[A version of this item appears in: Dementia: the Latest Evidence Newsletter (RWHT), Volume 3 Issue 2, September 2012].
This article summarises effective strategies for the detection and treatment of late-life depression. Older patients can be screened for depression using a standard rating scale. It is then possible to initiate treatments such as antidepressants or evidence-based psychotherapy, and to monitor depression symptoms. Patients who do not improve can be considered for psychiatric consultation and more radical treatments.
It is not uncommon for changes of treatment approaches to occur before patients achieve complete remission. Maintenance treatment and relapse-prevention planning reduce the risk of relapse. Important strategies include provision of summaries of the early warning signs for depression, maintenance treatments such as medication, and other strategies to reduce the risk of relapse; for example, regular physical activity or pleasant activities.
Collaborative programs, in which primary care clinicians work closely with mental health specialists appear to be more effective than primary care treatment alone (in the USA).
Neurological Conditions Which May Worsen or Contribute to Depression
Effective treatment of depression may improve cognitive functioning in patients without a prior history of cognitive impairment. Cognitive impairment first presenting in the context of depression may, however, be a sign of early dementia. Persistent cognitive deficits after treatment of depression should be evaluated. Cognitive screening can identify impairments which may be related to depression, delirium, or dementia.
The following factors suggest that cognitive deficits may be related to depression rather than dementia:
- Depressed affect, mood, or both.
- Neurovegetative signs such as poor energy, appetite, or sleep.
- Long response latency.
- Frequent responses of “I don’t know”.
- Little effort: quick to give up.
- Slow speech and movements.
- Patient “concerned” about cognitive difficulties.
- Movement, writing, and speaking may be slow: for example a marked slowing down in thought processes while language and memory functions remain relatively unaffected.
Full Text Link (Access to this article requires an Athens password, a journal subscription or a one-off payment).
Unützer, J. Park, M. (2012). Older adults with severe, treatment-resistant depression. JAMA: the Journal of the American Medical Association, September 5th 2012, Vol.308(9), pp.909-18. (Click here to view the PubMed abstract).
Possibly of interest:
Electroconvulsive Therapy (ECT)
The subject of ECT is not often touched-upon, as it is no longer in vogue. The authors of the above article do address it. Immediately following ECT, patients may display varying degrees of confusion, but this “resolves” within hours. Anterograde amnesia can occur after ECT, but usually resolves within 4 to 8 weeks although memory of events during the time shortly before or during ECT may never be recovered fully. Older adults with cognitive impairment from dementia may be at increased risk for cognitive adverse effects. Depression can contribute to cognitive impairment and hence cognition may improve after successful ECT for depression. A recent review of 27 studies found mixed results, and concluded that despite a deterioration in information processing speed during ECT there is negligible deterioration in the cognition of older adults receiving ECT
Since the effect of ECT in elderly patients’ cognition remains unclear, and further research is required, this latter (2008) review recommends brief focused cognitive tests before, during, and after treatment to monitor progress.
Full Text Link (Access to this article requires a suitable password, a journal subscription or a one-off payment).
Gardner, BK. O’Connor, DW. (2008). A review of the cognitive effects of electroconvulsive therapy in older adults. The Journal of ECT, 2008, Vol.24(1), pp.68-80. (Click here to view the PubMed abstract).