Psych · Old age psychiatry — mood disorders
Late-life depression
Also known as Geriatric depression · Depression in older adults · Late-onset depression · Vascular depression · Depressive pseudodementia · Old-age depression
Exam-exhaustive fellowship reference on late-life depression — early- vs late-onset and vascular depression constructs; suicide risk and high lethality in older adults; depressive cognitive impairment (pseudodementia) versus dementia and delirium; medical comorbidity work-up; SSRI/SNRI dosing and safety (hyponatraemia, falls, bleeding, QTc); collaborative care (IMPACT/PROSPECT); maintenance (Reynolds); ECT (PRIDE); bereavement differential. FRANZCP-primary, globally tagged.
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Target exams
Red flags
- Active suicidal ideation, plan, or access to lethal means in an older adult — same-day senior review, means restriction, do not discharge to an empty safety plan
- Psychotic depression, catatonia, or life-threatening refusal of food and fluids — urgent hospitalisation; ECT is often first-line rather than endless incomplete drug trials
- New confusion, falls, or seizures after starting or increasing an SSRI/SNRI — check sodium urgently for SIADH/hyponatraemia
- Acute fluctuating inattention — treat as delirium first; do not label as 'just depression' or 'just dementia'
- Rapid cognitive decline with focal neurology or stepwise course — urgent medical/neurovascular work-up, not antidepressant-only pathway
- Elder abuse, neglect, or unsafe discharge destination — escalate safeguarding and multi-agency response
Meet the patient
A 78-year-old widower is brought by his daughter. Three months after his wife's funeral he has stopped eating, woken at 4am every day for six weeks, and answers each question after a long pause. He says the neighbours have been "talking about the money".[3][13]
His GP started sertraline eight days ago at half-dose and told him to come back in three months. He takes furosemide for heart failure. Last night his daughter found a loaded rifle in the wardrobe and a note that says only "sorry".[4][14]
Two exam questions are now live, and they decide everything that follows. Is this delirium, dementia, or depression? And is he safe to go home tonight? Everything below answers both at consultant depth.[4][13]
[3]References18ShowHide
- [1]Alexopoulos GS, Meyers BS, Young RC, Campbell S, Silbersweig D, Charlson M 'Vascular depression' hypothesis Arch Gen Psychiatry, 1997.PMID 9337771
- [2]Alexopoulos GS, Meyers BS, Young RC, Kakuma T, Silbersweig D, Charlson M Clinically defined vascular depression Am J Psychiatry, 1997.PMID 9090349
- [3]Alexopoulos GS Depression in the elderly Lancet, 2005.PMID 15936426
- [4]Taylor WD Clinical practice. Depression in the elderly N Engl J Med, 2014.PMID 25251617
- [5]Unützer J, Katon W, Callahan CM, Williams JW Jr, Hunkeler E, Harpole L, et al. Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial JAMA, 2002.PMID 12472325
- [6]Bruce ML, Ten Have TR, Reynolds CF 3rd, Katz II, Schulberg HC, Mulsant BH, et al. Reducing suicidal ideation and depressive symptoms in depressed older primary care patients: a randomized controlled trial JAMA, 2004.PMID 14996777
- [7]Reynolds CF 3rd, Dew MA, Pollock BG, Mulsant BH, Frank E, Miller MD, et al. Maintenance treatment of major depression in old age N Engl J Med, 2006.PMID 16540613
- [8]Kellner CH, Husain MM, Knapp RG, McCall WV, Petrides G, Rudorfer MV, et al. Right Unilateral Ultrabrief Pulse ECT in Geriatric Depression: Phase 1 of the PRIDE Study Am J Psychiatry, 2016.PMID 27418379
- [9]Kellner CH, Husain MM, Knapp RG, McCall WV, Petrides G, Rudorfer MV, et al. A Novel Strategy for Continuation ECT in Geriatric Depression: Phase 2 of the PRIDE Study Am J Psychiatry, 2016.PMID 27418381
- [10]Nelson JC, Delucchi K, Schneider LS Efficacy of second generation antidepressants in late-life depression: a meta-analysis of the evidence Am J Geriatr Psychiatry, 2008.PMID 18591576
- [11]UK ECT Review Group Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis Lancet, 2003.PMID 12642045
- [12]Malhi GS, Bell E, Bassett D, Boyce P, Bryant R, Hazell P, et al. The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders Aust N Z J Psychiatry, 2021.PMID 33353391
- [13]Conwell Y, Van Orden K, Caine ED Suicide in older adults Psychiatr Clin North Am, 2011.PMID 21536168
- [14]Fabian TJ, Amico JA, Kroboth PD, Mulsant BH, Corey SE, Begley AE, et al. Paroxetine-induced hyponatremia in older adults: a 12-week prospective study Arch Intern Med, 2004.PMID 14769630
- [15]Yesavage JA, Brink TL, Rose TL, Lum O, Huang V, Adey M, et al. Development and validation of a geriatric depression screening scale: a preliminary report J Psychiatr Res, 1982.PMID 7183759
- [16]Kroenke K, Spitzer RL, Williams JB The PHQ-9: validity of a brief depression severity measure J Gen Intern Med, 2001.PMID 11556941
- [17]Sheline YI, Pieper CF, Barch DM, Welsh-Bohmer K, McKinstry RC, MacFall JR, et al. Support for the vascular depression hypothesis in late-life depression: results of a 2-site, prospective, antidepressant treatment trial Arch Gen Psychiatry, 2010.PMID 20194828
- [18]Lavretsky H, Reinlieb M, St Cyr N, Siddarth P, Ercoli LM, Senturk D Citalopram, methylphenidate, or their combination in geriatric depression: a randomized, double-blind, placebo-controlled trial Am J Psychiatry, 2015.PMID 25677354