Late life depression with cognitive impairment: Evaluation and treatment

Figures & data

Table 1 Risk factors for late life depression^28,29

Gender (Women are more likely than men)

Marital status (widowed, divorced, single)

Social isolation

Alcohol use

Medications

Chronic benzodiazepine use Narcotics Antihypertensives (beta blockers) Interferon alpha

Death of spouse or close loved-one

Severe and chronic pain

Medical illnesses

Cancer Hypothyroidism Stroke Dementing Illnesses- (Alzheimer’s disease, Parkinson’s disease) Myocardial Infarction Hip fracture Coronary artery bypass surgery

Table 2 DSM-IV diagnostic criteria for episode of major depression and special considerations in late life depression

Five or more of the following 9 symptoms present nearly every day for at least 2 weeks (at least one symptom being depressed mood or diminished interest or pleasure): Depressed mood Markedly diminished interest or pleasure in almost all activities Fatigue or loss of energy Feelings of worthlessness or excessive or inappropriate guilt Clinically significant weight loss or weight gain or decrease in appetite Insomnia or hypersomnia Observable psychomotor agitation or retardation Diminished ability to think or concentrate, or indecisiveness Recurrent thoughts of death or suicidal ideation

Special considerations for older adults with depressive symptoms Coexisting memory complaints are common Many older adults believe depression is normal with aging Psychosocial risk factors for depression are common Symptoms from chronic medical illnesses (fatigue, weight loss) may overlap with depressive symptoms Older men have highest rates of suicide

Figure 1 PHQ-9 for the assessment of depression.

Table 3 Select antidepressants

Antidepressant	Initial dose	Dosage range	Pharmacokinetics	Comments
SSRI:
1. Citalopram (Celexa)	10 mg	20–40 mg	Weak inhibitor of CYP450 2D6	Well tolerated. Tramadol may increase risk of seizure
2. Escitalopram (Lexapro)	5 mg	10–20 mg	No significant action on CYP450	Well tolerated. Caution if history of seizure
3. Sertraline (Zoloft)	25 mg	50–200 mg	Inhibits CYP450 2D6 and 3A4 (weakly at low doses)	Caution with use of HMG CoA reductase inhibitors. Tramadol, Alprazolam, Thioridazine
4. Fluoxetine (Prozac)	5 mg	10–40 mg	Inhibits CYP450 2D6 and 3A4	Long half life (2 weeks). Other cautions as for sertraline
5. Paroxetine (Paxil)	10 mg	10–40 mg	Inhibits CYP450 2D6	Caution with thioridazine, drugs with anticholinergic properties and theophylline
Others:
6. Bupropion SR (Wellbutrin)	100 mg	100–400 mg	Inhibits CYP450 2D6	Increases risk for seizure. Caution with levodopa and amantadine
7. Venlafaxine XR (Effexor XR)	37.5 mg	75–225 mg	No significant action on CYP450	Increased BP that is dose dependent. SIADH, Hyponatremia. Do NOT use in uncontrolled glaucoma
8. Duloxetine (Cymbalta)	20 mg	40–60 mg	Inhibits CYP450 2D6 and 1A2	Monitor BP as it may increase. Do NOT use in uncontrolled glaucoma or with thioridazine
9. Mirtazapine (Remeron)	7.5 mg	15–45 mg	No significant action on CYP450	May increase cholesterol, cause photosensitivity and rarely lower WBC count.

Table 4 Common side effects of SSRIs

Nausea

Vomiting

Diarrhea

Anorexia (early in the treatment)

Sedation

Sexual dysfunction

Insomnia

Hyponatremia

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