The psychosis gets worse with age
When the joy of life breaks
Many pharmaceuticals such as antibiotics, ACE inhibitors, beta blockers, glucocorticoids, cardiac glycosides, interferons, opiates, antivirals and cytostatics can cause depressive disorders. Therefore, not only should organic diseases be searched carefully, but the prescribed medication should also be critically examined for possible depressiogenic side effects. If the medication is essential, the doctor should consider reducing the dose, if necessary with regular blood level monitoring.
In addition to the explainable exogenous triggers such as concomitant illnesses and medication, the development of depressive illnesses is now assumed to be complex. Biographical factors, current psychosocial stress, organic brain and other physical changes as well as genetic factors ultimately cause a disruption of the neurotransmitter functions in the brain. It is assumed that serotonergic, noradrenergic, dopaminergic, GABAergic and cholinergic systems are involved. It is possible that there is an increased vulnerability in old age, so that acute and chronic emotional or physical difficulties have an increased effect on disease-causing.
There are models for understanding depression in old age that explain an increased susceptibility based on an individual's biography. Experiences of loss in old age could, for example, reactivate earlier experiences of emotional deficiency and thus trigger a depressive disorder. In addition, depression is understood as an adjustment disorder to the physical and emotional stresses of old age (10).
Therapy on three pillars
Since depressive syndromes are determined by many factors, the therapy should also be based on different approaches and should be interdisciplinary. A combination of psychotherapy, psychotropic drugs and extensive social support is considered optimal (1, 11, 12). The therapy of old patients does not differ fundamentally from the treatment of depressive disorders in younger or middle age. The success rate is also comparable: a significant improvement can be achieved at around 70 percent. It depends on the severity of the depression, a possible suicidal risk, the mobility of the patient and his general living situation, whether the treatment is outpatient, in the day clinic or fully inpatient.
Psychotherapy is a pillar of therapy. Contrary to many prejudices, it is also possible and effective for old people. However, the number of therapists who specialize in this target group is still small. Many senior citizens with outpatient care are therefore only treated with medication. However, supportive psychotherapy is still rarely prescribed not only for old but also for all outpatient depressed patients (2).
When working with old people, depth psychological methods, interpersonal psychotherapy and cognitive behavioral therapy have proven their worth (1, 11). Compared to middle age, the therapy sessions should be more structured. It is beneficial to shorten the sessions and repeat or write down certain things more often. To take account of possible hearing and memory weaknesses, the therapist should explain the basic ideas of the therapy repeatedly. A fundamental goal of psychotherapy in old age is the acceptance of the personal past. Otherwise, it is mainly about coping with current stress and life changes (8).
Social support is also intended to help patients cope better with everyday stress and to overcome problems. A social worker can, for example, see to it that an elderly person receives household help, meals on wheels or the financial support they are entitled to from the social welfare office. Or the supervisor supports the convalescent in establishing social contacts and making contact with a senior group. Regular visits to an outpatient psychiatric nursing service are very helpful. Last but not least, the carers relieve the relatives considerably and help them to cope better with the illness in the family.
It is imperative that the family and professionals pay attention to how the patient's body weight is developing. The loss of appetite that is typically associated with depression is one of the most common causes of malnutrition in old age. Especially in old age, too low body weight can set in motion a vicious circle of health problems such as weakness, susceptibility to infection, falls and broken bones. Preventive intervention should be undertaken here at an early stage (18). This is all the more true as weight loss in old age is difficult to reverse. In addition to the provision of wholesome food, it can make sense for the doctor to prescribe high-calorie, high-protein drinking food in addition to an antidepressant that prevents (further) weight loss.
Support psychiatric drugs
Physicians and pharmacists almost always have to take comorbidities and impaired organ functions into account when choosing a drug for elderly patients. Of course, this also applies to therapy with antidepressants.
Substances with no or only minor anticholinergic effects are recommended. The drugs of choice are the selective serotonin reuptake inhibitors (SSRIs) citalopram, escitalopram, sertraline and paroxetine, selective serotonin and norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine and duloxetine as well as mirtazapine and the reversible MAO inhibitor moclobemide (1, 11, 13) (1, 11, 13). Some experts rate venlafaxine as critical, as a study on nursing home patients revealed an increased rate of side effects (15).
Of course, the clinical picture is always one of the deciding factors: Is the patient inhibited-anxious, restless-anxious, delusional-depressive or is there even an acute risk of suicide? If a stimulating effect is desired, for example venlafaxine, moclobemide, paroxetine and fluoxetine come into consideration. Citalopram and sertraline are drive-neutral, while mirtazapine has a sedative effect in most patients.
The changes in pharmacokinetics in old age must be taken into account accordingly in the dosage. Since elderly people usually take several drugs, possible interactions must also be taken into account. SSRIs inhibit the CYP isoenzymes to varying degrees. Citalopram and escitalopram have the least blocking effect. Fluoxetine, fluvoxamine and paroxetine inhibit various CYP isoenzymes to a considerable extent and, for example, enhance the effects of phenytoin, benzodiazepines, ciclosporin and oral anticoagulants.
