should still be able to feel pleasure.

In older adults, rather than going through the DSM-5 criteria, I think through physical, emotional, and cognitive symptoms of depression. I first ask about physical symptoms like pain. I then assess for anhedonia and withdrawal behaviors, because remember, older adults may have depression without sadness. I'll ask questions like, “Have you stopped attending your weekly bridge games?” I also assess for symptoms of psychosis. I then explore a patient's cognitive symptoms, as the dementia syndrome of depression improves when the depression is treated.

Complications of Untreated Depression

Key points:

Why is it so important to recognize depression in older adults? We know that untreated depression leads to poor medical outcomes. It increases disability. It leads to a lower quality of life, and it places patients at higher risk for suicide and death. Up to 87 percent of older adults who die by suicide meet criteria for major depressive disorder.

As discussed earlier, depression is also associated with worsening cognitive performance. It also advances biological aging: it shortens telomere length, and it accelerates brain aging. Depression also increases the risk of obesity, frailty, and diabetes.

Overview of Treatment Modalities

Key points:

We made the diagnosis of depression. Which treatment should we consider first? We want to avoid the common pitfalls in treating late life depression, which is often inadequately treated. The majority of patients don’t receive any treatment at all, or they may receive lower than recommended doses of antidepressants, or they’re not treated long enough to see a difference. Our goal of treatment should be remission, because if a patient responds but doesn’t remit, they’re more likely to experience disabling symptoms. They’re at a higher risk for relapse and recurrence. They’ll have worse psychosocial functioning, and they often use higher levels of healthcare. Let’s review our treatment options, including medication, psychotherapy, lifestyle changes, supportive care, and ECT and TMS.

Pharmacological Treatments

Key points: 

Let's talk about medications first. In depression without dementia, you'll probably think about an antidepressant if a patient's symptoms are moderate to severe. This is corresponding to a PHQ 9 over 10. We know that older adults treated with antidepressants experience less suicidality than those given placebo. In general, antidepressants are modestly effective for late life depression, although depression in older adults responds less well to antidepressants than depression in younger adults. Still, about half of older adults at least respond to antidepressants with greater response rates seen in longer trials, those lasting for up to three months compared to those lasting six to eight weeks. Placebo rates in older adults are the same as in younger adults.

SSRIs are first line medications, and among them, your first antidepressant trial should probably be either sertraline or escitalopram. Both have been studied in older adults and are well tolerated, and they have minimal drug-drug interactions. Sertraline's well studied in patients with cardiovascular disease, although escitalopram is my go-to medication, as patients don't need a lot of titration to get to a therapeutic dose. Basically, you can start at 5mg and increase to 10mg after one week.

You can think about SNRIs in patients with pain, although they tend to have more of a withdrawal syndrome if discontinued. I think about bupropion in patients who may benefit from something activating, or mirtazapine if a patient needs help with their appetite or sleep. Bupropion and mirtazapine are both good options in patients with a history of hyponatremia.

With any medication, remember to start low, and go slow, but go. The majority of older adults need the same dose as younger adults. It's only the very old patients, or patients with physical comorbidity, who need lower doses. About a third of older adults treated with antidepressants remit. So—two thirds of patients need additional treatment.

When should you augment? As in younger adults, augmentation strategies and late life depression are more efficacious than switching to a different antidepressant. Common augmentation strategies include lithium, bupropion, aripiprazole and methylphenidate. Older adults have a higher relapse rate than younger adults. Even with maintenance treatment, about 35 to 40 percent of depressed older adults will relapse in two years, and more than half will relapse over four years.

