Late-life depression: issues for the general practitioner

Figures & data

Table 1 Differential diagnosis of late-life depression

Central nervous system disorders (dementia, Parkinson disease, and neoplastic lesions)

Related psychiatric disorders (dysthymia, bipolar, and anxiety disorders)

Endocrine disorders (hypothyroidism, hyperthyroidism, and hyperparathyroidism)

Adverse events of some pharmacological agents (e.g., β-blockers, centrally active antihypertensive medications, steroids, H2-blockers, sedatives, certain chemotherapy agents)

Life circumstances (e.g., grief, bereavement, financial loss)

Substance use, abuse, or dependence

Infectious and inflammatory diseases (e.g., HIV encephalopathy, systemic lupus erythematosus) and sleep disorders (in particular, obstructive sleep apnea)

Note: Data from Fountoulakis et al.⁹

Table 2 Summarizing table

Patients at risk for late-life depression
• Poor physical health and frailty • Female gender • Oldest elders (≥80 years) • Cognitive impairment and neurodegenerative disease	• Nutritional deficits • Vascular events • Lifestyle: smoking, alcohol, multiple medications • Being single or widow(er)
Screening tools
GDS	CES-D	PHQ2
• Yes/no format • Takes 3–4 min to complete • Validated for the oldest elders and MMSE >10 • Preferred screening tool for Parkinson disease • Cutoff 30-item list: 10–19, mildly depressed 20–30, severely depressed • Cutoff 15-item list: ≥5, major depressive disorder	• Scoring statements with 0–3 scores • Takes 5 min to complete • Validated in patients suffering from dementia • Cutoff: ≥20, major depression	• Two yes/no questions • Takes <1 min to complete • If positive, further investigations are necessary
Treatment options based on stepped care
Nonpharmacological	Pharmacological	ECT
• Psycho-education • Psychotherapy  • Patients who prefer talking over medication  • As adjunctive therapy • Structured physical exercise  • Frequency: 3–4 times a week  • One session: 45–60 min	• Substitution therapy (when deficit is present)  • Vitamin D: 2,000 IU daily  • Folic acid: 800 µg–2 mg • Antidepressants  • SSRIs (e.g., sertraline)  • TCAs (e.g., nortriptyline)  • SNRIs (e.g., duloxetine, venlafaxine)  • Mirtazapine	Reserved for • Oldest elders (≥80 years) • Treatment-refractory depression • Psychotic depression • Depression with severe weight loss and anorexia • Psychomotor agitation or retardation
Consider referral to a mental health specialist: preference nonpharmacological treatment, persistent depression (one to three trials of antidepressants), psychosis, mania, or concern about suicide

Abbreviations: GDS, Geriatric Depression Scale; CED-D, Center for Epidemiologic Studies; PHQ2, Patient Health Questionnaire; MMSE, Mini–Mental State Examination; ECT, electroconvulsive therapy; SSRIs, selective serotonin reuptake inhibitors; TCAs, tricyclic antidepressants; SNRIs, serotonin–norepinephrine reuptake inhibitors.

Table 3 Differential diagnosis: late-life depression versus dementia

	Late-life depression	Dementia
Onset	Slow or acute	Slow and progressive onset
Evolution	Chronological order of events can be recalled	History of the disease cannot be restored by the patient
Quality of life (as experienced by the patient)	Decreased	The patient does not experience his/her disease as a problem
Memory	Decreased ability to think or concentrate or being slowed down	Decreased Impaired ability to learn new information or to recall previously learned information Patient tries to hide cognitive problems
Language and praxis	Normal	Decreased
Affect	Apathetic, depressed mood, psychomotor retardation	Lability of affect
Somatic	Sleep disturbances Somatic problems (insomnia, dizziness, pain, etc.) Low energy Diurnal mood variation	Can be present, but will not be chief complaint
Prognosis	Treatable	Irreversible

Table 4 Comparison of validated screening tools for late-life depression in primary care

	Geriatric Depression Scale (GDS)-15^Citation36	Center for Epidemiologic Studies Depression Scale (CES-D)^Citation37	Patient Health Questionnaire 2 (PHQ-2)^Citation38
What	Yes/no questionnaire	A short self-report scale of 20 statements, divided into multiple categories, designed to measure depressive symptoms over the past week	Questions depressed mood and anhedonia in the previous 2 weeks
Cutoff	5	25	Positive response to one of the two questions
Sensitivity	79%–100%^Citation37	85%^Citation39	100%^Citation4
Specificity	67%–80%^Citation37	64%^Citation39	77%^Citation4
Time to complete	3–4 min	5 min	1 min
Extra	1. Validated in the oldest elder (≥80 years) with cognitive impairment (lower limit: Mini-Mental Status Exam 10)^Citation40	Can be used for patients with patients with dementia (average Mini-Mental Status Exam score of 19)^Citation41
	2. Preferred screening instrument in Parkinson patients

Figure 1 Stepped care approach to late-life depression, based on the severity of depression and patient preference. Initiate the next step if the patient does not respond to the therapy.

Table 5 Side effects and relative contraindications of antidepressant treatment

	Important and frequent side effects	Relative contraindications
SSRIs	• Gastrointestinal irritation, nausea, or diarrhea • Parkinsonism • Increased risk of gastrointestinal bleeding (due to direct effect of serotonin on platelets) • Hyponatremia (due to syndrome of inappropriate antidiuretic hormone secretion) • Falls and fractures • Serotonin syndrome	• Bipolar disorder • Hypersensitivity • Concomitant use of monoamine oxidase inhibitors
TCAs	• Anticholinergic symptoms (constipation, dry mouth, blurred vision, and retention of urine) • Arrhythmia • Orthostatic hypotension • Falls and fractures	• Recent myocardial infarction • Heart failure • Arrhythmias • Glaucoma
SNRIs	• Gastrointestinal irritation • Sexual side effects • Headaches • Excessive sweating • Hypertension	• Disturbed liver function • Renal clearance <30 mL/min • Uncontrollable hypertension
Mirtazapine	• Sedation • Increased appetite and weight • Dry mouth	• Use of monoamine oxidase inhibitors • Hypersensitivity

Abbreviations: SSRIs, selective serotonin reuptake inhibitors; TCAs, tricyclic antidepressants; SNRIs, serotonin–norepinephrine reuptake inhibitors.

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