Tricyclic antidepressants are as effective as SSRIs in the elderly, but they are significantly less well tolerated due to a wide range of side effects (16). Seniors often react more strongly to anticholinergic effects with urinary retention, constipation, bladder-intestinal atony, glaucoma and even anticholinergic syndrome (9). Dry mouth is particularly agonizing for denture wearers and makes it difficult to speak. Tricyclics are therefore of little importance in the therapy of elderly patients. This also applies to the prescription of St. John's wort preparations. The risk of relevant interactions due to enzyme induction is too great here (16).
Antidepressants are usually dosed gradually to reduce side effects. Most patients feel the first signs of the desired effect after 10 to 14 days, after which the effect slowly increases. Full antidepressant effectiveness is achieved after six weeks at the latest. It is problematic for compliance that side effects often occur before the antidepressant effect. It is therefore important to educate patients accordingly. The drive-increasing component also occurs relatively quickly. This can mean an increased risk of suicide!
Patience is needed
The success of the therapy is not always immediately satisfactory. Whether the chosen antidepressant was right for the patient can be assessed after four to six weeks. However, before the doctor changes to another active ingredient, he should check whether the patient has taken the prescribed drug at all and in the required dosage.
It is entirely possible that several antidepressants may need to be tried before they are sufficiently effective. The doctor can also combine antidepressants from different drug groups. However, SSRIs and SNRIs must not be given together with MAO inhibitors, as this can lead to a drastic increase in effectiveness (serotonin syndrome). When switching from SSRI or SNRI to MAOIs (or vice versa), a grace period of 14 days is required.
Another possibility to increase the effect (augmentation) is the additional administration of an atypical neuroleptic, for example opipramol or buspirone, lithium or thyroid hormones. Lithium salts are less well tolerated with age. Interactions and intoxication easily occur. A dose reduction is necessary if thiazide-containing diuretics are administered at the same time. Serum lithium levels should be kept low and monitored frequently.
How long should antidepressant therapy last? As with younger patients, this depends on the individual medical history. If a depressive disorder occurs for the first time, experts recommend a one-year treatment. For one to three years, patients should be treated who have fallen ill for the second time. Patients who have been affected three or more times require more than three years of therapy (11). Antidepressants may have to be given for life. However, there is a tendency among general practitioners not to prescribe medication for a long enough time (2).
In specialist clinics, electroconvulsive therapy (ECT) is an established procedure for the treatment of severe and therapy-resistant depression - even in the elderly (11). The success rate is 70 to 90 percent. With ECT, a generalized seizure similar to an epileptic seizure is triggered with short electrical surges of precisely defined strength. The mechanism of action has not yet been clarified. Possibly the antidepressant effect comes from a decrease in β1-Receptor density and an increase in 5HT2-Receptors mainly in the hippocampus and cortex.
The treatment takes place exclusively under short anesthesia and medicinal muscle relaxation. In most cases six to twelve treatments are scheduled. Caution is advised after myocardial infarction and cerebral insult, increased intracranial pressure, coagulation disorders and retinal detachment (13).
Other non-pharmacological procedures are also used in younger patients, most notably sleep deprivation or light therapy. Whether these treatment methods are also suitable for elderly depressed patients has not yet been systematically investigated scientifically.
Therapy of demented patients
For the treatment of depressive symptoms in demented patients, SSRIs such as escitalopram or sertraline as well as SNRI (venlafaxine, duloxetine) and mirtazapine have proven themselves (14, 19, 20). However, SSRIs can lead to increased restlessness or anxiety at the beginning. The appetite-increasing effect of some SSRIs is advantageous, as demented patients often lose a lot of weight due to the increased energy requirement (14).
Reversible MAO inhibitors are only recommended for people with neurodegenerative forms of dementia. The rather weakly effective reversible MAO inhibitor moclobemide has no anticholinergic side effects and is usually well tolerated, this also applies to purely noradrenergic substances.
Tri- and tetracyclics with anticholinergic effects are unsuitable. In addition to the well-known problem of anticholinergic side effects, there is a risk that a so far only slowly progressing dementia with mild symptoms will worsen considerably due to the anticholinergic medication (1).
Antidepressant therapy is difficult in patients with Parkinson's disease. In some, dopaminergic treatment for Parkinson's disease also improves depression. Some substances such as pramipexole are even said to have antidepressant effects themselves. However, there is no clear evidence of this. Unfortunately, there are only a few controlled studies on the effectiveness of antidepressants in Parkinson's patients. It is even questionable whether they are effective at all (21). In any case, the patients respond much more poorly to the medication than older patients without Parkinson's syndrome. The use of antidepressants such as paroxetine, sertraline or citalopram is essentially based on experience. All conventional neuroleptics as well as lithium are contraindicated, as these can aggravate the akinetic-rigid symptoms even in small doses (22).
Depression usually has to be treated with medication and psychotherapy. Older patients also have the right to have their illness taken seriously and treated with determination. Because being old does not mean living hopelessly and full of worries. There are a number of antidepressants that are well tolerated in old age and cause little or no interaction. In this way, seniors can also overcome the disease and shape their lives positively within their means. Another goal of antidepressant therapy is that you can look back on your life in reconciliation and accept it as it has been.
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