Group of Investigation on Multimorbidity and Mental Health in Aging (GIMMA), Geriatrics Division, Department of Internal Medicine, Jundiaí Medical School, Jundiaí, Brazil.
University of Groningen, University Medical Center Groningen, Department of Psychiatry, Groningen, the Netherlands.
Clin Interv Aging. 2022 Jun 22;17:979-990. doi: 10.2147/CIA.S328432. eCollection 2022.
Although the public importance of frailty is widely acknowledged by the World Health Organization, physical frailty is still largely neglected in geriatric mental health care. Firstly in this narrative review, we summarize the knowledge on the epidemiology of the association between depression and frailty, whereafter implications for treatment will be discussed. Even though frailty and depression have overlapping diagnostic criteria, epidemiological studies provide evidence for distinct constructs which are bidirectionally associated. Among depressed patients, frailty has predictive validity being associated with increased mortality rates and an exponentially higher fall risk due to antidepressants. Nonetheless, guidelines on the treatment of depression neither consider frailty for risk stratification nor for treatment selection. We argue that frailty assessment enables clinicians to better target the pharmacological and psychological treatment of depression as well as the need for interventions targeting primarily frailty, for instance, lifestyle interventions and reduction of polypharmacy. Applying a frailty informed framework of depression treatment studies included in a meta-analysis reveals that the benefit-harm ratio of antidepressants given to frail depressed patients can be questioned. Nonetheless, frail-depressed patients should not withhold antidepressants as formal studies are not available yet, but potential adverse effects should be closely monitored. Dopaminergic antidepressants might be preferable when slowness is a prominent clinical feature. Psychotherapy is an important alternative for pharmacological treatment, especially psychotherapeutic approaches within the movement of positive psychology, but this approach needs further study. Finally, geriatric rehabilitation, including physical exercise and nutritional advice, should also be considered. In this regard, targeting ageing-related abnormalities underlying frailty that may also be involved in late-life depression such as low-grade inflammation might be a promising target for future studies. The lack of treatment studies precludes firm recommendations, but more awareness for frailty in mental health care will open a plethora of alternative treatment options to be considered.
虽然世界卫生组织广泛承认衰弱的公众重要性，但在老年精神卫生保健中，身体衰弱仍然在很大程度上被忽视。首先，在本叙事性综述中，我们总结了关于抑郁与衰弱之间关联的流行病学知识，此后将讨论其对治疗的影响。尽管衰弱和抑郁有重叠的诊断标准，但流行病学研究提供了证据，表明它们是相互关联的不同结构。在抑郁患者中，衰弱具有预测有效性，与死亡率增加以及由于抗抑郁药而使跌倒风险呈指数级增加有关。尽管如此，关于抑郁症治疗的指南既不考虑衰弱进行风险分层，也不考虑治疗选择。我们认为，衰弱评估使临床医生能够更好地针对抑郁的药物和心理治疗以及针对衰弱的干预措施（例如生活方式干预和减少多药治疗）进行治疗。应用纳入荟萃分析的抑郁治疗研究的衰弱信息框架表明，可以质疑给予衰弱抑郁患者的抗抑郁药的获益-危害比。尽管如此，由于目前尚无正式研究，衰弱的抑郁患者不应拒绝使用抗抑郁药，但应密切监测潜在的不良反应。当缓慢是突出的临床特征时，多巴胺能抗抑郁药可能更可取。心理治疗是药物治疗的重要替代方法，尤其是积极心理学运动中的心理治疗方法，但这种方法需要进一步研究。最后，老年康复，包括体育锻炼和营养建议，也应考虑。在这方面，针对衰弱的潜在衰老相关异常（这些异常也可能与老年抑郁症有关，例如低度炎症）可能是未来研究的一个有前途的目标。缺乏治疗研究使得无法做出确切的建议，但在精神卫生保健中更多地认识到衰弱问题，将为考虑更多的替代治疗方案提供机会。
