Depression in the Elderly

Highlights:

• Unique features of depression in the elderly.
• Keys to picking up the diagnosis.
• Pharmacologic treatment.
• When to recommend referral.

Q: What is the best screening tool for assessingdepression in elderly patients?

A:

The Geriatric Depression Scale is the most widelyvalidated screening tool. The questionnaire has beenreduced to a single question that is as sensitive and as specificas the 15-item shortened form of the original 30-itemscale. The question is: "How often do you feel sad or depressed?"This is certainly something that is easy to ask inthe course of a general physical examination or routine officevisit.

Q:Some patients don't admit to being sad ordepressed. Instead, they report feelings ofexhaustion or other somatic symptoms. What are thetricks to reading between the lines and spottingdepression in such patients?

A:

Asking patients if they feel "anxious" or if their"nerves are bad" will often uncover depression, becauseanxiety is a very common feature of depression in elderlypersons. Find out about diurnal variation in symptomsby asking patients what time of day they feel the most exhaustedor tired or have symptoms such as pain. Patientswho are depressed often say that they feel worst in themorning and better as the day progresses. In contrast, patientswho have chronic diseases tend to feel more exhaustedand fatigued as the day wears on.

Q:How do the symptoms of depression in elderlypersons differ from those in younger ones?

A:

In many ways, the most prominent features of depressionin the elderly are unique to this age group

(Table 1).

Once you determine the severity of these symptoms,you can better establish therapeutic goals and selectthe most appropriate treatment:

• Vegetative components. These include poor appetite andpoor sleep. Unlike younger patients with depression, whosometimes increase their food intake, depressed older personstend to manifest anorexia and weight loss. The weightloss is often attributed to other medical conditions insteadof serving as a prompt to ask about depression. Particularlyin patients who have been obese, rapid weight loss resultingfrom depression may lead to unrecognized proteinmalnutrition and related complications that present as physicalillness.Sleep patterns vary in older persons with depression,but early morning awakening is common. Some patientsalso complain of nocturia, but they may in fact be getting upto go to the bathroom because they are awake, rather thanawakening because of the urge to urinate.
• Multiple somatic complaints. Elderly depressed patientsmay complain of pain everywhere in the body. Try to teaseout which pain is related to an underlying medical conditionand which might be related to depression. Pain is exacerbatedby depression and tends not to fit easily into a singlediagnostic picture. For example, a patient with angina whois going to undergo coronary artery bypass surgery haspain that is obviously related to a medical condition, but thepain may be exacerbated if the patient is also depressed.Painful conditions often improve with antidepressanttherapy, which suggests that the state of reduced neurotransmitterlevels associated with depression is also part ofthe pathophysiology of pain. Antidepressants increase thenerve transmitter levels that help suppress pain perception.For example, patients with shingles often become depressed.It may be difficult to determine whether the depressionis related to shingles or whether the pain of shinglesis exacerbated by depression.
• Psychological symptoms. These may involve obsessivefeelings of guilt and worry or rumination during the night.Some patients review all of the things they've ever donewrong and may feel that they're a burden to their families.Ask such patients whether they wish to die or have madeplans to take their life. A patient who has developed a specificplan for suicide is in a critical situation. Urgent referralto a psychiatrist is warranted for consideration of electroconvulsivetherapy or initiation of antidepressant medicationwith careful follow-up to ensure that treatment is effective.Some depressed patients also complain of memoryproblems; this is because their ability to concentrate isimpaired by the depression. A high index of suspicion iscrucial when a patient complains ofmemory problems but is obviously depressed--for example, if he or she frequentlyanswers "I don't know" toquestions on cognitive screening tests.In contrast, patients with underlyingdementia generally do not complainof--and may deny--memory problems.More often, it is their familieswho raise the question of memoryimpairment. During memory testing,patients with dementia either give thewrong answer or look to a familymember for the correct one.
• Psychomotor changes. Some depressedolder patients appear to have"slowed down," which is a typical finding in depressedyounger persons. When asked, however, older patientsoften complain about their "nerves" or report feeling anxious.Many manifest signs of agitation. These psychomotorchanges may be mistaken for an anxiety disorder, and abenzodiazepine or other sedative may be inappropriatelyprescribed. Even though anxiety is a very common featureof depression, it is the depression, not the anxiety, that requirestreatment. The anxiety will resolve with appropriateantidepressant therapy.
• Diurnal variation in symptoms. The single most importantquestion to ask a patient with suspected depression ishow he feels in the morning. If a patient reports that morningis the worst time and that it takes hours to get going,you can be sure he is depressed. Unlike patients with arthritis,whose stiffness dissipates during the first few hours, patientswith depression report that their overall sense of wellbeingis worst in the morning. Occasionally, a patient reportsthat he feels worse later in the day, and some feelafraid to be alone at night.Part of the challenge of diagnosingdepression in the elderly is to beaware that depression presents a littledifferently in this group and to be ableto differentiate which patient is reactingnormally to life events and whichpatient is depressed. Although grief reactionsto the multiple losses of late lifemay occur frequently, suspect depressionif a patient's symptoms result infunctional decline that persists longerthan 2 to 3 months after a significantloss. With the features I've outlinedabove, it is a fairly straightforwardprocess to diagnose depression andprescribe the appropriate treatment.