When should you consider the NMDA receptor channel inhibitors, ketamine and esketamine? IV ketamine resulted in a remission rate of about 12 percent of older adults, which is comparable to remission rates seen in patients who progressed to later stages of the STAR D study. In a trial of intranasal esketamine in treatment resistant late life depression, 17 percent of patients achieved remission with a number needed to treat of 10, although that study didn't detect a statistically significant difference in their primary endpoint. Secondary analyses suggested that participants with an earlier life onset of depression, or those who are less than 75 years old, had greater improvement. Both ketamine and esketamine are generally well tolerated in older adults. Their most common side effects are dizziness, dissociative symptoms, fatigue, and transiently elevated blood pressure.

Try to keep these three things in mind when using medications to treat depression in older adults. First, there's side effects. In older adults, you're also concerned about falls, osteoporosis, hyponatremia. The second is, if you're going to use an antidepressant, think about other ways to minimize polypharmacy. Think about using the START/STOPP criteria, which are available online for free. The third piece to keep in mind is that antidepressants are generally ineffective for treating depression in people with dementia. In patients with vascular depression, also think about treating their blood pressure and cholesterol.

Psychotherapy and Counseling

Let’s move on to psychotherapy and counseling. This should really be your first line treatment for mild to moderate depression in older adults. That’s a PHQ corresponding to 5 through 14. Psychotherapy is comparable with the effectiveness of antidepressants.

There are many evidence-based therapies that can help older adults beyond CBT, problem solving therapy, or behavioral activation. For example, there’s life review therapy, which is an individual or group storytelling intervention that focuses on integrating life stories through different phases in life. It’s been found to significantly improve quality of life in older patients. Interpersonal psychotherapy, or IPT, addresses depression that arises from changes in a person’s interpersonal environment. It focuses on areas frequently encountered in late life depression, like significant life changes, conflict with others, grief, isolation, loneliness, or lack of purpose.

Engage therapy is a therapy for older adults based on the idea that depression involves dysfunction of the reward system, and it uses reward exposure as its main intervention. But unfortunately, realistically, evidence-based psychotherapies are rarely used correctly in the community.

Regardless of psychotherapy choice, we know of a couple modifications that can help older adults maximize the benefits of therapy. It’s been shown that older adults benefit from shorter sessions, but a greater number of sessions. They benefit from increasing social engagement to target loneliness. They benefit from adapting to sensory impairment like vision or hearing loss, and making sure that these impairments are addressed. By optimizing sensory function, like using hearing aids, you can reduce depressive symptoms and depression risk, improve a patient’s quality of life, improve their cognitive performance. And this is especially true when vision and hearing are affected. As you would expect, older adults benefit when therapy focuses on topics that are more common in old age, like role transitions and grief

Lifestyle Interventions

Key points:

• Physical and mental activity
• Bright light therapy
• Nutrition
• Social engagement
• Action plans
• Management of sleep disturbances
• Smoking cessation and addressing alcohol use

Lifestyle interventions are often overlooked, but they're really effective in treating depression in old age, both as standalone treatments and when combined with other treatments. Where do we start here? I recommend first increasing and optimizing physical activity as it's comparable with antidepressant medication in achieving response. Adding exercise to medications is linked to higher and faster remission rates in late life depression. I next make sure patients are engaging in activities, generally pleasurable activities, that involve leaving their room or their house. I work in New England, which can be pretty gloomy in winter, so I often think about bright light therapy and not just for seasonal affective disorder.

In patients when I suspect their mood is affecting their eating habits, I might discuss referral to a dietician. For patients who are isolating, I discuss the need to optimize social activity and engagement, especially when they don't feel up to it. To set them up for success, we come up with a specific action plan during our appointment, which helps give them a sense of making progress.

If I suspect a sleep disorder, I screen patients with the Epworth Sleepiness Scale, and I refer patients for a sleep study if positive. I also treat insomnia, often using sleep restriction to limit time in bed and to optimize sleep quality. Finally, if a patient's using substances, I address this right away. Smoking is associated with higher rates of depression, and drinking alcohol is both a risk factor for late life depression and an obstacle to effective treatment. Patients are often more agreeable to giving up substances when I ask them to discontinue for a few months, while we target depression in other ways.

