Course Authors
Rafi Kevorkian, M.D.
Dr. Kevorkian is a Fellow, Division of Geriatric Medicine, St. Louis University School of Medicine. Dr. Kevorkian reports no commercial conflict of interest.
Estimated course time: 1 hour(s).
Albert Einstein College of Medicine – Montefiore Medical Center designates this enduring material activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
In support of improving patient care, this activity has been planned and implemented by Albert Einstein College of Medicine-Montefiore Medical Center and InterMDnet. Albert Einstein College of Medicine – Montefiore Medical Center is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Upon completion of this Cyberounds®, you should be able to:
List the causes of depression in elders
Manage depression in chronic medical illness and dementia
Discuss suicide risk in the geriatric population.
Depression in the elderly is prevalent, persistent, disabling and sometimes fatal. As clinicians we need to be aware that the psychiatric needs of our geriatric patients are different from young patients, and that the causes leading to a mood disorder are different. The myth that depression is a natural result of aging is prevalent in society and among patients. As such, many elder patients go unnoticed or are not offered treatment.
It is estimated that there are 2 million people over the age of 65 in the U.S. who are depressed. Because medicine can be too focused on chronic medical illness, physicians, as a result, do not have enough time to discuss issues regarding emotional health. As our population ages, it is imperative that society and physicians become more sensitive to emotional health concerns in order to improve the total well being of elders.
Assessment
Assessment of depression in the elderly begins with an emphasis on risk factors that are typically more relevant to older patients: severe life events, ongoing stresses, spousal bereavement, care giving burden and loss of independence by medical illness.(1) The five D's of depression in the elderly are: disability, decline, diminished quality of life, demand on caregivers and dementia.
Co-morbid conditions can also impact mood. Post myocardial infarction and post cerebrovascular events have been associated with a greater incidence of depression. Although not enough research has been done, alcohol has been implicated as a co-morbid condition. Twenty percent of alcoholics suffer from depression(2) and remission of alcohol abuse increases the likelihood of depression remission.(3) Thirty-three percent of depressed elderly patients have an anxiety disorder. Depressed elderly patients may, additionally, have personality disorders -- typically, avoidance and dependence, obsessive compulsive and passive-aggressive types, as compared to antisocial, borderline, histrionic and narcissistic types more commonly seen in younger patients with mood disorders.(4)
Family history of depression is an important risk factor for late life depression.(5) A survey done by the National Mental Health Association in 1996 showed that 58 % felt depression was a normal part of the aging process, and 49 % attributed depression to personal weakness. Although depression is more common in younger patients, 20 % of suicides are in older patients (highest in any age group),(6) specifically older white men, who also had a greater rate of success of suicide. These men tended to live alone, were widowed, had chronic medical illnesses and saw their primary medical doctor a few weeks prior to suicide. Again, it is important to pay attention to the life stresses to raise awareness for suicide.
It has been shown that 50 to 70 % of all medical visits by the elderly have, as a major component, emotional distress or dysfunction. These patients were less likely to have greater social contacts. They had an increasing feeling that their health was poor. As a result, they had more doctor visits and medical costs.
A study of outpatients showed that only 9 % of doctors used routine questioning or screening for depression.(7) The diagnosis of depression was made 33 % of the time by formal criteria. Fifty-eight percent of doctors asked about suicide. One-third of doctors offered 5 minutes of counseling. Seventy-two percent gave medicines and 38 % referred to a psychiatrist.
In the presence of chronic medical illness, physicians are less likely to discuss depression but are very receptive to patient requests for medication. Older patients tended to have more somatic and cognitive symptoms than affective symptoms as compared to younger patients. They also tended to have depression without sadness. It has been shown that 5 to 10% of nursing home patients are depressed, as well as 11% of inpatients and 12 to 22% of nursing home patients.(8) Loss of independent functioning has been associated with depression and the treatment of depression can improve function even when no change occurs in the medical condition that caused disability. It is also important to treat depression because, otherwise, medical burden is increased.
Medical Causes
Infection, endocrinopathies, cancer (high rate with pancreatic cancer), brain diseases, dementia, chronic pain, and medications can cause mood disorders. Pain is amplified by depression and chronic pain worsens depression. Some medications that have caused depression include corticosteroids, interferon, sedatives, calcium channel blockers, tamoxifen, clonidine, cimetidine and digitalis. It has been shown that dementia causes apathy and loss of initiative.
