Atypical Presentation
Depression in elderly often presents differently: somatic complaints (fatigue, pain, GI symptoms) rather than mood symptoms. Cognitive impairment (pseudodementia — depression masquerading as dementia). Irritability, apathy, social withdrawal. Sleep changes. Weight loss. Anxiety. Medical comorbidities. Underdiagnosed: only recognized in 50% of cases. Suicide: elderly men have highest suicide rate (especially white men over 85). Risk factors: chronic illness, pain, social isolation, bereavement, functional decline, medication side effects.
Screening
PHQ-9 (Patient Health Questionnaire): 9 items, scores 0-27, >=10 suggests depression. Geriatric Depression Scale (GDS): 15 items, yes/no, >=5 suggests depression. GDS is specifically validated for elderly. Assess suicide risk: ideation, plan, means, intent, prior attempts. Warning signs: giving away possessions, saying goodbye, sudden improvement (suicide plan), access to firearms. Screen all elderly at routine visits and at hospital admission.
Treatment
Psychotherapy: CBT (adapted for elderly, slower pace, practical focus), problem-solving therapy, interpersonal therapy. Medications: SSRIs (first-line: sertraline, escitalopram — fewer interactions), SNRIs (duloxetine, venlafaxine). Avoid: TCAs (anticholinergic, cardiac), MAOIs (interactions). Start low, go slow. Response: 4-8 weeks. Augment if needed. ECT: severe, treatment-resistant, psychotic, or suicidal depression — safe and effective in elderly. Address: pain, social isolation, hearing/vision, sleep, functional decline. Monitor for suicide.
Important Notes
- Depression in elderly presents differently — somatic complaints (fatigue, pain) rather than mood symptoms — and is underdiagnosed (only 50% recognized).
- Elderly white men over 85 have the highest suicide rate — assess suicide risk in all depressed elderly patients.
Clinical Tips
- SSRIs are first-line for elderly depression (sertraline, escitalopram) — start low, go slow, response in 4-8 weeks.
- Geriatric Depression Scale (GDS) is specifically validated for elderly — >=5 suggests depression. Assess at routine visits.
Summary
Depression in elderly requires recognizing atypical presentation (somatic complaints, pseudodementia), screening (GDS, PHQ-9), SSRIs, and suicide risk assessment (highest-risk group).