Q:Which features help distinguish a trueanxiety disorder from anxiety that is really amanifestation of depression?

A:

Anxiety disorders typically have their onset in earlyadulthood. Although generalized anxiety disordermay occur in up to 5% of community-dwelling older adults,these persons usually have a history of anxiety that began in their 20s or 30s. Thus, an older person with anxiety ofrecent onset and no history of previous anxiety is morelikely to be depressed. Consider a diagnosis of agoraphobiain an older person with anxiety of recent onset who isnot depressed.It is crucial to distinguish an anxiety disorder from depression-associated anxiety. Serious complications, such ascognitive dysfunction, fall-related injuries, and worsening ofdepressive symptoms, can result if a benzodiazepine is mistakenlyprescribed for a depressed patient.

Q:Many of my elderly patients believe thatdepression is a normal partof the aging process. Does agingitself cause depression, or are exogenousfactors, such as bereavement,the cause?

A:

We infer that depression in olderpersons is much more likely tohave a biological basis than in youngerones, simply because antidepressantpharmacotherapy is so effective in these patients. About 70%of elderly patients respond to the first drug prescribed,and about 90% respond to a second agent if the first wasn'tbeneficial.One hypothesis for a biological basis is that elderly personsare at greater risk for depression because of age-relatedneuronal dropout, which results in a loss of the brain's reservecapacity to deal with stressful situations--precisely atthe time when the number of stressful situations increases because of bereavement and other traumas. Even so, depression--like cognitive dysfunction--should never be considereda "normal" part of the aging process. Depression isalways a medical diagnosis and is usually treatable.I've observed that elderly persons who have experiencedextreme traumatic events early in their lifetime--such as waror incarceration in a concentration camp--and who seem tohave been able to cope with them very well may in later yearshave a diminished ability to cope with additional psychologicalstresses, even though these may not be as severe.Exogenous factors undoubtedly play a key role in depressionat any age, but as is the case with many bodilysystems, our reserve capacity to copewith stress is diminished with age.

Q:Other than age, what arethe major risk factors fordepression in the elderly?

A:

Chronic diseases, especiallychronic pain syndromes, areoften associated with depression(Table 2). Acute illnesses or disorders that have a suddenonset and that result in significant disability may also leadto depression. Surgery (even if uncomplicated) can bestressful enough to precipitate a depression; this is a commonphenomenon in older patients who have undergone acoronary artery bypass procedure.Undiagnosed depression--which may underlie othermedical conditions--is the most common cause of hospitalreadmission in elderly patients.

Q:Which pharmacotherapeutic agents are mosteffective in elderly persons? What are thespecific pitfalls associated with these agents?

A:

The selective serotonin reuptake inhibitors (SSRIs)are first-line therapy for depression in the elderly;these agents also relieve depression-related anxiety. Theyare considered first-choice agents because they have a bettersafety profile than the tricyclics--for example, they areassociated with fewer cardiac side effects. Nevertheless,SSRIs are not associated with a reduced incidence of fallscompared with the older agents. The SSRIs have a somewhatquicker onset of action than the tricyclics; however, itstill takes 2 to 3 weeks to begin to see improvement.Tricyclic antidepressants, such as nortriptyline, may behelpful in a very anxious depressed patient, particularly onewith insomnia. Even though SSRIshave become the therapy of choice, recentstudies have shown that nortriptylinecan be as effective for depressionin older persons.

^1-3

Fluoxetine is best prescribed withcaution in elderly patients, primarilybecause of its very long half-life. Thiscan be problematic if delirium or anotheracute illness develops. Moreover,the risk of extrapyramidal side effectsmay be increased with a rapiddosetitration of fluoxetine.The "start low and go slow" recommendationabsolutely applies to theSSRIs. I recommend initiating therapyat half of the usual starting dose. The dose should not betitrated up from this level more often than every couple ofweeks; thereafter, it can be titrated monthly until a therapeuticdose is achieved.

Q:Which SSRI adverse effects are most troublesomein the elderly?

A:

Extrapyramidal side effects--including akathisia andParkinsonian-type symptoms--are sometimes notrecognized as side effects of SSRIs and may be confusedwith persistent symptoms of depression; this can lead to inappropriatedosage escalation. Some patients experience GIside effects, including constipation, diarrhea, or stomachupset. These can be avoided by starting therapy at lowdoses. Vivid dreams may be a dose-limiting side effect. Thepotential for drug interactions exists, but this does not generallyoccur at the lower doses recommended.Generally, the SSRIs are very easy to use. Ironically,this is why it can be difficult to judge how well a patient is doing. Sometimes we assume that as long as a patient is nothaving side effects, his depression is being effectively treated--but this isn't always true. That's why I recommendusing the 5 features outlined above (see

Table 1

) to determineif the patient is making progress and to ascertain thathis symptoms have been fully treated.

