Experts Advise How to Maximize Treatment of Late-Life Depression

Recent advancements in geriatric psychiatry research have allowed the creation of a new evidence-based algorithm for the treatment of patients with difficult to treat late-life depression, according to two experts in the field who spoke at this year’s Annual Meeting.

The complexity of late-life patient care has increased exponentially in psychiatry in just a few decades, said Eric J. Lenze, M.D., professor and chair of the Department of Psychiatry at the Washington University School of Medicine in St. Louis. There are far more treatments available than before, including new antidepressants, augmentation agents, and interventional choices like brain stimulation.

Thirty years ago, a typical patient presenting with late-life depression might be a 65-year-old woman, with no history of mental health treatment, and taking just three medications for arthritis, hypertension, and coronary artery disease. Today, a typical patient might be 78 years old, with heart failure, stage 3 renal disease, diabetes, hypertension, and five past-year hospitalizations. She might be taking 25 medications, many of which may be CNS (central nervous system)-active, drinking alcohol daily, and taking “gummies” for sleep.

“Have you ever looked at a patient’s medication list and scratched your head, wondering ‘How did they get there?’ With so many treatments available, it raises the question of which one to choose,” Lenze said. “However, we now have enough high-quality data to create an algorithm that considers the best available data to maximize benefits and minimize risks.”

Lenze’s treatment algorithm for treating late-life depression is as follows:

Another study by this group found that 10 weeks of aripiprazole augmentation improved the chance of remission and psychological well-being significantly more than a switch to bupropion. Although bupropion augmentation also had a large positive effect, aripiprazole augmentation resulted in 67% fewer falls, Lenze explained. “Antidepressants in general are associated with an increase in falls in older adults, because they can cause orthostasis, dizziness, reduced reaction time, and unsteadiness in gait.”

Another study found that ultra-brief unilateral ECT is associated with fewer memory side effects and is better tolerated than traditional ECT among older patients. In addition, nearly 62% of patients reached remission after an average of seven treatments.

Jordan F. Karp, M.D., professor and chair of the Department of Psychiatry at the University of Arizona College of Medicine in Tucson, said the complexity of today’s late-life patients requires psychiatrists to wear many hats, including that of primary care doctor and social worker. “I address patients’ cognition, living conditions, loneliness, driving, finances, multi-morbidities, and pain. It is especially important to ensure diabetes and sleep apnea, if present, are effectively treated.”

Karp gave several additional tips to optimize treatment of late-life depression, including the following:

Clinical inertia and therapeutic nihilism often interfere with better outcomes for older adults, Karp said. For example, clinicians are less likely to optimize dosing and more likely to miss residual symptoms when treating late-life depression. Common reasons include ageism, an erroneous assumption that nothing can be done about depression in older patients, and a lack of clinic appointments to schedule needed follow-ups. Yet treating late-life depression is feasible and one of the most cost-effective ways to improve older adults’ quality of life and minimize disability, Karp said. ■