Since elderly patients are often dependent on caregivers, clinicians need to ask caregivers about their observations. Have they noticed crying spells, insomnia, weight loss, emotional lability, psychomotor slowing and poor affect? Mildly demented patients may refuse medical treatment or food and may express the desire not to live. Prompt investigation should be carried out for depression if that occurs.
Assessment Tools
The DSM IV criteria, the Geriatric Depression Scale, the General Health Questionnaire and the Beck Depression Inventory are used to assess depression. What's important is not which test is better but whether it is a positive. It is important to note that if there is a negative screen, the patient may still be depressed and may benefit from treatment.
In geriatrics, the most commonly used screen is the Geriatric Depression Scale (GDS):(9)
Answer Yes or No to the following -
- Are you basically satisfied with your life?
- Have you dropped many of your activites and interests?
- Do you feel that your life is empty?
- Do you often get bored?
- Are you hopeful about the future?
- Are you bothered by thoughts you can't get out of your head?
- Are you in good spirits most of time?
- Are you afraid that something bad is going to happen to you?
- Do you feel happy most of the time?
- Do you often feel helpless?
- Do you often get restless and fidgety?
- Do you prefer to stay at home, rather than going out and doing new things?
- Do you frequently worry about the future?
- Do you feel you have more problems with memory than most?
- Do you think it is wonderful to be alive now?
- Do you often feel downhearted and blue?
- Do you feel pretty worthless the way you are now?
- Do you worry a lot about the past?
- Do you find life very exciting?
- Is it hard for you to get started on new projects?
- Do you feel full of energy?
- Do you feel that your situation is hopeless?
- Do you think that most people are better off than you are?
- Do you frequently get upset over the little things?
- Do you frequently feel like crying?
- Do you have trouble concentrating?
- Do you enjoy getting up in the morning?
- Do you prefer to avoid social gatherings?
- Is it easy for you to make decisions?
- Is your mind as clear as it used to be?
At a minimum all patients should be asked if they are sad. Men are less likely to report mood problems and doctors are less likely to recognize mood problems in men. It has been consistently observed that chronic medical illness contributes to late life depression as much as do bereavement and death of a loved one. There is strong evidence that disability and lack of social contact also provoke late life depression.(10) However, negative life events and ongoing difficulties have not been consistently shown to cause depression. It is useful to remember that not everyone gets depressed as they age. Indeed, for some, advanced age may improve self-esteem and maturation may protect these seniors from the impact of psychosocial risk factors.
Chronic Medical Illness and Depression
As mentioned previously, chronic medical illness contributes to depression in late life. Although there are no controlled studies, 20% of patients with heart disease at time of cardiac catheterization were depressed, 33% developed depression over 12 months after a myocardial infarction and 17% of heart transplant patients were depressed.(11) It has been noted that 25 % of cancer patients are depressed, although no longitudinal studies have been done.(12)
Depression also occurs among patients with neurologic disease -- 25 to 50% of stroke patients were noted to be depressed.(13) There was a peak at 3 to 6 months post stroke for depression, and one-year prevalence in some studies as high as 50%. Some patients had a spontaneous remission of their depression 1 to 2 years after their stroke.(14) In one study, sertraline reduced morbidity, but not depression, as compared to the non-treated group, and in another study higher incidence of depression with stroke was seen than with physical illnesses with similar disability.(15)
It has been hypothesized that strokes in certain locations such as the left basal ganglia may disrupt pathways of mood regulation and lead to depression. Studies estimate that 10% of Alzheimer's disease patients and 20% of Parkinson's patients were depressed.(16) According to researchers, depressed patients with Alzheimer's disease had aggression and agitation 20% of the time, delusions 16% of the time, apathy 28% of the time, problem behavior in 19% of the time as well as sleep disturbance.(17) In cases of change in behavior, clinicians need to consider possible medical causes such as hypothyroidism, urinary tract infections, constipation and pain. The Cornell Scale for Depression in Dementia(18) can be used in these patients. A score greater than 12 indicates depression.
The Cornell Scale for Depression in Dementia (CSDD) Ratings should be based on symptoms and signs occurring during the week prior to interview. No score should be given if symptoms result from physical disability or illness.
