DIAGNOSIS AND TREATMENT ISSUES IN THE ELDERLY

Major depression of the elderly presents with the same features as in the general adult population. Cognitive dysfunction may be prominent. The illness may take one of two forms. First, it may be the continuation of recurrent unipolar major depressive disorder which had its onset at a much earlier age and now recurrent episodes occur at a later stage of life.

Second, the illness may have its onset in the later years. In such cases, one should be particularly receptive to the possibility that this may be secondary to a medical disorder or to medication use. Major depression in the elderly tends to run a more chronic and persistent course and may also be more liable to recurrence.

Depression is under recognized in the elderly for several reasons:
• It is often assumed that some of the symptoms of depression such as social withdrawal, fatigue, lack of energy and even a sense of despair and hopeless are explained by advancing age. This is clearly untrue.

• The overlap between depression and dementia presents numerous diagnostic challenges. Many demented patients will have secondary depression and conversely depression may manifest with predominantly cognitive abnormalities.

• The elderly may often have multiple medical diagnoses and be taking a variety of non-psychotropic medications. This may confuse the diagnostic picture and suggest depressive symptoms secondary to medical illness or medication use rather than a primary major depressive disorder.

The principles of treatment are similar to those for the adult. The first phase of treatment, acute treatment, involves the use of antidepressants with principles of treatment similar to those in adults. However, there are some notable exceptions.

First, the newer antidepressants including serotonin re-uptake inhibitors, the serotonin norepinephrine re-uptake inhibitors, Nefazadone and even the reversible inhibitors of monoamine oxidase are more appropriately used in this age group than the tricyclics antidepressants. The tricyclic antidepressants have an unacceptably high side effect burden for this population and the anti-cholinergic side effects are particularly worrisome considering their adverse effects on cognition. Furthermore, postural hypotension is a common side effect of most tricyclics and this is of particular concern in the elderly where falls can easily result in various fractures, particularly fractures of the hip.

Second, with the newer antidepressants, the aim is to achieve doses similar to those used in the adult but to go much more slowly in achieving the therapeutic dose. In some of the literature, a distinction is made between the young elderly, those less than 80 years old and the old elderly, those 80 years of age or older. It is suggested that for the young elderly the principles of acute antidepressant treatment are no different from the adult whereas in the old elderly, one has to be much more cautious even with the new antidepressants and often the same target doses as used for adults are not necessary.

Third, the duration of initial acute treatment response is in the order of 8-12 weeks rather than the 6 weeks for the general adult population. It may take substantially longer for a therapeutic response to antidepressants to be evident in this age group. The continuation phase of treatment would last about 6 months and in this respect is similar to the general adult population. In the elderly, as with the young adult, the dose used for continuation therapy is the same as that used to achieve an antidepressant response. Maintenance therapy, the prolonged use of antidepressants to prevent recurrence, is commonly employed in the elderly.

The role of electroconvulsive therapy in this age group should not be underestimated. It is a safe, rapid and effective treatment for all patients but particularly this age group. ECT means fewer difficulties with drug therapy including management of side effects and drug interactions considering that many elderly patients on a variety psychotropic and non-psychotropic medications.