Abstract
Depression in the elderly is a serious condition, and if not treated effectively, it can increase morbidity and mortality. In addition, it is associated with cognitive impairment and multiple medical problems. Frailty is also associated with depression. Depression in this age group can easily become resistant to the usual treatment, even with adequate medication and or psychotherapy, and it is difficult to achieve remission. It is imperative that other methods to treat depression such as neuromodulation therapies, also known as brain stimulation therapies or techniques, should be used earlier than later in the disease to control effectively the depression and achieve a sense of well being in the elderly. Neuromodulation therapies available at this time are electroconvulsive therapy (ECT), vagus nerve stimulation (VNS), magnetic seizure therapy (MST), and deep brain stimulation (DBS); these are invasive and are not office-based. Noninvasive therapies that are available are repetitive transcranial magnetic stimulation (rTMS) and direct transcranial direct current stimulation (tDCS). Other than ECT, limited data are available for other modes of therapy, but information available to date shows promise in treating this debilitating illness in the elderly.
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Alexopoulos GS, Meyers BS, Young RC, Kakuma T, Feder M, Einhorn A, Rosendahl E. Recovery in geriatric depression. Arch Gen Psychiatry. 1996;53:305–12.
Mojtabai R, Olfson M. Major depression in community-dwelling middle-aged and older adults: prevalence and 2- and 4-year follow-up symptoms. Psychol Med. 2004;34:623–34.
Steffens DC, Skoog I, Norton MC, Hart AD, Tschanz JT, Plassman BL, Wyse BW, Welsh-Bohmer KA, Breitner JC. Prevalence of depression and its treatment in an elderly population: the Cache County study. Arch Gen Psychiatry. 2000;57:601–7.
Mueller TI, Kohn R, Leventhal N, Leon AC, Solomon D, Coryell W, Endicott J, Alexopoulos GS, Keller MB. The course of depression in elderly patients. Am J Geriatr Psychiatr Off J Am Assoc Geriatr Psychiatr. 2004;12:22–9.
Trivedi MH, Rush AJ, Wisniewski SR, Nierenberg AA, Warden D, Ritz L, Norquist G, Howland RH, Lebowitz B, McGrath PJ, Shores-Wilson K, Biggs MM, Balasubramani GK, Fava M, Team SDS. Evaluation of outcomes with citalopram for depression using measurement-based care in STAR*D: implications for clinical practice. Am J Psychiatry. 2006;163:28–40.
Beekman AT, Geerlings SW, Deeg DJ, Smit JH, Schoevers RS, de Beurs E, Braam AW, Penninx BW, van Tilburg W. The natural history of late-life depression: a 6-year prospective study in the community. Arch Gen Psychiatry. 2002;59:605–11.
Livingston G, Watkin V, Milne B, Manela MV, Katona C. The natural history of depression and the anxiety disorders in older people: the Islington community study. J Affect Disord. 1997;46:255–62.
Unutzer J, Park M. Older adults with severe, treatment-resistant depression. JAMA J Am Med Assoc. 2012;308:909–18.
American Psychiatric Association. Task Force on Electroconvulsive T. The practice of ECT: recommendations for treatment, training and privileging. Convuls Ther. 1990;6:85–120.
Kennedy SH, Milev R, Giacobbe P, Ramasubbu R, Lam RW, Parikh SV, Patten SB, Ravindran AV, Canadian Network for M, Anxiety T. Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical guidelines for the management of major depressive disorder in adults. IV. Neurostimulation therapies. J Affect Disord. 2009;117 Suppl 1:S44–53.
Riva-Posse P, Hermida AP, McDonald WM. The role of electroconvulsive and neuromodulation therapies in the treatment of geriatric depression. Psychiatr Clin N Am. 2013;36:607–30. This is succient review of geraitric depression and shows evidence of safety and efficacy of ECT and gives a breif overwiew of other the neuromodulation therapies in geriatric depression.
Kho KH, van Vreeswijk MF, Simpson S, Zwinderman AH. A meta-analysis of electroconvulsive therapy efficacy in depression. J ECT. 2003;19:139–47.
McDonald WM, Holtzheimer 3rd PE, Byrd EH. The diagnosis and treatment of depression in Parkinson's disease. Curr Treat Options Neurol. 2006;8:245–55.
Bartels SJ, Horn SD, Smout RJ, Dums AR, Flaherty E, Jones JK, Monane M, Taler GA, Voss AC. Agitation and depression in frail nursing home elderly patients with dementia: treatment characteristics and service use. Am J Geriatr Psychiatr Off J Am Assoc Geriatr Psychiatr. 2003;11:231–8.