Scoring System
A = unable to evaluate
0 = absent
1 = mild or intermittent
2 = severe
Mood-Related Signs
| Anxiety (anxious expression, ruminations, worrying) | A 0 1 2 |
| Sadness (sad expression, sad voice, tearfulness) | A 0 1 2 |
| Lack of reactivity to pleasant events | A 0 1 2 |
| Irritability (easily annoyed, short-tempered) | A 0 1 2 |
Behavioral Disturbance
| Agitation (restlessness, handwringing, hairpulling) | A 0 1 2 |
| Retardation (slow movements, slow speech, slow reactions) | A 0 1 2 |
| Multiple physical complaints (score 0 if GI symptoms only) | A 0 1 2 |
| Loss of interest (less involved in usual activities) (score only if change occurred acutely, ie. in less than 1 month) |
A 0 1 2 |
Physical Signs
| Appetite loss (eating less than usual) | A 0 1 2 |
| Weight loss (score 2 if greater than 5 pounds in 1 month) | A 0 1 2 |
| Lack of energy (fatigues easily, unable to sustain activities) (score only if change occurred acutely, ie. in less than 1 month) | A 0 1 2 |
Cyclic Functions
| Diurnal variation of mood (symptoms worse in the morning) | A 0 1 2 |
| Difficulty falling asleep (later than usual for this individual) | A 0 1 2 |
| Multiple awakenings during sleep | A 0 1 2 |
| Early-morning awakening (earlier than usual for this individual) | A 0 1 2 |
Ideational Disturbance
| Suicide (feels life is not worth living, has suicidal wishes, or makes suicide attempt) | A 0 1 2 |
| Poor self-esteem (self-blame, self-deprecation, feelings of failure) | A 0 1 2 |
| Pessimism (anticipation of the worst) | A 0 1 2 |
| Mood-congruent delusions (delusions of poverty, illness, or loss) | A 0 1 2 |
Suicide Prevention
Clinicians need to be on the alert for depression in their geriatric patients so that a devastating event such as suicide can be potentially averted. In a study from Sweden, patients 85 years or older were asked about mood.(19) Sixteen percent of the patients who were undemented had thoughts of taking their life or had passive suicidal ideation, such as life not worth living in the preceding month. These patients tended to have more than three physical disorders (e.g., cardiac disease, peptic ulcer disease), had a higher rate of anxiolytic and neuroleptic usage of agents and had mental disorders. In this study group, rates of suicidal ideation were twice as high in women as in men.
Elder patients have a greater determination to die, give fewer warnings, use more violent and deadly methods to commit suicide, do more planning, have greater resolve and complete suicide at a higher rate. Suicide is the 13th leading cause of death in elders in the U.S.(20) The incidence is 62/100,000 in white men -- guns were used 71% of the time.
Treatment
There are many medical and non-medical options for the treatment of elderly depression. It is not known whether treating depression can actually reduce mortality including among post myocardial infarction patients. Behavior therapy has been shown to be equally effective in management of depression in younger and older individuals.
A literature review for 1995 to 2001 produced 33,167 subjects with a mean age of 72.(21) Ninety-seven studies reported on antidepressants and 12 on electroconvulsive therapy. Eleven studies compared tricyclic antidepressants versus therapy with selective serotonin reuptake inhibitors (SSRIs). Eight of the studies showed equal efficacy and three showed that tricyclics were better. All types of antidepressants were tolerated well. Side effect profile was similar for all classes of antidepressants, although in some studies SSRIs had a better side effect profile.(Table 1)
Click to see full sized image
Click to see full sized image
Treatment of the frail elderly must be monitored closed because they are more prone to side effects from antidepressants.(22) In demented patients, some studies showed SSRIs and tricyclics, as compared to placebo, were equal in efficacy but most showed no benefit. If patients are not responding to treatment, switching to a different class of antidepressant has been shown to be efficacious.
Electroconvulsive therapy (ECT) is the first choice in persons who are suicidal or who have severe weight loss, and ECT has been shown to be more effective than antidepressants.(23),(24) In a few studies, estrogen(25) and methylphenidate(26) demonstrated possible benefits. Psychotherapy in addition to medical therapy is better than medical therapy by itself.(27) Finally, vagal stimulation is being used experimentally to treat depression, as is electromagnetic brain stimulation.
Conclusion
Older depressed adults are less likely to be recognized or diagnosed in primary care settings because of differences in presentation, beliefs that depression is a natural component of aging and lack of adequate history by the clinician. Late life events -- disability, chronic medical illness, bereavement and dementia -- increase the elderly patient's risk of depression. All types of antidepressants are effective and when failure occurs electroconvulsive therapy (ECT) should be considered. If the primary physician is unable to provide counseling, the patient should be referred for those services.