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Depression in the Elderly: Recognition,
Diagnosis, and Treatment
LOUIS A. CANCELLARO, PhD, MD, EFAC Psych
Professor Emeritus and Interim Chair
ETSU Department of Psychiatry & Behavioral Sciences
Diagnosis
 Diagnosing depression in elderly
• Use family + patient for history
• Report >2 weeks history of (one or more):
•
Loss of energy, loss of interests
•
Increase in somatic symptoms w/o adequate
physical explanation
•
Behavioral and/or personality change
•
Suicidal tendencies
•
Delusions
MDD
 The symptoms cannot be the result of a
medical illness, alcohol or drug usage,
medications, or other psychiatric
disorder.
Atypical Presentation of the
Geriatric Patient
 Older patients are more likely to report
somatic complaints and less depressed mood
than younger adults.
 Older depressed patients may present with
a “masked presentation,” i.e., the patient
reports physical rather than mood
complaints such as back pain or
constipation.
Predisposing Factors
 Prior history of depression
• Women with prior history are more likely than men to
have recurrent episodes
 Prior suicidal attempts/family history of
depression/suicide
 History of substance or alcohol abuse
 Lack of social support
• Males living alone/loss of spouse
 Medical illness/disability
 Cognitive impairment/dementia
Barriers to Recognition of MDD
 Medical Illness
 Most geriatric patients suffer from several chronic
illnesses, particularly cardiac disease, Type 2 diabetes,
hypertension, arthritis, COPD, malignancies and G I
disorders
 MDD in older medically ill patients is 10 times more
frequent than in community dwelling older individuals
 MDD is diagnosed in 25% to 50% of geriatric
inpatients referred for psychiatric consultation
Barriers to Recognition of MDD
Primary Care Clinicians
 May not be aware of the MDD diagnostic
criteria
 May attribute depressive symptoms to:
• The aging process
• Functional decline
• Personal loss
Barriers to Recognition of MDD
Primary Care Clinicians
 May not routinely screen for depression
 May believe treatments are marginally
effective
 May inadequately treat patients with
depression
Cognitive Decline and Depressive
Symptoms
 Depressed patients tend to exaggerate the degree
of their cognitive dysfunction as well as
emphasizing their disabilities; while downplaying
their depressive symptoms. Hence the term
“pseudo dementia depressive syndrome”.
 Following charts will assist the clinician in
distinguishing the difference between depression
and dementia; and depression and grief.
Features
Dementia
Depression
Onset
Vague, insidious, no clear cut
Clear, recent, rapid
time frame. Several months to years onset with episodic
course
Progression
Relatively steady decline
Uneven, often no
progression
Affect
Bland, labile fluctuating from
laughter to tears, not consistent or
sustained. Influenced easily by
suggestion. Environmentally
responsive
Marked disturbance,
feelings of despair,
hopelessness which are
pervasive and
persistent. Not
influenced by
suggestion
Features
Dementia
Memory
Short term Impaired for recent events
Long Term Unimpaired early in
Disease, later confabulation
and/or perseveration
Orientation
Depression
Minimal impairment as
determined by
objective testing
Varying levels of awareness as Basically unaffected
disease progresses. May exhibit
disorientation to time and place
Features
Dementia
Depression
Insight
Lacking, minimal appreciation for Nearly always aware of
illness particularly in later stages. defects and can be quite
Not distressed.
distressed.
Intellect
Grossly impaired on testing.
May appear impaired
clinically but performs
well on formal testing.
Psychotic Mainly visual hallucinations
Auditory hallucinations
symptoms and/or delusions of paranoid type and delusions may occur
in psychotic depression
Features
Dementia
Depression
Physical
complaints
Vague complaints of
aches and pains in
head/back. Fatigue and
feelings of malaise
Vegetative signs of
depression are present
Neurological
signs
Global amnesia, anomia, None present
aphasia, apraxia
Test
performance
Good cooperation and
effort. Near miss
responses. Little test
anxiety
Poor cooperation and
effort. Variable
achievement.