Role of Caregivers and Family

When seeing older adults, I often see patients together with their family members or other supports. When family members are involved, patients often have better treatment adherence and outcomes. In patients with depression, I focus on four topics with caregivers. The first is safety. In any patient with severe depression or thoughts of SI, I review a safety plan, not just with the patient, but also with the family. We may brainstorm how to decrease their access to lethal means, like removing firearms. The second topic we talk about is how family members can intervene to keep the patient from isolating themselves. Late life depression often makes patients want to stay in their room or stay in bed under the covers. It can be extremely helpful to have someone encourage them to go for a walk or to eat breakfast when they don't feel like it. I also provide psychoeducation about how to best communicate with their family member, like using supportive language, listening without judging, and giving positive reinforcement. Finally, depressive symptoms are on the spectrum, and things can move quickly. I often review a patient's warning signs, and I come up with a plan if anything changes.

Neuromodulation: ECT and TMS

What about ECT and TMS? Where do these fit in?

• ECT

• Superior to pharmacotherapy and psychotherapy but underutilized
• Rapid effect: treatment of choice for depression with psychosis or SI
• Also beneficial in LLD associated with catatonia, delusions, mania
• RUL-UB ECT achieves similar cognitive outcomes as pharmacotherapy

Older adults are more likely to have treatment resistant depression, and ECT is the treatment of choice for patients with severe and chronic symptoms, psychosis, SI. It resolves symptoms quickly. It's also a great treatment for catatonia, mania. It can help treat delusions. It's a good treatment for patients with severe malnutrition or a medical condition that worsens because they won't take their medications. Since it's the most effective treatment we have in late life depression by far, with remission rates between 70 and 90 percent, in many cases, I think about ECT first. Patients with late onset depression tend to respond better to ECT than individuals with early life depression onset. Although many patients are initially resistant because of concerns about their memory, I like to highlight that ECT has come a long way in terms of its effects on cognition. There's even a study showing that right unilateral ultra-brief treatment has the same cognitive outcomes as only treating with antidepressants after six months. I also think about adding ECT to continuation pharmacotherapy to reduce relapse rates in treatment resistant depression. However, although ECT has a high remission rate, unfortunately this needs to be balanced out by its high relapse rate after an initial ECT course. 40 to 50 percent of patients relapse within 6 months of stopping ECT, so it often makes sense to continue maintenance ECT.

• rTMS

• Well tolerated, minimal cognitive effects
• Deep rTMS compensates for brain atrophy
• Older adults respond more slowly: aim for a course of at least 6 weeks

Repetitive TMS ( rTMS) uses a pulsed magnetic field to induce a local electrical field on the brain surface, which stimulates cortical pathways. rTMS treatment of depression usually targets the dorsolateral prefrontal cortex. I think about TMS in patients who prefer neuromodulation to antidepressants, and when we're concerned about cognitive effects of ECT or who want a treatment option that is well tolerated and doesn't interact with other medications. Recent work has modified TMS to improve outcomes and to reduce burden. Bilateral deep rTMS may be able to help older adults with age associated brain atrophy, as it's able to compensate for it. And more recent work in late life depression compared rTMS to theta burst stimulation, which reduces sessions from about 47 minutes for rTMS to 4 minutes for theta burst stimulation, with a similar reduction in depression severity.

Still, TMS is less effective than ECT, although it's still an effective treatment for older adults. It's equally effective in older adults as compared to younger adults. However, older adults may need longer to respond to TMS. So try to stick with it for at least 6 weeks to see results in older adults.

Overcoming Barriers to Treatment

Key points:

• Addressing stigma
• Navigating healthcare systems
• Financial considerations

We have seen that there are many treatments for late life depression. But not every older adult with depression ends up on the right treatment. What's standing in the way? And what can you do as a clinician? Although this isn't unique to late life depression, think about stigma and how it flavors the experience of your patients. Unfortunately, stigma against mental disorders is even greater in later life.

