geropsych pearls


Here are a few factoids about depression in older adults: 

  • If your first episode of major depression is early in life, you actually do better with it as you age. You know what it’s like, you recognize it, etc. But if your first episode of MDD is in your 70s-90s, you are more likely to have very severe symptoms, including psychotic features. (So go get depressed NOW! Your mind will thank you later. J/K.)
  • ​Here’s another factoid: the most common depression-related psychotic feature is auditory hallucinations. If Grandma is hearing voices, rule out depression. If you are already treating depression, now is the time to add a pinch of antipsychotic.
  • And another factoid: Grandma hearing a bunch of voices, or a choir, may actually be SSRI-induced musical ear syndrome (MES), which is not a psychosis at all. Kind of like the auditory version of Charles Bonnet Syndrome. Tx is a referral to audiology for amplification. Scaling back the dose of the SSRI might also help.

Try this:
1.  Start with monotherapy, usually an SSRI. I like sertraline for a starter.
2.  If no improvement, try a different SSRI; eg citalopram or escitalopram. Paroxetine can be cognitively-blunting, and fluoxetine has a higher fall risk than other SSRIs.
3.  If no improvement, AND if they have concurrent insomnia OR if you also want them to gain weight, add mirtazapine.
4.  If partial response switch to venlafaxine or duloxetine (avoid duloxetine if kidney probs).
5.  If depression severe, SI, or psychosis, add a second-generation antipsychotic (SGA) – best evidence supports quetiapine, olanzapine, aripiprazole.
6.  If still no improvement, add buspirone, lithium, or lamotrigine.

And here’s another bit of trivia: “California Rocket Fuel” refers to the combo of a triphasic + biphasic (eg venlafaxine + mirtazapine). It’s overly stimulating because you are boosting NE from 2 separate agents. CRF can be useful for pts with severe vegetative sx, but be cautious. You don’t want to fix depression so aggressively that they have a stroke.

And finally: Always, always, always screen for suicide. Suicide rates are disproportionately elevated in older adults. Highest risk are white males with military service that own firearms. 

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