Amara G, Saada W, Ben Nasr S, Ben Hadj Ali B
Service de psychiatrie, CHU Farhat Hached, faculté de médecine Ibn Jazzar, université de Sousse, avenue Ibn Jazzar, 4000 Sousse, Tunisia.
Encephale. 2010 Feb;36(1):77-81. doi: 10.1016/j.encep.2009.02.004. Epub 2009 Aug 31.
Depression in the elderly is characterized by an atypical expression with delusion, major anxiety, behaviour disorders, somatic complains or cognitive impairment. These clinical aspects are suspected to be at the origin of the poor response to antidepressants observed in these cases. It is currently indicated to add sedative medicines to antidepressants, when a major anxiety is associated with depression, or an antipsychotic in the delusional forms of the depression. However, it is not consensually established that cholinesterase inhibitors can be helpful in depression with cognitive impairment. Cholinesterase inhibitors are efficient among patients with Alzheimer disease. They improve cognitive performances and slow down the degenerative process during the first years of treatment. Today, new findings on neurobiological mechanisms of depression involve a located degenerative process, with some similar anomalies in the brain in both depression and pre-Alzheimer states. New therapeutic trials have shown that cholinesterase inhibitors can be also efficient on depressed symptoms among patients with Alzheimer disease. These evidences support the hypothesis that the association of cholinesterase inhibitors to antidepressants can bring more benefits to depressed elderly patients.
Through a review of the literature and a case report, we tried to specify whether cholinesterase inhibitors can be useful in the treatment of depression among the elderly.
We report the case of a 68-year-old man who had presented, four years ago, a second episode of major depression with a cognitive impairment. Treated with an antidepressant (venlafaxine), the improvement was poor with major anxiety, slow thoughts, and an evidence of a persistent cognitive impairment. Despite normal cerebral scanning images, we decided to add a cholinesterase inhibitor (donepezil) to the same antidepressant. With this association, we rapidly obtained a total remission from depression with restitution of cognitive performances. This state is still maintained until today (four years after the last depressive episode) with no new mood relapses. Recent cerebral scanning images did not show any degenerative process.
The association of cholinesterase inhibitors and an antidepressant seems a good alternative, when the response to antidepressant is partial in depression with cognitive impairment in the elderly. However, further therapeutic trials are still needed, to prove the usefulness of cholinesterase inhibitors among depressed elderly patients.
老年抑郁症的特征表现为伴有妄想、重度焦虑、行为障碍、躯体主诉或认知障碍的非典型症状。这些临床症状被认为是导致此类患者对抗抑郁药反应不佳的原因。目前，当重度焦虑与抑郁症并存时，建议在抗抑郁药基础上加用镇静药物；对于伴有妄想症状的抑郁症患者，则加用抗精神病药物。然而，胆碱酯酶抑制剂对伴有认知障碍的抑郁症是否有效，尚未达成共识。胆碱酯酶抑制剂对阿尔茨海默病患者有效。在治疗的最初几年，它们能改善认知功能并减缓退行性病变进程。如今，关于抑郁症神经生物学机制的新研究发现，抑郁症存在局部退行性病变过程，且在大脑中，抑郁症与阿尔茨海默病前期状态存在一些相似的异常。新的治疗试验表明，胆碱酯酶抑制剂对阿尔茨海默病患者的抑郁症状也有效。这些证据支持了以下假设：胆碱酯酶抑制剂与抗抑郁药联合使用，可能会给老年抑郁症患者带来更多益处。
通过文献综述和病例报告，我们试图明确胆碱酯酶抑制剂对老年抑郁症的治疗是否有效。
我们报告一例68岁男性患者，四年前曾出现伴有认知障碍的重度抑郁症第二次发作。使用抗抑郁药（文拉法辛）治疗后，改善效果不佳，仍存在重度焦虑、思维迟缓以及持续的认知障碍。尽管脑部扫描图像正常，但我们决定在同一种抗抑郁药基础上加用胆碱酯酶抑制剂（多奈哌齐）。联合使用后，患者迅速实现抑郁症完全缓解，认知功能恢复。这种状态一直维持至今（距上次抑郁发作四年后），未出现新的情绪复发。近期脑部扫描图像未显示任何退行性病变。
当老年抑郁症伴有认知障碍且对抗抑郁药反应不完全时，胆碱酯酶抑制剂与抗抑郁药联合使用似乎是一种不错的选择。然而，仍需进一步的治疗试验，以证实胆碱酯酶抑制剂对老年抑郁症患者的有效性。
