Depression in the Elderly: Recognition, Diagnosis, and Treatment

LOUIS A. CANCELLARO, PhD, MD, EFAC PsychProfessor Emeritus and Interim ChairETSU Department of Psychiatry & Behavioral SciencesDepression in the Elderly: Recognition, Diagnosis, and TreatmentDiagnosisDiagnosing depression in elderlyUse family + patient for historyReport >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 DelusionsMDDThe symptoms cannot be the result of a medical illness, alcohol or drug usage, medications, or other psychiatric disorder.Atypical Presentation of the Geriatric PatientOlder 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 FactorsPrior history of depressionWomen with prior history are more likely than men to have recurrent episodesPrior suicidal attempts/family history of depression/suicideHistory of substance or alcohol abuseLack of social supportMales living alone/loss of spouseMedical illness/disabilityCognitive impairment/dementiaBarriers to Recognition of MDDMedical IllnessMost geriatric patients suffer from several chronic illnesses, particularly cardiac disease, Type 2 diabetes, hypertension, arthritis, COPD, malignancies and G I disordersMDD in older medically ill patients is 10 times more frequent than in community dwelling older individualsMDD is diagnosed in 25% to 50% of geriatric inpatients referred for psychiatric consultationBarriers to Recognition of MDDPrimary Care Clinicians May not be aware of the MDD diagnostic criteriaMay attribute depressive symptoms to:The aging processFunctional declinePersonal lossBarriers to Recognition of MDDPrimary Care CliniciansMay not routinely screen for depressionMay believe treatments are marginally effectiveMay inadequately treat patients with depressionCognitive Decline and Depressive SymptomsDepressed 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.

FeaturesDementiaDepressionOnsetVague, insidious, no clear cut time frame. Several months to yearsClear, recent, rapid onset with episodic courseProgressionRelatively steady declineUneven, often no progressionAffectBland, labile fluctuating from laughter to tears, not consistent or sustained. Influenced easily by suggestion. Environmentally responsiveMarked disturbance, feelings of despair, hopelessness which are pervasive and persistent. Not influenced by suggestionFeaturesDementiaDepressionMemory Short term Long TermImpaired for recent eventsUnimpaired early in Disease, later confabulationand/or perseverationMinimal impairment asdetermined byobjective testingOrientationVarying levels of awareness as disease progresses. May exhibit disorientation to time and placeBasically unaffectedFeaturesDementiaDepressionInsightLacking, minimal appreciation for illness particularly in later stages. Not distressed.Nearly always aware of defects and can be quite distressed.IntellectGrossly impaired on testing.May appear impaired clinically but performs well on formal testing.Psychotic symptomsMainly visual hallucinations and/or delusions of paranoid typeAuditory hallucinations and delusions may occur in psychotic depressionFeaturesDementiaDepressionPhysicalcomplaintsVague complaints of aches and pains in head/back. Fatigue and feelings of malaiseVegetative signs of depression are presentNeurological signsGlobal amnesia, anomia, aphasia, apraxiaNone presentTest performanceGood cooperation and effort. Near miss responses. Little test anxietyPoor cooperation and effort. Variable achievement. Considerable anxiety. I dont know answers are typical.Grief vs DepressionGriefDepressionFunctional impairment 2moFluctuating anhedoniaRelatively fixed anhedoniaSelf-esteem preservedSelf-esteem decreasedFunctioning:muddles throughFunctioning severely impairedGuilt not generalized:Focused on better care of the deceasedGeneralized guiltPassively suicidal or not at allOften actively suicidalAids to Recognition ofDepressionAsk the patient about depressive feelings Do you often feel sad or depressed? Lose interest or pleasure?Patients with unexplained complaintsFailure to thriveMaking a slower than expected recovery from a medical illness; older patients are less likely to be spontaneous in reporting depressive symptomsInquire about recent loss of any kind. Losses equate to increased risk.

Aids to Recognition of DepressionAsk directly about suicidal thoughts or morbid preoccupation with deathFor all patients 65 years of age