Depression in Older Adults Depression is common in older adults, and especially prevalent in older adults with chronic illnesses EPIDEMIOLOGY OF DEPRESSION   A diagnosis of depression is associated with increased length of hospitalization, increased medical costs, and a higher rate of readmission. Risk factors of depression include specific diagnoses of MI, CVA, or malignancy. 50% of patients who commit suicide were seen by a provider in the preceding 30 days. Risk factors for suicide: living alone, male, alcoholism, comorbid physical illnesses. Suicide is a significant risk in older adults, men more than women. Older men are at highest risk for completed suicide (15% of population, 25% of suicides). Older individuals are more susceptible to medication toxicity such as serotonin syndrome. Early dementia may co-occur with late onset depression. TREATMENT OF NON-PSYCHOTIC MAJOR DEPRESSIVE DISORDER IN PRIMARY CARE Pearls of Wisdom Pearls for SSRIs:  Sertraline is the preferred SSRI in patients with CAD/CVD. Fluoxetine has a very long half-life; avoid in patients who have had ADRs to previous SSRIs. Hyponatremia – Risk with SSRIs, SNRIs; increased risk in elderly, women and patients on thiazides. Sexual Dysfunction – Sexual dysfunction can be seen when treating depression with pharmacologic therapies. Of the treatment options, mirtazapine and buproprion have the lowest incidence of sexual dysfunction.   Pearls for SNRIs and Other:  Mirtazapine – Good in patients with decreased appetite and insomnia. Avoid SNRIs and Buproprion in patients with uncontrolled hypertension (or those on >2 antihypertensives). Duloxetine – Potential complications include abnormal bleeding and hepatic failure. Partial Response No response Partial Response No response Key: BUP = bupropion SR/XL BUS = buspirone CBT = cognitive behavior therapy MRT = mirtazapine SNRI = serotonin-noreprinephrine reuptake inhibitor SSRI = selective serontonin reuptake inhibitor Medications Associated with Depression No response SSRIs SNRIs Other Citalopram Escitalopram Fluoxetine Duloxetine Venlafaxine Mirtazapine Buproprion Fluvoxamine Paroxetine Sertraline Varenacline Benzodiazepines & other sedative hypnotics Opiates Isotretinoin Finasteride (high dose) Leukotriene antagonists Anti-hypertensives – (Weak Association) CBT (Cognitive Behavioral therapy) is an option before starting or in combination with pharmacotherapy at any stage in the algorithm. Reference: Espinoza, RT and J Unutzer. Diagnosis and management of late-life depression. In: UpToDate, Solomon, D. (Ed), UpToDate, Waltham, MA, 2013 UpToDate Funded by D.W. Reynolds Foundation