is one of the most frequent psychiatric problems experienced by
older adults. When measured by criteria established by the American
Psychiatric Association, the prevalence of a major depressive disorder
is 4-5% in the elderly. However, perhaps as many as 20% of the elderly
living in the community have some symptoms of depressive symptomatology.
Depression is even higher among the elderly in hospitalized or nursing
home populations: 12 to 23% in acute care and 15-30% in nursing
homes. Depression can result in poor recovery from other acute illnesses,
impede the management of concomitant illnesses, and is associated
with a high suicide rate. Furthermore, while depression is potentially
treatable, the treatment modalities may be associated with significant
side effects, making an accurate diagnosis imperative.
are the Clinical Features of Depression in the Elderly?
is easily overlooked in elderly patients in whom symptoms suggestive
of depression are commonly due to physical illnesses. Although a
dysphoric mood or sadness is key to diagnosing depression, the most
important expression of depression may be anhedonia, the loss of
ability to enjoy one's usual activities. Compared to younger adults,
the depressed elderly are more likely to manifest somatic symptoms,
hyperactive agitated behavior and delusions and are less likely
to express feelings of guilt.
diagnosing depression, the physician must recognize the presence
of several categories of depressive disorders. In major depression,
as defined by the American Psychiatric Association, fourth edition,
patients will manifest a depressed mood or loss of interest or pleasure
in all or most activates most of the day plus at least four of the
following symptoms for a period of at least two weeks: loss of interest
in usual activities, either increase or decrease in appetite and
weight, increased or decreased sleep, agitation or retardation,
inappropriate guilt or worthlessness, diminished concentration,
and suicidal ideation. Other categories are bipolar disorder (depression
in the context of at least one prior manic episode); organic depression
secondary to a concomitant organic metabolic or toxic illness, adjustment
disorders in which depressive symptoms occur in response to a known
physical or psychosocial stress; and dysthymia in which only a few
of the classic symptoms of a major depression are present.
disturbed mood is the dominant characteristic of depression, patients
may manifest cognitive deficits, suggestive of dementia or delirium.
The combination of depression and cognitive impairments has sometimes
been called pseudodementia or more recently, the dementia of depression,
implying that the cognitive symptoms are secondary to depression.
To distinguish dementia from pseudodementia, the physician must
consider the pattern of onset and the level of severity of the cognitive
versus the affective symptoms. In this case, one needs to determine
whether the cognitive or affective deficits are dominant. Patients
suffering from a bipolar disorder may simulate a hyperactive delirious
state while in their manic phase but the presence of grandiosity
and euphoria and the history of depression will help establish the
correct diagnosis. True pseudodementia, that is cognitive deficits
due to depression, is uncommon. More often, dementia and depression
coexist, especially during early stages of dementia. Therefore,
the task of the physician is not to choose between dementia and
depression but to determine whether either or both exist.
Are Some Common Causes of Depression in the Elderly?
of depression such as fatigue, weakness, insomnia, and anorexia
may be due to a variety of treatable physical illnesses and to other
psychiatric diagnoses: Parkinson's disease, hyper and hypothyroidism,
malnutrition, chronic obstructive lung disease, heart failure, malignancies,
and stroke. Drugs are the most common cause of treatment-induced
depression. Among the wide variety of drugs that can produce symptoms
of depression, antihypertensive agents, particularly centrally acting
alpha agents and beta blockers, and sedatives are probably the most
common. Steroids, antiparkinsonism drugs, and narcotic analgesics
are also common offenders.
the Elements of the Physical Examination of the Depressed Patient?
addition to the mental status features described above, the physical
examination of a patient suspected of depression must include a
standard neurologic examination, focusing on focal neurological
deficits, language, gait, incontinence and sensory impairment. Laboratory
tests are necessary to establish the presence of medical illnesses
associated with depression. The following tests are recommended:
A complete blood count, tests of thyroid function, serum calcium,
and liver and renal function tests. When used as screening tests
of depression, head CT scanning, electroencephalography and chest
radiography have seldom been shown to affect management. These tests
should only be obtained when suggested by clinical symptoms or signs.
should Depression in the Elderly Be Treated?
treatment modalities are important in managing depression. The choice
of treatments will depend on the severity of the depression as indicated
by its impact on functional status and the risks of suicide or death,
(for example due to malnutrition or the interference of the depression
with treatment of concomitant illnesses). As a general rule, physical
illnesses in the depressed patient should be optimally treated before
using antidepressant drugs or electroconvulsive therapy. However,
the suicidal, delusional, or starving patient, requires treatment
of the depressive disorder immediately. Supportive measures including
exercise, environmental manipulation, involvement of families and
friends, and social stimulation are crucial in combination with
psychotherapy or electroconvulsive therapy.
types of drugs are used to treat depression in the elderly: tricyclic
antidepressants, monoamine oxidase inhibitors (MAOIs), lithium,
psychostimulants, and most recently, selective serotonin reuptake
inhibitors (SSRIs). A full discussion of these drugs is beyond the
scope of this review. However, several points are useful for the
practicing physician. First, if the practitioner is uncertain of
the diagnosis of depression, a psychiatrist should be consulted.
Second, although efficacy has been demonstrated for most of the
medications on the market, all these medications have potential
side effects and therefore should only be used by practitioners
familiar with their dosing and side effects. However, drugs have
been less beneficial in elderly with psychotic symptoms than in
other depressed groups. Last, elderly patients should be treated
with lower than the standard doses used in middle aged and young
adults because of the higher incidence of adverse effects.
the Adverse Effects of Antidepressants?
of antidepressant therapy is largely dependent upon the side effect
profile of the drugs. MAOIs can cause significant hypotension. Lithium
has a narrow therapeutic ratio in the elderly, its blood levels
are influenced by diuretics and angiotensin converting enzyme inhibitors,
and its is unlikely to be useful in the treatment of acute depression.
The principal side effects of the tricyclic antidepressants are
sedation, postural hypotension, and anticholinergic side effects
including possible delirium. Antidepressants with potent anticholinergic
effects should be avoided if possible in patients with urinary retention
or gastrointestinal symptoms of reflux or constipation. Whereas
tricyclic antidepressants can be administered safely in patients
with impaired myocardial contractility, they are contraindicated
in patients with conduction disturbances, left or right bundle branch
block. Among the cardiovascular side effects of the tricyclic antidepressants,
orthostatic hypotension is often overlooked. Drugs with a high potential
for orthostasis should be avoided in patients with a low blood pressure
or those with postural hypotension prior to therapy.
selective serotonin reuptake inhibitors (fluoxetine, sertraline,
paroxetine, and fluvoxamine) have acquired a significant role in
treating the elderly depressed patients because they are better
tolerated in general than other agents. They have few to none of
the anticholinergic side effects of other classes of antidepressants
but they are associated with insomnia, nausea, and in some cases
sexual dysfunction. They also generally require less dosage titration
than do the tricyclics in order to reach the final dose.
Therapy Safe in the Elderly?
drug treatment of depression fails or if treatment is required for
rapid relief, electroconvulsive therapy (ECT) should be considered.
Although ECT has a controversial past, it is relatively safe and
can be highly effective in the elderly