LOUIS A. CANCELLARO, PhD, MD, EFAC Psych Professor Emeritus and
Interim Chair ETSU Department of Psychiatry & Behavioral
Sciences Depression in the Elderly: Recognition, Diagnosis, and
Treatment
Slide 2
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
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MDD The symptoms cannot be the result of a medical illness,
alcohol or drug usage, medications, or other psychiatric
disorder.
Slide 4
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.
Slide 5
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
Slide 6
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
Slide 7
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
Slide 8
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
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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.
Slide 10
FeaturesDementiaDepression Onset Vague, insidious, no clear cut
time frame. Several months to years Clear, recent, rapid onset with
episodic course ProgressionRelatively steady decline Uneven, often
no progression AffectBland, 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
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FeaturesDementiaDepression Memory Short term Long Term Impaired
for recent events Unimpaired early in Disease, later confabulation
and/or perseveration Minimal impairment as determined by objective
testing OrientationVarying levels of awareness as disease
progresses. May exhibit disorientation to time and place Basically
unaffected
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FeaturesDementiaDepression Insight Lacking, 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
symptoms Mainly visual hallucinations and/or delusions of paranoid
type Auditory hallucinations and delusions may occur in psychotic
depression
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FeaturesDementiaDepression 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, aphasia, apraxia None present Test
performance Good cooperation and effort. Near miss responses.
Little test anxiety Poor cooperation and effort. Variable
achievement. Considerable anxiety. I dont know answers are
typical.
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Grief vs Depression GriefDepression Functional impairment 2mo
Fluctuating anhedoniaRelatively fixed anhedonia Self-esteem
preservedSelf-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 allOften actively suicidal
Slide 15
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.
Slide 16
Aids to Recognition of Depression Ask directly about suicidal
thoughts or morbid preoccupation with death For all patients 65
years of age
