Late-life depression: Managing mood in patients with vascular disease
Initiate preventive strategies to protect your patient’s brain and reduce the risk of stroke
Antidepressants. A trial of antidepressant therapy is advisable for moderate-to-severe, chronic vascular depression, even though comorbid CVD may diminish the antidepressant response. In elderly patients, start with one-third to one-half the usual adult antidepressant dosage and increase while balancing efficacy and tolerability.
Match the medication’s side-effect profile with the patient’s target symptoms (such as anxiety vs apathy).32 Selective serotonin reuptake inhibitors are probably first-line, but bupropion, venlafaxine, duloxetine, or mirtazapine may be more appropriate for some patients (Table 3).
In PSD, nortriptyline has shown a significantly greater response rate than fluoxetine or placebo in improving anxiety symptoms and recovery of activities of daily living.33 Tricyclic antidepressants’ anticholinergic properties are a safety concern in patients with heart disease, however. In general, avoid agents with substantial anticholinergic effects in elderly patients to minimize the risk of cognitive impairment and other side effects, such as urinary retention or worsening of glaucoma.
Because of the substantial risk of postural hypotension, nonselective monoamine oxidase inhibitors are probably appropriate only for geriatric patients with highly treatment-refractory depression. Dopaminergic agents such as methylphenidate in a relatively moderate dose (such as 5 to 20 mg/d) may improve apathy and social withdrawal, but research into their use in vascular depression is lacking.
Other options. Clinical experience suggests that electroconvulsive therapy (ECT) is effective for patients who do not respond to antidepressants. ECT appears quite safe in older patients, especially if not used in the first 6 months post-stroke. Strategies to reduce the risk of cognitive side effects include:
- 2 rather than 3 weekly treatments
- unilateral or bifrontal rather than bilateral treatments
- frontal lead placement.34
In the only study of transcranial magnetic stimulation (TMS) for geriatric patients with depression (N=92), those with treatment-resistant vascular depression showed higher remission rates with TMS (27.3%) compared with sham TMS (3.5%). Response rates to TMS were negatively correlated with advancing age and positively correlated with higher frontal gray matter volumes.35
Fish oil or vitamin B complex may be used to manage hyperlipidemia or nutritional deficiencies.36 Herbal preparations such as St. John’s wort (Hypericum perforatum) or S-adenosyl-L-methionine (SAMe) have shown some efficacy in adults with MDD, but further study is needed.
Table 2
Clinical management of late-life vascular depression
| Decision point | Assessment/intervention |
|---|---|
| Diagnosis | Apply DSM-IV-TR diagnostic criteria based on results of comprehensive assessment (neuropsychiatric, neuropsychological, structural neuroimaging, vascular and genetic risk factors) |
| Prevention | Identify and treat modifiable risk factors for the development or worsening of cerebrovascular disease, especially in high-risk populations (Table 4) |
| Treatment goals | Target 1: Achieve remission of depressive symptoms, improved cognition and function Target 2: Maintain remission and prevent relapse |
| Managing psychological and behavioral symptoms | Step 1: Consider psychotherapy addressing existing stressors and environmental management in patients with mild-to-moderate depression Step 2: If depression is severe or Step 1 is ineffective, an antidepressant trial* is highly recommended (Table 3); consider ECT or TMS in severe cases |
| *Avoid medications that could worsen cognition or motor functioning, such as tricyclic antidepressants or neuroleptics | |
| ECT: electroconvulsive therapy; TMS: transcranial magnetic stimulation | |
Table 3
Recommended antidepressant dosing
for elderly patients with vascular depression*
| Drug | Starting daily dosage (usual therapeutic range) | Side effect profile (patient characteristics) |
|---|---|---|
| SSRIs | ||
| Escitalopram | 5 mg (10 to 20 mg) | Nausea, headaches, GI upset, insomnia, anxiety |
| Fluoxetine | 10 mg (10 to 60 mg) | |
| Paroxetine | 10 mg (10 to 30 mg) | |
| Sertraline | 25 mg (50 to 150 mg) | |
| Others | ||
| Bupropion | 75 mg (75 to 300 mg) | GI upset, anxiety (may be useful for patients with high apathy) |
| Mirtazapine | 7.5 mg (15 to 45 mg) | Sedation, weight gain (may be useful for patients with severe insomnia or anorexia) |
| Venlafaxine | 37.5 mg (75 to 300 mg) | Nausea, headaches, anxiety, blood pressure elevation, insomnia (may be useful for patients with chronic pain) |
| Duloxetine | 20 mg (30 to 120 mg) | |
| *Avoid medications that could worsen cognition or motor functioning, such as tricyclic antidepressants or neuroleptics | ||
| GI: gastrointestinal; SSRIs: selective serotonin reuptake inhibitors | ||
Treating vascular factors
In addition to treating your patients’ depressive symptoms, collaborate with their primary care physicians to modify physiologic and behavioral factors that increase the risk for vascular injury—such as hypertension, diabetes mellitus, cigarette smoking, and hyperlipidemia. All can be controlled in presymptomatic or mildly symptomatic stages (Table 4).
Anticoagulation. In appropriate patients, anticoagulation can prevent thromboembolic strokes, although risks such as increased hemorrhagic complications must be considered.37 In elderly adults, base treatment decisions on individual risk factors, goals of treatment, and quality-of-life expectancy. In a study of low-dose aspirin (81 mg/d) and low-intensity oral anticoagulation in men at risk of cardiovascular disease, verbal fluency and mental flexibility were significantly better in men taking antithrombotic medications (especially aspirin) than in those taking placebo.38