Oudman E. Is electroconvulsive therapy (ECT) effective and safe for treatment of depression in dementia? A short review. J ECT. 2012;28:34–8.
Ujkaj M, Davidoff DA, Seiner SJ, Ellison JM, Harper DG, Forester BP. Safety and efficacy of electroconvulsive therapy for the treatment of agitation and aggression in patients with dementia. Am J Geriatr Psychiatr Off J Am Assoc Geriatr Psychiatr. 2012;20:61–72. Dementia and depression are common and coexist and retroespective chart reveiws of 16 patients shows that ECT is effective in decreasing agitation and aggression. This article also gives insight into modification and management of side effects that happened during the ECT. This article may increase the comfort level of psychiatrists in using ECT in this population.
Harmandayan M, et al. Successful use of ECT in post stroke depression. Gen Hosp Psychiatry. 2012;34:102.e5–6.
Rabheru K. The use of electroconvulsive therapy in special patient populations. Can J Psychiatry. 2001;46(8):710–9.
van Schaik AM, Comijs HC, Sonnenberg CM, Beekman AT, Sienaert P, Stek ML. Efficacy and safety of continuation and maintenance electroconvulsive therapy in depressed elderly patients: a systematic review. Am J Geriatr Psychiatr Off J Am Assoc Geriatr Psychiatr. 2012;20:5–17. An excellent systematic review of good qaulity that again shows effectiveness of ECT.
Rapinesi C, Kotzalidis GD, Serata D, Del Casale A, Scatena P, Mazzarini L, Caccia F, Brugnoli R, Carbonetti P, Fensore C, Girardi P. Prevention of relapse with maintenance electroconvulsive therapy in elderly patients with major depressive episode. J ECT. 2013;29:61–4.
Rabheru K. Maintenance electroconvulsive therapy (M-ECT) after acute response: examining the evidence for who, what, when, and how? J ECT. 2012;28:39–47.
Kellner CH, Knapp RG, Petrides G, Rummans TA, Husain MM, Rasmussen K, Mueller M, Bernstein HJ, O'Connor K, Smith G, Biggs M, Bailine SH, Malur C, Yim E, McClintock S, Sampson S, Fink M. Continuation electroconvulsive therapy vs pharmacotherapy for relapse prevention in major depression: a multisite study from the Consortium for Research in Electroconvulsive Therapy (CORE). Arch Gen Psychiatry. 2006;63:1337–44.
Nordenskjold A, von Knorring L, Ljung T, Carlborg A, Brus O, Engstrom I. Continuation electroconvulsive therapy with pharmacotherapy versus pharmacotherapy alone for prevention of relapse of depression: a randomized controlled trial. J ECT. 2013;29:86–92. Rare to find randomized controlled studies in ECT that gave gudielines on maintenace ECT.A good study that can be used by psychiatrist as evidence based treatment option.
Sackeim HA, Prudic J, Fuller R, Keilp J, Lavori PW, Olfson M. The cognitive effects of electroconvulsive therapy in community settings. Neuropsychopharmacol Off Publ Am Coll Neuropsychopharmacol. 2007;32:244–54.
Fujita A, Nakaaki S, Segawa K, Azuma H, Sato K, Arahata K, Otsuki K, Hori M, Mochida Y, Uchida M, Yamada T, Nakamura C, Akechi T, Furukawa TA. Memory, attention, and executive functions before and after sine and pulse wave electroconvulsive therapies for treatment-resistant major depression. J ECT. 2006;22:107–12.
Petrides G, Braga RJ, Fink M, Mueller M, Knapp R, Husain M, Rummans T, Bailine S, Malur C, O'Connor K, Kellner C, Group C. Seizure threshold in a large sample: implications for stimulus dosing strategies in bilateral electroconvulsive therapy: a report from CORE. J ECT. 2009;25:232–7.
Sanacora G, Mason GF, Rothman DL, et al. Increased cortical GABA concentration in depressed patients receiving ECT. Am J Psychiatry. 2003;160(3):577–9.
Nobler MS, Oquendo MA, Kegeles LS, Malone KM, Campbell CC, Sackeim HA, Mann JJ. Decreased regional brain metabolism after ECT. Am J Psychiatry. 2001;158:305–8.