Considerable anxiety. I
don’t know answers are
typical.
Grief vs Depression
Grief
Depression
Functional impairment <2mo
Impairment>2mo
Fluctuating anhedonia
Relatively fixed anhedonia
Self-esteem preserved
Self-esteem decreased
Functioning:
“muddles through”
Functioning severely impaired
Guilt not generalized:
Focused on better care of the
deceased
Generalized guilt
Passively suicidal or not at all
Often actively suicidal
Aids to Recognition of
Depression
• Ask the patient about depressive feelings –
“Do you often feel sad or depressed?” “Lose interest or pleasure?”
• Patients with unexplained complaints
• Failure to thrive
• Making a slower than expected recovery from a medical illness;
older patients are less likely to be spontaneous in reporting
depressive symptoms
• Inquire about recent loss of any kind. Losses equate to increased risk.
Aids to Recognition of Depression
 Ask directly about suicidal thoughts or morbid
preoccupation with death
 For all patients 65 years of age <65; rate is 50%
higher. Lethality is 1 out of 2 attempts vs 1 out of 8
in younger.
 Suicide is highest in elderly white, depressed,
drinking males with medical problems who live
alone.
 Use of firearms are the most common completion
method in elderly, both men and women.
Aids to Recognition of
Depression
 Use screening instruments, simple scales
can serve clinicians such as Brief Geriatric
Depression Scale
Treatment
 Use pharmacological and non-
pharmacological modalities
 Some patients are reluctant to take
medication, therefore it is necessary to
educate the patient and significant family
members as to choice rationale
 Become familiar with several
antidepressants from different classes
Choice of Antidepressant
 Previous history of response
 Side effect profile
 Safety profile
 Pharmacokinetic profile
 Potential for drug/drug interactions
 Cost
 Medical condition/age
Duration of Treatment
 30% -40% of geriatric MDD are chronic
with recurrence rates greater than 30% 3-6
years after resolution of initial depression
 Recommend maintenance indefinitely
Pharmacotherapy
Selective Serotonin Reuptake Inhibitors (SSRIs)
 Generally considered first line of choice
 Well tolerated in the elderly-no cognitive
impairment-1/4 to ½ normal starting dose
 Favorable side effect profile
 Common GI complaints; nausea and appetite loss
may diminish if taken with meals and full glass of
water
 Low toxicity
Pharmacotherapy
 Withdrawal symptoms may occur if stopped
abruptly-flu-like symptoms, dizziness, and
agitation
 Shorter acting drugs are preferred; paroxetine
and sertraline.
 Sexual dysfunction may occur with usage
 May inhibit P450-2D6 system, thus requires
lower dose or a lower dose of other drugs given
in concert. Sertraline is least interactive.
Treatment of Comorbid Anxiety and
Depression in Elderly Patients
 Risk of chronic benzodiazepine use increases
with advancing age. Often one sees both an antidepressant and benzodiazepine used in
combination
 Benzodiazepine use should be avoided. Use
occurs 3-10 times more frequently than
antidepressants
 Venlafaxine XR and SSRIs are useful for both
anxiety and depression
Reasons for Treatment Failure
Inadequate trial
Inadequate dosage
Poor compliance
Noncompliance
 Lack of knowledge about the illness
 Lack of knowledge about drug side effects
 Cost-can’t afford to purchase
 Can’t read the label
 Can’t access the drug-safety caps
 Polypharmacy-too many drugs taken
When do you Refer to a
Psychiatrist
 Presence of a comorbid psychiatric disorder
 Presence of comorbid medical and
neurological conditions
 Drug resistant depression
 Presence of psychosis
(hallucinations/delusions)
 Need for electroconvulsive therapy
 Need for psychotherapy
Remember: Clinical Responsibilities
 Foster a clinical/patient relationship
 Understand patient stressors
 Educate patient and care providers
 Correct prejudices
 Simplify drug regimen
 Convey confidence
 Know medication cost