Empfehlungen für Diagnostik und Therapie der Depression im Alter
Therapy Recommendations for Diagnosis and Treatment of Depression in Old Age
Abstract
Zusammenfassung. Diese Empfehlungen sollen dazu dienen, Fachpersonen das Wissen über die aktuelle Evidenz von Diagnostik und Therapie der Depression im Alter zur Verfügung zu stellen und damit zur frühzeitigen Erkennung und evidenzbasierten Behandlung beizutragen. Da für einige Behandlungsansätze nur rudimentär kontrollierte Studien vorliegen, wird auch das klinische Expertenwissen in die Beurteilung einbezogen. Im diagnostischen Vorgehen wird die besondere Symptomatik der Depression im Alter beleuchtet, auf die Suizidalität eingegangen und werden die häufig vorkommenden somatischen Komorbiditäten hervorgehoben. Auch Hypothesen zur Pathogenese, wie Neuroendokrinologie, Neurodegeneration und vaskuläre Faktoren, werden erläutert. In der Behandlung gilt heute ein integrierter biopsychosozialer Ansatz mit gezielten psychosozialen Interventionen, spezifischer Psychotherapie und einer antidepressiven Pharmakotherapie bei schweren Depressionen als sinnvoll. Daneben kommen auch chronobiologische oder Neurostimulationsverfahren zum Einsatz.
Abstract. The main goal of these treatment recommendations is to provide experts with current evidence on diagnostic procedures and therapy of depression in the elderly. After description of current diagnostics according to ICD-10, the special presentation of symptoms in old-age depression is highlighted and, in particular, the risk factors of the markedly increased suicide risk in the elderly are described. Assessment instruments are helpful in the diagnosis and are discussed in detail. Most importantly, prodromal dementia has to be taken into consideration in differential diagnosis. Additional important comorbidities are substance use disorders, and chronic somatic diseases such as pain syndromes, cardiovascular diseases or metabolic disorders. Moreover, facing the frequent polypharmacy in old age, the triggering of depression by medication has to be considered. Besides the known age-specific psychosocial triggers and the classic aminergic deficiency hypothesis, neuroendocrinology and neurodegeneration as well as vascular factors are discussed as crucial pathogenetic mechanisms. However, genetics may also play an important role in the elderly patient. For treatment of depression in old age, an integrated biopsychosocial approach with targeted psychosocial interventions, specific psychotherapy and antidepressant pharmacotherapy is deemed adequate. Biological non-pharmacological treatments are also treatment options in elderly depressed patients, i.e. chronobiological procedures and electroconvulsive therapy. In conclusion, the present treatment recommendations for old age depression by the Swiss professional societies provide an aid for therapy based on evidence and clinical expertise. The latter is most important, since evidence is often lacking in this patient population. Finally, in view of the frequent age-related polypharmacy, a comprehensive understanding of the pharmacotherapeutical evidence is an important prerequisite for its careful application.
Résumé. Le but principal de ces recommandations de traitement est de fournir aux experts l’évidence actuelle concernant le diagnostic et le traitement de la dépression chez la personne âgée. Après description des diagnostics selon la classification actuelle ICD-10, les symptômes particuliers de la dépression des malades âgés sent présentés, et notamment les facteurs de risque de suicide qui est augmenté dans cette classe d’âge. Les moyens d’évaluation utiles pour le diagnostic sont discutés en détail. Particulièrement important est la nécessité de prendre en compte les prodomes de la démence dans le diagnostic différentiel. D’autres importantes comorbidités sont relatées à un emploi inapproprié de substances, à la coexistence de maladies somatiques chroniques comme les syndromes douloureux, les maladies cardiovasculaires et les troubles métaboliques. De plus, du fait de la fréquence élevée de polypharmacie chez la personne âgée, la possibilité qu’un médicament puisse déclencher une dépression doit être considérée. A côté des facteurs déclenchants psycho-sociaux associés à l’âge et l’hypothèse classique d’un manque d’amines, des facteurs neuroendocriniens et neurodégénératifs ainsi que des facteurs vasculaires peuvent jouer un rôle pathophysiologique. Par ailleurs, des facteurs génétiques peuvent aussi être impliqués chez la personne âgée. Pour le traitement de la dépression chez la personne âgée, il y a le besoin d’une approche biopsychosociale intégrée avec des interventions psychosociales ciblées, d’une psychothérapie spécifique et d’antidépresseurs pharmacologiques. Les traitements biologiques non-pharmacologiques représentent aussi une option thérapeutique chez ces malades, comme par exemple les interventions chronobiologiques et l’électroconvulsivothérapie. En conclusion, les recommandations de traitement pour la prise en charges de la dépression chez la personne âgée, proposées actuellement par les sociétés professionnelles en Suisse, offrent une aide de traitement fondée sur l’évidence et l’expertise clinique. Ce dernier point est important puisqu’il manque souvent des preuves fondées sur l’évidence dans cette population. Finalement, étant donné la polypharmacie fréquente dans cette classe d’âge, la prise en compte de la pharmacothérapie dans son ensemble est nécessaire pour une utilisation adéquate des médicaments.
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