Lyden H, Espinoza RT, Pirnia T, Clark K, Joshi SH, Leaver AM, et al. Electroconvulsive therapy mediates neuroplasticity of white matter microstructure in major depression. Transl Psychiatry. 2014;1-8. An interesting original article that shows the possibility that ECT can modify microstructre in white matter of the brain. This opens up the possiblity of understanding ECTand its effectiveness clinically.
George MS, Nahas Z, Bohning DE, Lomarev M, Denslow S, Osenbach R, Ballenger JC. Vagus nerve stimulation: a new form of therapeutic brain stimulation. CNS Spectr. 2000;5:43–52.
Nahas Z, Marangell LB, Husain MM, Rush AJ, Sackeim HA, Lisanby SH, Martinez JM, George MS. Two-year outcome of vagus nerve stimulation (VNS) for treatment of major depressive episodes. J Clin Psychiatry. 2005;66:1097–104.
Rush AJ, Sackeim HA, Marangell LB, George MS, Brannan SK, Davis SM, Lavori P, Howland R, Kling MA, Rittberg B, Carpenter L, Ninan P, Moreno F, Schwartz T, Conway C, Burke M, Barry JJ. Effects of 12 months of vagus nerve stimulation in treatment-resistant depression: a naturalistic study. Biol Psychiatry. 2005;58:355–63.
George MS, Rush AJ, Marangell LB, Sackeim HA, Brannan SK, Davis SM, Howland R, Kling MA, Moreno F, Rittberg B, Dunner D, Schwartz T, Carpenter L, Burke M, Ninan P, Goodnick P. A one-year comparison of vagus nerve stimulation with treatment as usual for treatment-resistant depression. Biol Psychiatry. 2005;58:364–73.
Sackeim HA, Keilp JG, Rush AJ, George MS, Marangell LB, Dormer JS, Burt T, Lisanby SH, Husain M, Cullum CM, Oliver N, Zboyan H. The effects of vagus nerve stimulation on cognitive performance in patients with treatment-resistant depression. Neuropsychiatry Neuropsychol Behav Neurol. 2001;14:53–62.
Daban C, Martinez-Aran A, Cruz N, Vieta E. Safety and efficacy of Vagus Nerve Stimulation in treatment-resistant depression. A systematic review. J Affect Disord. 2008;110:1–15.
Sirven JI, Sperling M, Naritoku D, Schachter S, Labar D, Holmes M, Wilensky A, Cibula J, Labiner DM, Bergen D, Ristanovic R, Harvey J, Dasheiff R, Morris GL, O'Donovan CA, Ojemann L, Scales D, Nadkarni M, Richards B, Sanchez JD. Vagus nerve stimulation therapy for epilepsy in older adults. Neurology. 2000;54:1179–82.
Merrill CA, Jonsson MA, Minthon L, Ejnell H, Silander HC-s, Blennow K, Karlsson M, Nordlund A, Rolstad S, Warkentin S, Ben-Menachem E, Sjogren MJ. Vagus nerve stimulation in patients with Alzheimer's disease: additional follow-up results of a pilot study through 1 year. J Clin Psychiatry. 2006;67:1171–8.
Helmstaedter C, Hoppe C, Elger CE. Memory alterations during acute high-intensity vagus nerve stimulation. Epilepsy Res. 2001;47:37–42.
Wassermann EM, Lisanby SH. Therapeutic application of repetitive transcranial magnetic stimulation: a review. Clin Neurophysiol Off J Int Fed Clin Neurophysiol. 2001;112:1367–77.
Luber B, McClintock SM, Lisanby SH. Applications of transcranial magnetic stimulation and magnetic seizure therapy in the study and treatment of disorders related to cerebral aging. Dialogues Clin Neurosci. 2013;15:87–98. An excellent overview of rTMS and MST in geriatric population, a good reading with insights into its effect on cognition as well, even though rTMs is not used widely.
Fitzgerald PB, Fountain S, Daskalakis ZJ. A comprehensive review of the effects of rTMS on motor cortical excitability and inhibition. Clin Neurophysiol Off J Int Fed Clin Neurophysiol. 2006;117:2584–96.
Moreines JL, McClintock SM, Holtzheimer PE. Neuropsychologic effects of neuromodulation techniques for treatment-resistant depression: a review. Brain Stimulation. 2011;4:17–27.
Lisanby SH, Husain MM, Rosenquist PB, Maixner D, Gutierrez R, Krystal A, George MS. Daily left prefrontal repetitive transcranial magnetic stimulation in the acute treatment of major depression: clinicla predictors of outcome in a multisite, randomized controlled clinical trial. Neuropsychopharmacology. 2009;34:522–34.
