Applied Evidence

Tips for treating patients with late-life depression

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Zeroing in on the right drug regimen requires a look at an agent’s clinical benefits, tolerability profile, and risk of drug interactions, as well as the patient’s comorbidities.


› Begin treatment with a selective serotonin reuptake inhibitor (SSRI) unless another antidepressant has worked well in the past. A

› Consider augmenting therapy with bupropion XL, mirtazapine, aripiprazole, or quetiapine for any patient who responds only partially to an SSRI. C

› Add psychotherapy to antidepressant pharmacotherapy, particularly for patients who have difficulties with executive functions such as planning and organization. B

Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series



Late-life depression is the onset of a major depressive disorder in an individual ≥ 60 years of age. Depressive illness compromises quality of life and is especially troublesome for older people. The prevalence of depression among individuals > 65 years of age is about 4% in women and 3% in men.1 The estimated lifetime prevalence is approximately 24% for women and 10% for men.2 Three factors account for this disparity: women exhibit greater susceptibility to depression; the illness persists longer in women than it does in men; and the probability of death related to depression is lower in women.2

Beyond its direct mental and emotional impacts, depression takes a financial toll; health care costs are higher for those with depression than for those without depression.3 Unpaid caregiver expense is the largest indirect financial burden with late-life depression.4 Additional indirect costs include less work productivity, early retirement, and diminished financial security.4

Many individuals with depression never receive treatment. Fortunately, there are many interventions in the primary care arsenal that can be used to treat older patients with depression and dramatically improve mood, comfort, and function.

The interactions of emotional and physical health

The pathophysiology of depression remains unclear. However, numerous factors are known to contribute to, exacerbate, or prolong depression among elderly populations. Insufficient social engagement and support is strongly associated with depressive mood.5 The loss of independence in giving up automobile driving can compromise self-confidence.6 Sleep difficulties predispose to, and predict, the emergence of a mood disorder, independent of other symptoms.7 Age-related hearing deficits also are associated with depression.8

There is a close relationship between emotional and physical health.9 Depression adds to the likelihood of medical illness, and somatic pathology increases the risk for mood disorders.9 Depression has been linked with obesity, frailty, diabetes, cognitive impairment, and terminal illness.9 Other conditions associated with depression include Parkinson disease, alcohol dependence, and chronic pain.10-12 Cerebrovascular disease may predispose to, precipitate, or perpetuate this mood disorder.13

Inflammatory markers and depression may also be related. Plasma levels of interleukin­-6 and C-reactive protein were measured in a longitudinal aging study.14 A high level of interleukin-6, but not C-reactive protein, correlated with an increased prevalence of depression in older people.

Escitalopram is often better tolerated than paroxetine and has fewer pharmaceutical interactions, compared with sertraline.

Chronic cerebral ischemia can result in a “vascular depression”13 in which disruption of prefrontal systems by ischemic lesions is hypothesized to be an important factor in developing despair. Psychomotor retardation, executive dysfunction, severe disability, and a heightened risk for relapse are common features of vascular depression.15 Poststroke depression often follows a cerebrovascular episode16; the exact pathogenic mechanism is unknown.17

Continue to: A summation of common risk factors


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