arc E. Agronin, MD, on Depression in Late Life: Key Differences
In this video, Psych Congress 2020 presenter Marc E. Agronin, MD, discusses the differences between depression in late life and depression in younger people. Dr. Agronin, a geriatric psychiatrist, is the senior vice president for Behavioral Health and chief medical officer for MIND Institute at Miami Jewish Health in Florida.
Late-life depression was among the topics Dr. Agronin discussed in his presentation at the virtual conference, "The Top Dos and Don’ts in the Psychopharmacologic Treatment of Geriatric Patients: Focus on Dementia and Late-Life Depression and Anxiety" .
Without question, we see similar forms of depression in late life as we see in younger individuals. There are however a number of key differences to keep in mind.
First of all, we need to put out of our minds this stereotype that older people are by necessity more depressed because of being older. It's simply not true. In fact, the prevalence rates for major depressive disorder actually go down in late life, from a rate of roughly 6 to 7 percent in the population for younger individuals, to about 2 percent in older individuals.
Nonetheless, if we look within hospitalized individuals, individuals with neurocognitive disorder or chronic medical illnesses such as diabetes, post-stroke, Parkinson's disease, we clearly see increased rates of different depressive syndromes. What are some of the key differences?
First of all, probably up to a third of older individuals with depression also have changes in executive function, often due to damage between, in the frontal limbic circuits in the brain. These individuals may have slight memory changes, decrease in executive function. They really struggle with depressive symptoms.
A lot of the compensatory mechanisms in the brain that help us cope with depression to work therapeutically to improve it are damaged, and so without question, these individuals tend to have a more difficult course. It's more challenging to help them with psychotherapy and with medications. In general, we tend to see, both in these individuals and across the board in late life, a slightly lower response rate to antidepressants. It often means that we need to be more persistent and more creative in our use of medications.
Sometimes, depression presents in late life, especially within the setting of cognitive impairment, less in terms of mood symptoms, although we certainly see those, but more in terms of behavioral symptoms, so, irritability, agitation, resistance to care, someone who's just not really meeting goals and in rehab, physical pain, social isolation, resistance to care. Sometimes, these can be the hallmarks of depression in late life that we will not see as much earlier in life, and so it's important to be aware of those.
Finally, I'd say keep in mind the following. Even though across these different subtypes of depression in late life we might see less responsiveness to treatment, nonetheless, we have to be persistent.
We know that in general, all antidepressants work better than placebo. We also need to incorporate psychotherapy, and there are modalities like problem‑solving therapy which can be really helpful in late life. Cognitive behavioral therapy can be very helpful for many individuals.
When we combine this type of psychotherapy with medications, with a lot of support, we will provide the best therapeutic approach that can address some of these key differences in how depression may manifest and unfold in older individuals.