Feb 5, 2020
George T. Grossberg, MD, conducts a Masterclass on treating
mood disorders in geriatric patients from the CP/AACP
Psychiatry Update 2019 meeting in Las Vegas. The meeting was
sponsored by Global
Academy for Medical Education and
Dr. Grossberg is the Samuel W. Fordyce professor and director of
geriatric psychiatry at St. Louis University School of Medicine in
Later, Renee Kohanski, MD,
discusses the first thing psychiatrists can do for patients.
Take-home points from Dr. Grossberg:
- The prevalence of major depressive disorder among older adults
who reside in the community is similar to that of the general
population (6%). In nursing homes, the prevalence of significant
clinical depression is close to 25%.
- Depression in older adults in long-term care facilities is
underrecognized and undertreated. Risk factors for depression
include advanced age (80-90 years), loneliness and lack of social
support, painful conditions, frailty, and medical comorbidities.
Medications that are central nervous system depressants, such as
opiates and benzodiazepines, also can contribute to depression.
Alcohol can also be a depressant. Depression in the face of
cognitive impairment is extremely common and can even speed
- Apathy, defined as lack of motivation, can look like
depression. However, depression will have amotivation coupled with
vegetative symptoms, such as disrupted sleep and loss of appetite,
and mood changes, such as sadness and tearfulness. Low-dose
stimulants are effective for apathy, but antidepressants are not;
so, it’s important to differentiate the two.
- Undiagnosed and untreated depression contributes to a
significant degree of morbidity because it can slow recovery in
rehabilitative settings and impair adherence to essential
medications. Treating depression also can improve pain control by
making it more tolerable as a somatic symptom.
- Individuals older than 65 years account for more than 20% of
all completed suicides in the United States. Psychological autopsy
studies suggest that many of these individuals had undiagnosed
- Clinicians should not shy away from treating geriatric patients
for depression with medication and interventions such as
cognitive-behavioral therapy. With pharmacotherapy, start low, go
slow, and titrate up to a therapeutic dose. Older adults may take
longer, up to 8-12 weeks, to respond to SSRIs, so it’s imperative
not to give up on medications too soon.
- Electroconvulsive therapy is the most effective treatment for
severe depression in geriatric patients. Some consider advanced age
an indication for ECT; medical comorbidities are not a
contraindication for ECT.
- It is unclear how effective ketamine is in older patients, but
it deserves consideration.
- Prompt diagnosis and treatment of mood disorders is paramount
in patients of advanced age and those living in long-term care
facilities. Treating depression in the older patient also improves
the quality of life for caregivers and professional staff.
Birer RB et al. Depression in later life: A diagnostic and
therapeutic challenge. Am Fam Physician.
2004 May 15;69(10):2375-82.
Sjoberg L et al. Prevalence of depression: Comparisons of
different depression definitions in population-based samples of
J Affect Disord. 2017 Oct 15;221:123-31.
Grossberg GT et al. Rapid depression assessment in geriatric
Clin Geriatr Med. 2017 Aug;33(3):383-91.
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