George MS, Lisanby SH, Avery D, McDonald WM, Durkalski V, Pavlicova M, Anderson B, Nahas Z, Bulow P, Zarkowski P, Holtzheimer 3rd PE, Schwartz T, Sackeim HA. Daily left prefrontal transcranial magnetic stimulation therapy for major depressive disorder: a sham-controlled randomized trial. Arch Gen Psychiatry. 2010;67:507–16.
O'Reardon JP, Solvason HB, Janicak PG, Sampson S, Isenberg KE, Nahas Z, McDonald WM, Avery D, Fitzgerald PB, Loo C, Demitrack MA, George MS, Sackeim HA. Efficacy and safety of transcranial magnetic stimulation in the acute treatment of major depression: a multisite randomized controlled trial. Biol Psychiatry. 2007;62:1208–16.
Manes F, Jorge R, Morcuende M, Yamada T, Paradiso S, Robinson RG. A controlled study of repetitive transcranial magnetic stimulation as a treatment of depression in the elderly. Int Psychogeriatr IPA. 2001;13:225–31.
Mosimann UP, Schmitt W, Greenberg BD, Kosel M, Muri RM, Berkhoff M, Hess CW, Fisch HU, Schlaepfer TE. Repetitive transcranial magnetic stimulation: a putative add-on treatment for major depression in elderly patients. Psychiatry Res. 2004;126:123–33.
Jorge RE, Robinson RG. Treatment of late-life depression: a role of non-invasive brian stimualtion techniques. Int Rev Psychiatry. 2011;23(5):437–44. Another good review of all studies of rTMs and MST.
Jorge RE, Moser DJ, Acion L, Robinson RG. Treatment of vascualr depression using repetitive transcranial magnetic stimulation. Arch Gen Psychiatry. 2008;65:268–76.
Lisanby SH. Update on magnetic seizure therapy: a novel form of convulsive therapy. J ECT. 2002;18:182–8.
Lisanby SH, Luber B, Schlaepfer TE, Sackeim HA. Safety and feasibility of magnetic seizure therapy (MST) in major depression: randomized within-subject comparison with electroconvulsive therapy. Neuropsychopharmacol Off Publ Am Coll Neuropsychopharmacol. 2003;28:1852–65.
Lisanby SH, Schlaepfer TE, Fisch HU, Sackeim HA. Magnetic seizure therapy of major depression. Arch Gen Psychiatry. 2001;58:303–5.
Kosel M, Frick C, Lisanby SH, Fisch HU, Schlaepfer TE. Magnetic seizure therapy improves mood in refractory major depression. Neuropsychopharmacol Off Publ Am Coll Neuropsychopharmacol. 2003;28:2045–8.
Kayser S, Bewernick BH, Grubert C, Hadrysiewicz BL, Axmacher N, Schlaepfer TE. Antidepressant effects, of magnetic seizure therapy and electroconvulsive therapy, in treatment-resistant depression. J Psychiatr Res. 2011;45:569–76.
Rapoport MJ. Depression following traumatic brain injury: epidemiology, risk factors and management. CNS Drugs. 2012;26:111–21.
Jimenez F, Velasco F, Salin-Pascual R, Hernandez JA, Velasco M, Criales JL, Nicolini H. A patient with a resistant major depression disorder treated with deep brain stimulation in the inferior thalamic peduncle. Neurosurgery. 2005;57:585–93. discussion 585-593.
Kosel M, Sturm V, Frick C, Lenartz D, Zeidler G, Brodesser D, Schlaepfer TE. Mood improvement after deep brain stimulation of the internal globus pallidus for tardive dyskinesia in a patient suffering from major depression. J Psychiatr Res. 2007;41:801–3.
Lozano AM, Mayberg HS, Giacobbe P, Hamani C, Craddock RC, Kennedy SH. Subcallosal cingulate gyrus deep brain stimulation for treatment-resistant depression. Biol Psychiatry. 2008;64:461–7.
Ramasubbu R, Anderson S, Haffenden A, Chavda S, Kiss ZH. Double-blind optimization of subcallosal cingualte deep brain stimulation for treatment-resistant depression: a pilot study. J Psychiatry Neurosci. 2013;38(5):325–32. A small study but of improtance as research papers in DBS are difficult to conduct and getting a larger sample size is not prctical. Learning about stimulus parameters and adjusting the parameters throws some light on stimulus optimization for TRD.
