DEPRESSION

Depression is a significant health problem that affects the older adult population. Estimates of depression in older adults vary widely; however, there is a consensus that the size of the problem is underestimated owing to misdiagnosis and mistreatment. Approximately 15% of community-dwelling older adults are thought to have depressive symptoms. The estimate drops to approxi­mately 3% when diagnosis is restricted to major depres­sion. Depressive symptoms are seen in approximately 15% to 25% of nursing home residents.⁵⁶

The term depression is used to describe a symptom, syndrome, or disease. As listed in the American Psychiatric Association's 1994 Diagnostic and Statistical Manual of Men­tal Disorders (DSM-IVR), the criteria for the diagnosis and treatment of major depression include at least five of the following symptoms during the same 2-week period, with at least one of the symptoms being depressed mood or an-hedonia (i.e., loss of interest or pleasure): depressed or irri­table mood; loss of interest or pleasure in usual activities; appetite and weight changes; sleep disturbance; psycho-motor agitation or retardation; fatigue and loss of energy; feelings of worthlessness, self-reproach, or excessive guilt; diminished ability to think or concentrate; and suicidal ideation, plan, or attempt.⁵⁷

Depressive symptomatology can be incorrectly attrib­uted to the aging process, making recognition and diagno­sis difficult. Depressed mood, the signature symptom of depression, may be less prominent in the older adult, and more somatic complaints and increased anxiety are re­ported, confusing the diagnosis. Symptoms of cognitive im­pairment can be seen in the depressed older adult. Because it can be misdiagnosed as dementia, a thorough medical evaluation is in order. Unlike true dementia, pseudo-dementia of depression usually improves with treatment for depression. Although they are similar in clinical pres­entation, there are some subtle distinctions between the two conditions (Table 3-3). Physical illnesses can compli­cate the diagnosis as well. Depression can be a symptom of a medical condition, such as pancreatic cancer, hypothy-roidism or hyperthyroidism, pneumonia and other infec­tions, congestive heart failure, dementia, and stroke.⁵⁶,⁵⁸ Medications such as sedatives, hypnotics, steroids, anti-hypertensives, and analgesics also can induce a depressive state. Numerous confounding social problems, such as be­reavement, loss of job or income, and loss of social sup­port, can obscure or complicate the diagnosis.⁵⁸,⁵⁹

The course of depression in older adults is similar to that in younger persons. As many as 40% experience re­currences. Suicide rates are highest among the elderly population. There is a linear increase in suicide with age, most notably among white men older than 60 years of age. Although the exact reasons are unclear, it may be caused by the emotional alienation that can accompany the aging process, combined with complex biopsycho-social losses.^58–60

Because diagnosis of depression can be difficult, use of a screening tool may help to measure affective function­ing objectively. The Geriatric Depression Scale, an instru­ment of known reliability and validity, was developed to

measure depression specifically in the noninstitutional-ized older adult population. The 30-item dichotomous scale elicits information on topics relevant to symptoms of depression among older adults, such as memory loss and anxiety.⁶¹ Many other screening tools, each with its own advantages and disadvantages, exist to evaluate the older adult's level of psychological functioning, in its entirety or as specific, separate components of function.

Treatment goals for older adults with depression are to decrease the symptoms of depression, improve the qual­ity of life, reduce the risk for recurrences, improve health status, decrease health care costs, and decrease mortality. Pharmacotherapy (i.e., use of antidepressants) is an effective treatment approach for the depressed older adult. The se­lection of a particular medication depends on a variety of factors, such as a prior positive or negative response, history of first-degree relatives responding to medication, concur­rent medical illnesses that may interfere with medication use, concomitant use of nonpsychotropic medications that may alter the metabolism or increase the side-effect profile, likelihood of adherence, patient preference, and cost.

Selective serotonin reuptake inhibitors (SSRIs), a class of antidepressants (e.g., sertraline, paroxetine, escitalopram), provide high specificity by blocking or slowing serotonin reuptake without the antagonism of neurotransmitter re­ceptors or direct cardiac effects. Because of this, they are an attractive first choice for pharmacotherapy. Dosing is usually once per day, creating ease of administration. They also are less lethal in overdose than other types of antide­pressants, such as the tricyclics, an important considera­tion because of the high suicide rate among older adults. The anticholinergic and cardiovascular side effects that can be problematic with tricyclic antidepressants (e.g., nor-triptyline, desipramine, amitriptyline) are minimal with SSRIs. Regardless of the classification, psychotropic med­ications should be given in low doses initially and gradu­ally titrated according to response and side effects. Response to antidepressants usually requires 4 to 6 weeks at thera­peutic dose levels. For a single episode of major depression, drug therapy usually should continue for a minimum of 6 months to 1 year, and 2 to 5 years for recurrent depres­sion, to prevent relapse.^56,58,59

Electroconvulsive therapy (ECT) may be the treat­ment of choice for older adults with severe, pharmacolog­ically resistant major depressive episodes. Studies indicate that individuals older than 60 years of age are the largest group of patients who receive ECT. Despite the negative publicity that has been associated with ECT, the evidence for its efficacy in the treatment of depression is strong. Unfortunately, relapse after ECT is common, and alter­native treatment strategies, including maintenance ECT or maintenance antidepressants after ECT, are being used.⁶²

"Talking therapy," such as supportive counseling or psychotherapy, is considered to be an important part of the treatment regimen, alone or in combination with pharma­cotherapy or ECT. Alterations in life roles, lack of social sup­port, and chronic medical illnesses are just a few examples of life event changes that may require psychosocial support and new coping skills. Counseling in the older adult popu­lation requires special considerations. Individuals with sig­nificant vision, hearing, or cognitive impairments may require special approaches. Many elderly persons do not see themselves as depressed and reject referrals to mental health professionals. Special efforts are needed to engage these individuals in treatment. Family therapy can be ben­eficial as a way to help the family understand more about depression and its complexities and as an important source of support for the older adult. Although depression can im­pose great risks for older adults, it is thought to be the most treatable psychiatric disorder in late life and therefore war­rants aggressive case finding and intervention.

3 Characteristics That Distinguish Dementia From Pseudodementia of Depression

Dementia

Pseudodementia of Depression

Insidious onset

Symptoms present for long duration

Inaccurate in answering orientation questions; attempts to

cover up inaccuracies May try to conceal deficits Consistently performs poorly on tasks of similar difficulty

Mood and behavior tend to be labile

May have neurologic symptoms of dysphasia, apraxia, or agnosia

Rapid onset

Symptoms present for relatively short time

May show lack of interest in answering questions;

frequent "don't know" or "don't care" response May tend to emphasize deficits; highlight disabilities May display marked variability in performing tasks

of similar difficulty Mood consistently depressed; may have

superimposed agitation or anxiety Neurologic symptoms not present