1. 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