Malone Jr DA, Dougherty DD, Rezai AR, Carpenter LL, Friehs GM, Eskandar EN, Rauch SL, Rasmussen SA, Machado AG, Kubu CS, Tyrka AR, Price LH, Stypulkowski PH, Giftakis JE, Rise MT, Malloy PF, Salloway SP, Greenberg BD. Deep brain stimulation of the ventral capsule/ventral striatum for treatment-resistant depression. Biol Psychiatry. 2009;65:267–75.
McNeely HE, Mayberg HS, Lozano AM, Kennedy SH. Neuropsychological impact of Cg25 deep brain stimulation for treatment-resistant depression: preliminary results over 12 months. J Nerv Ment Dis. 2008;196:405–10.
Grubert C, Hurlemann R, Bewernick BH, Kayser S, Hadrysiewicz B, Axmacher N, Sturm V, Schlaepfer TE. Neuropsychological safety of nucleus accumbens deep brain stimulation for major depression: effects of 12-month stimulation. World J Biol Psychiatry Off J World Fed Soc Biol Psychiatry. 2011;12:516–27.
Laxton AW, Lozano AM. Deep brain stimulation for the treatment of Alzheimer disease and dementias. World Neurosurg. 2013;80:e21–8. Interesting summary of three case studies that show some improvement in Alzheimer’s and Parkinson’s dementia. Preliminary and limited but innovative, even though not related to the present paper, depression and dementias in elderly can coexist, DBS should be explored as an option. Warrants further research.
Nitsche MA, Boggio PS, Fregni F, Pascual-Leone A. Treatment of depression with transcranial direct current stimulation (tDCS): a review. Exp Neurol. 2009;219:14–9.
Fritsch B, Reis J, Martinowich K, Schambra HM, Ji Y, Cohen LG, Lu B. Direct current stimulation promotes BDNF-dependent synaptic plasticity: potential implications for motor learning. Neuron. 2010;66:198–204.
Nitsche MA, Paulus W. Excitability changes induced in the human motor cortex by weak transcranial direct current stimulation. J Physiol. 2000;527(Pt 3):633–9.
Zheng X, Alsop DC, Schlaug G. Effects of transcranial direct current stimulation (tDCS) on human regional cerebral blood flow. NeuroImage. 2011;58:26–33. Even thouhg this study was done in young healthy, it is intersting to learn that tDCS can increase cerebral blood flow in the brain region realted to the stimaulted area. Another postulate that has been entertained in the effect of brain stimulation therapies for depression.
Fregni F, Boggio PS, Nitsche MA, Marcolin MA, Rigonatti SP, Pascual-Leone A. Treatment of major depression with transcranial direct current stimulation. Bipolar Disord. 2006;8:203–4.
Boggio PS, Rigonatti SP, Ribeiro RB, Myczkowski ML, Nitsche MA, Pascual-Leone A, Fregni F. A randomized, double-blind clinical trial on the efficacy of cortical direct current stimulation for the treatment of major depression. Int J Neuropsychopharmacol Off Sci J Coll Int Neuropsychopharmacologicum. 2008;11:249–54.
Fregni F, Boggio PS, Nitsche MA, Rigonatti SP, Pascual-Leone A. Cognitive effects of repeated sessions of transcranial direct current stimulation in patients with depression. Depression Anxiety. 2006;23:482–4.
Javadi AH, Walsh V. Transcranial direct current stimulation (tDCS) of the left dorsolateral prefrontal cortex modulates declarative memory. Brain stimulation. 2012;5:231–41. Even though this study is in young helathy college students, it can be of some merit to consider similar improvements in the depressed and the elderly.
Jo JM, Kim YH, Ko MH, Ohn SH, Joen B, Lee KH. Enhancing the working memory of stroke patients using tDCS. Am J Phys Med Rehabil Assoc Acad Physiatrists. 2009;88:404–9.
Ren J, Li H, Palaniyappan L, Wang J, Rossini PM. Repetitive transcranial magnetic stimulation versus electroconvulsive therapy for major depression: a systematic review and meta-analysis. Prog Neuropsychopharmacol Biol Psychiatry. 2014;51:181–9. A well done meta-analysis that takes us back again to the most effective acute treatment for Major depression as ECT.
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Jothika Manepalli and Nidesh Sapkota declare that they have no conflict of interest.
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Manepalli, J., Sapkota, N. Neuromodulation Therapies in the Elderly Depressed Patient. Curr Geri Rep 3, 229–236 (2014). https://doi.org/10.1007/s13670-014-0098-1
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DOI: https://doi.org/10.1007/s13670-014-0098-1