Depression and chronic heart failure in the elderly: an intriguing relationship

Abstract

Chronic heart failure and depressive disorders have a high prevalence and incidence in the elderly. Several studies have shown how depression tends to exacerbate coexisting chronic heart failure and its clinical outcomes and vice versa, especially in the elderly. The negative synergism between chronic heart failure and depression in the elderly may be approached only taking into account the multifaceted pathophysiological characteristics underlying both these conditions, such as behavioural factors, neurohormonal activation, inflammatory mediators, hypercoagulability and vascular damage. Nevertheless, the pathophysiological link between these two conditions is not well established yet. Despite the high prevalence of depression in chronic heart failure elderly patients and its negative prognostic value, it is often unrecognized especially because of shared symptoms. So the screening of mood disorders, using reliable questionnaires, is recommended in elderly patients with chronic heart failure, even if cannot substitute a diagnostic interview by mental health professionals. In this setting, treatment of depression requires a multidisciplinary approach including: psychotherapy, antidepressants, exercise training and electroconvulsive therapy. Pharmacological therapy with selective serotonin reuptake inhibitors, despite conflicting results, improves quality of life but does not guarantee better outcomes. Exercise training is effective in improving quality of life and prognosis but at the same time cardiac rehabilitation services are vastly underutilized.

Keywords: Chronic heart failure; Depression; The elderly.

Figure 1.. Multi-factorial pathophysiology of the relationship between depression and CHF.

Depression and CHF are able to negatively affect one-other, interacting at several different pathophysiological levels. CHF: chronic heart failure.

Figure 2.. Cox regression survival curve in the absence (A) and presence (B) of chronic heart failure stratified in tertiles of geriatric depression scale.

Depression is predictive of long-term mortality in the absence and even more in the presence of CHF, being the increasing GDS score associated with a decreased survival, significantly more marked in CHF patients. CHF: chronic heart failure; CI: confidence interval; GDS: geriatric depression scale; HR: hazard ratio. Modified with permission.