• The Review Course in Family Medicine

Canadian Guidelines on Prevention, Assessment and Treatment of Depression Among Older Adults

We bring you the 2021 updated guidance regarding management of depression among older adults from the Canadian Coalition for Seniors Mental Health (CCSMH) and Canadian Academy of Geriatric Psychiatry (CAGP).

*Strength of recommendation is graded from [A] to [D] based on strength of evidence.

Prevention

Recommendation 1: *NEW: Group-based therapy in LTC settings reduces social isolation [B]

Recommendation 2: *NEW: Social prescribing to community-based non-clinical services can improve mild to moderate depression [C]


Recommendation 3: *NEW: Community-dwelling older adults with subthreshold depression or anxiety benefit from a stepped-care approach [B]


Recommendation 4: *NEW: Physical activity lowers the risk of developing depression [B]

Recommendation 5: *NEW: Instilling hope and positive thinking is an important therapeutic tool to prevent depression in all healthcare settings [D]


Screening and Assessment

Recommendation 1: *UPDATE: Older adults without cognitive impairment should use self-rating screening tools, with new guidelines recommending the Geriatric Depression Scale (GDS) or the Patient Health Questionnaire-9 (PHQ-9) [B]

Treatment and Management


Recommendation 1: *UPDATE: New guidelines indicate severe depression with psychotic features or suicidal ideation can safely and effectively be managed with a combination of antidepressants and antipsychotics. At the clinician’s discretion patients with severe symptoms or risk of poor outcomes can be offered Electroconvulsive therapy (ECT) [B]


Recommendation 2: *NEW: Repetitive transcranial magnetic stimulation (rTMS) can be considered for those who fail pharmacotherapy, but not for those who fail ECT [B]


Recommendation 3: *UPDATE: Cognitive behaviour therapy (CBT) and problem solving therapy (PST) have the most evidence and should be available to all older adults with depression [A]. Internet-delivered therapy increases accessibility and can be considered comparable to face-to-face [C]


Recommendation 4: *NEW: Exercise is an effective non-pharmacological intervention to improve mood [B]

Recommendation 5: *UPDATE: Duloxetine or sertraline are preferred SSRIs for acute depression, as

escitalopram and citalopram are effective but risk QT prolongation at therapeutic doses [A]. Fluoxetine and paroxetine are no longer recommended in older adults. Updated guidelines recommend serum sodium levels at 2-4 weeks of initiation of SSRI and SNRI therapy instead of 30 days [C]

Recommendation 6: *UPDATE: We suggest using antidepressants with the lowest anticholinergic properties, leaving tricyclic antidepressants (TCA) as third line agents [C]


Recommendation 7: *UPDATE: See patients every 1–2 weeks from initiation of antidepressants to assess response and dose titration [D]


Recommendation 8: *UPDATE: Patients with incomplete recovery, consider augmentation with additional antidepressants, lithium or psychotherapy. Updated guidelines suggest atypical antipsychotics (e.g. aripiprazole) are effective in some groups [C]


Recommendation 9: *UPDATE: New guidelines prefer behavioural intervention to pharmacotherapy for mild to moderate depression in patients with dementia [D]


Recommendation 10: *UPDATE: SSRIs are still first-line treatment for post-stroke depression, using SNRI or mirtazapine as second line. Updated guidelines suggest use of Methylphenidate if apathy is significant [B]


Recommendation 11: *NEW: SSRI is preferred first-line therapy for patients with co-existing Parkinson’s disease [B]


Recommendation 12: *NEW: The core of management is an individualized care plan with collaboration of interprofessional staff and a stepped care approach [A]

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