As the baby boomer generation ages, the “silver tsunami” is contributing to a significant demographic shift. According to the U.S. Census Bureau, the population of Americans over age 65 increased by 13 million between 2010 and 2020, marking the fastest growth rate since the late 19th century. This trend is expected to accelerate, bringing with it various public health challenges, including a rising prevalence of late-life depression. The numerous factors contributing to late-life depression often fuel the misconception that it is inevitable, which may partly explain why it remains underrecognized and undertreated. This issue is further compounded by the complexity of treating this age group which comes with its own distinct needs.
Understanding Late-Life Depression
Late-life depression refers to the onset of depression later in life, a condition that is found among individuals 65 years and above, who have had no previous history of depression.
The causes of depression in older adults are multifaceted, encompassing biological factors as well as psychological factors, e.g., bereavement, loss of socialization, less independent activities, etc. These factors can create loneliness and reduced autonomy.
What’s more is that these factors often interact, creating a complex cycle where one issue can exacerbate another. For example, physical illness leading to reduced mobility might result in depression, which in turn can decrease the likelihood of exercise, further impacting mental health. The challenge is compounded by polypharmacy—the use of multiple medications—which has been identified as an independent risk factor for depression in older adults. One study from the Netherlands on late-life depression found that polypharmacy was more prevalent among patients with depression (46.9%) versus non‐depressed controls (19.7%). In the United States, the rates of polypharmacy for those aged 65 years and older are estimated to be as high as 65%. Older depressed patients are more likely to be exposed to polypharmacy with its associated increased risks, including falls, cognitive impairment, and delirium1.
Adding to the intricacy of late-life depression is its symptomatic overlap with dementia. Cognitive symptoms such as confusion, memory impairment, and difficulty focusing are common in both conditions, often leading to misdiagnosis. Pseudodementia, a term used to describe cognitive symptoms caused by conditions other than dementia, typically depression, is found in a significant portion of older adults with cognitive issues.
Current Challenges in Treating Late-Life Depression
The rise in late-life depression and its causes highlight the need for effective, evidence-based treatment options. While there is no shortage of options for mental health solutions available to patients today, the age of this group comes with a particular set of nuances that must be kept in mind to achieve success and help ensure the quality of life.
For example, traditional approaches, such as pharmacotherapy with selective serotonin reuptake inhibitors (SSRIs) or serotonin and norepinephrine reuptake inhibitors (SNRIs) while proven successful in treating depression, are less effective for older patients due to altered metabolic rates, with non-response rates as high as 50%. Further, response rates to antidepressant treatments can vary from 35% to 72%, while remission rates range from 28% to 44%2. There is also an increased risk of side effects and drug interactions among this group, which makes their use more complicated.
Older adults can also face challenges with treatments that are typically proven effective in treating depression, ranging from electroconvulsive therapy (ECT) to pharmacotherapy (treatment using medication).
ECT has proven particularly challenging for this demographic due to its invasiveness and intolerability; while ECT is considered a safe and effective treatment for all ages, it is important to weigh the risk-benefit ratio of this intervention. On the other end, while pharmacotherapy is considered a noninvasive approach and addresses the concerns with ECT, patients in this age demographic can have conditions both physical and mental that could complicate which medications can be used. The limitations of ECT and pharmacotherapy heighten the need for alternative treatments that constitute safe and efficacious options for those with late-life depression.
Some brain stimulation techniques have proven to be helpful options for many patients, however, once again, these treatments are not without their limitations when it comes to older individuals. There are morphological changes that occur in the brain with healthy aging. Starting at around age 40, the brain atrophies, or shrinks, which increases the distance from the scalp to the brain. In addition, the volume of gray and white matter is reduced and the spaces in the brain – the ventricles (the cavities that store cerebrospinal fluid) and sulci (the grooves and furrows) – enlarge, which means the skull isn’t as densely packed, making it more difficult for standard brain stimulation devices to achieve a therapeutic effect.
Expanding Options for Older Patients
Deep TMS technology can penetrate deeper, broader areas of the brain when compared to traditional TMS, resulting in the stimulation of millions more neurons. While this may sound intimidating, Deep TMS is a noninvasive, non-pharmacologic treatment modality with a favorable safety profile and fewer side effects, thus offering a more favorable risk/benefit ratio. Its neurostimulation technology uses a patented magnetic H-coil within a cushioned helmet that stimulates the neural activity of the brain structures implicated in mental health disorders. For depression treatment, the patients sit comfortably for about 20 minutes in a chair, often scrolling their phone or speaking with their provider; they can leave immediately after to perform their daily activities with zero downtime required.
Deep TMS has been successful in treating patients aged 22 to 68 since 2014. And now studies have shown that it is effective for older adults as well, leading to its FDA label expansion for late-life depression in patients ages 68-86. The treatment can be used alone or in conjunction with medication and/or talk therapy.
Continued Innovation in Late-Life Care
As the U.S. population continues to live longer, healthcare providers must continue to explore and validate treatments to better manage the challenges that often accompany aging, including mental health conditions such as late-life depression. Advancements in treatment modalities show promise to help enhance not only the number of years but also the quality of life for many older adults.
About Dr. Colleen A. Hanlon
Dr. Colleen A. Hanlon has served as BrainsWay’s Vice President of Medical Affairs since 2022. Dr. Hanlon brings 17 years of clinical research experience in TMS and brain imaging to this position. Before joining BrainsWay, she led multidisciplinary clinical research programs at the Medical University of South Carolina and Wake Forest School of Medicine. During her rapid ascent through the ranks of faculty, she published over 80 articles, authored six book chapters, and delivered over 100 invited talks and educational sessions globally. Recognized as a pioneering leader in the field, Dr. Hanlon received over $12 million in support from the National Institute of Health to develop neural-circuit based therapeutics for patients with a variety of psychiatric and neurologic disorders.
References
1 Kaiser R, Physiological and clinical considerations of geriatric patient care. In: Steffens D, Blazer D, Thakur M, editors. Textbook of geriatric psychiatry. Arlington: American Psychiatric Publishing; 2015.
2 Roose SP, Schatzberg AF. The efficacy of antidepressants in the treatment of late-life depression. J Clin Psychopharmacol. 2005;25(4)(suppl 1):S1-S7.
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