An example is the stigma against agitation in people with dementia, many of whom spend days or weeks in emergency rooms because long-term care facilities will no longer admit them, and our society has not provided alternatives. Keep this in mind as you advocate for the right level of care for your patient.

Equally sadly, there are more people with severe mental disorders, excluding dementia, and substance use disorders who are aging in prisons and jails than in hospitals in the U.S. As mental illness is so stigmatized in older adults, think about your word choice when working with patients and families. To avoid an “I'm not depressed” response, which is a barrier to making the right diagnosis and receiving the right treatment, it's more helpful to use words from the patient's own speech, like using the words “worrying” or “not sleeping” or “stressed.” And then asking family caregivers for their perspectives.

Another thing you can do to help your patients with late life depression is to help them navigate their healthcare system, help them understand where to go, advocate for their treatment needs, and do what you can to make the messy maze of finding care a little easier for them. For example, consider referring your patient to an agency that can provide in home support to help address social isolation and loneliness. Although there are others who specialize in the financial piece, we can still help our patients struggling with the cost of treatment. This could be by showing them how to find a Goodrx coupon, or considering cheaper treatment alternatives, or spending a moment to understand their insurance, or finding free resources like the CBT-i Coach mobile app for insomnia.

Optimizing Outcomes in Geriatric Depression: Next Steps for Mr. A

Getting back to our case, you're pretty sure Mr. A is experiencing late life depression as he has a history of depression and reports sadness, loss of interest, and insomnia. What are your next steps? First, before making the depression diagnosis, you want to rule out the common medical causes. For more information. You want to get labs to rule out any treatable medical disorders that mimic depression. This includes a complete blood cell count, comprehensive metabolic panel, urinalysis, thyroid labs, a B12 level. In some patients you'll think about estradiol and testosterone levels, as well as vitamin D or folate. A C-Reactive Protein level can be helpful if you're wondering about an ongoing inflammatory process. You might also consider neuroimaging or a sleep study. Given Mr. A's hypertension, it would make sense to monitor his blood pressure and to think about optimizing any of his cardiovascular risk factors.

If no underlying medical cause is found, you next want to optimize Mr. A's psychiatric treatment. If he's already taking antidepressants, you probably want to change what he's taking. You may want to increase his dose or add an augmentation agent, but resist the temptation to continue an ineffective medication.

How do you make sure he's improving after changing his meds? I recommend monitoring improvement with a scale. I use a 15 item Geriatric Depression Scale, or GDS. If therapy is an available option and Mr. A is agreeable, this would be another good treatment option, and it would also be the preferred option for mild to moderate symptoms.

Mr. A would also likely benefit from lifestyle interventions, especially given his cardiovascular risk factors. This includes increasing his physical activity and social engagement. You might ask Mr. A to identify a goal for the next two weeks, like 30 minutes of brisk walking outside every day. Don't forget to treat his insomnia. You may think about brief behavioral treatment for insomnia or cognitive behavioral treatment for insomnia, or maybe even mirtazapine. Just keep in mind that sleep hygiene is never enough on its own and doesn't change outcomes if it's the only intervention. Finally, you want to involve his family in his treatment, especially to help support him during bereavement.

CARLAT TAKE

First, make sure it's depression and not normal aging, or dementia, or delirium. Make sure to rule out an underlying medical cause and to think about medical contributors. If you're treating with medications, make sure to tailor them to the patient. Don't continue ineffective medications. Think about drug interactions. If your patient is receiving psychotherapy, think about some of the modifications that have been shown to improve outcomes in older adults, like shorter but more numerous sessions, and focusing on interventions that target loneliness, as well as optimizing sensory function. Finally, you want to make sure that what you're doing is working, that patients really are getting better. Consider using scales like the GDS to monitor improvement, and keep hyponatremia, falls, and osteoporosis in mind when using antidepressants in older adults.

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