Q:If a patient is having difficulty tolerating aparticular antidepressant, should I encouragehim to try it for a bit longer, or is a switch to a newdrug a better option?

A:

If a patient whose depression appears to have respondedto an antidepressant is clearly having unacceptableside effects, the first step is to reduce the dose. Idon't like to discontinue an agent that seems effective if theproblem is simply too high a dose. Onthe other hand, if a patient is not derivingany benefit from a medication, aswitch to a different SSRI is in order.You can usually tell after about an 8-week trial of a drug--if you've titratedit properly--whether the patient is improving.This is a subjective evaluation.It is helpful to document the patient'spresenting symptoms undereach of the 5 categories listed aboveand to use that as a guide for follow-upquestioning.

Q:What is your next step whena patient's depression doesnot seem to be responding to a particular SSRI, even ifthere are no adverse effects?

A:

I first try another SSRI. Enough of these agents arenow available that there are often several from whichto choose based on the patient's symptom profile.It's a good idea to prescribe a limited number of SSRIsinitially so that you become very familiar with the effectivenessand potential side effects of each one. This familiaritywill be useful when a significant dose escalation is required.Newer drugs can be used as second-line agents to facilitatefamiliarity with them as they become available.

Q:Which SSRIs might you recommend in specificsettings?

A:Fluvoxamine, which is available in generic form, isparticularly effective in elderly patients who need energyduring the daytime but who aren't sleeping at night.Drug interactions with this agent have not been an issue at doses up to 100 mg. However, if drug interactions are aconcern, venlafaxine is a good alternative. I have achievedgood therapeutic effect with many of the other SSRIs,which I use according to the labeling and data reported inthe literature.

Q:What is the optimal follow-up time for a patientwhose depression has responded to medication?

A:

It's a good idea to see such patients every 6 months.Always encourage patients to make an appointmentsooner if they have any questions or problems. Particularlyif they have any concerns about side effects and are consideringdiscontinuing their medication, encourage themto call you first. If their condition has been stable with aparticular dose of an antidepressant, chances are the "sideeffect" is related to a different medication or to an intercurrentillness. When patients become ill, they may considertheir antidepressant to be the most expendable medication.Be sure to reinforce the idea that the antidepressantis effective only if taken exactly as prescribed.

Q:If a patient has had a good response to amedication at a maintenance dosage, how longshould I wait to taper the dosage?

A:

With a depression of recent onset and with a firsttimediagnosis of depression, older patients shouldgenerally be treated for 1 to 2 years (depending on theseverity of the depression and the response to treatment),because of the increased risk of recurrence. For a trial ofdrug withdrawal, a gradual taper is recommended. If thedepression recurs during the taper, the patient will probablyneed to take the medication at the established therapeuticdose for life.

Q:For which patients should I consider psychiatricreferral?

A:

Depending on the perceived urgency of treatmentand on your own comfort level with higher doses, referralto a geropsychiatrist may be considered, especially ifthe depression has not responded to a second SSRI. One ofthe most common reasons for lack of therapeutic effectivenessis insufficiently high doses.Also consider consultation if your patient has had onlya partial response to therapy; that is, if his symptoms persist,but to a lesser degree, or if he has frequent episodes ofrecurrent symptoms. Certainly, urgent referral is warrantedin any patient with suicidal ideation.It is inappropriate to continue with a drug if its effect issuboptimal--especially since there are so many pharma-cotherapeutic options. It is much more complicated in thelong run to manage patients who have been undertreatedor partially treated.

Q:Some of my patients are uncomfortable withthe idea of taking an antidepressant.Is psychotherapy an effective option in this setting?

A:

I often refer such patients to a licensed clinical socialworker or other professional who can provide psychotherapy.Many patients do benefit, even those who havemild cognitive impairment. Often, the decision to undergopsychotherapy is based on cost and convenience considerations.Patients can also seek counseling from a member ofthe clergy or become involved in group programs or otherinformal activities. Some patients' familiesgive them all the support theyneed, and this can be a key factor inovercoming a depressive illness.Some older patients may resisttaking antidepressants because theygrew up in a time when psychiatric illnesswas a major stigma. Some patientsmay be more receptive to psychotherapyor may have mild depressionthat responds very well to thistype of therapy. The decision whetherto use antidepressants, psychotherapy,or a combination of the two dependson the severity of the depression, the patient's response toa single modality, and practical considerations.

Q:Would you comment on the use ofSt John's wort?

A:

The results of clinical trials of St John's wort havebeen ambiguous. Although this herb may be usefulfor mild to moderate depression, recent trials (including oneconducted by the NIH) suggest that St John's wort is ineffectivein treating a major depression of moderate severity.4Side effects of St John's wort include dry mouth, dizziness,GI symptoms, increased sensitivity to sunlight, and fatigue.This agent may also have adverse interactions with otherdrugs or reduce their effectiveness.Because complementary medicines are not heldto the same FDA standards as prescription or overthe-counter agents, the contents may not correspond exactlyto statements on the label. There may also be significantbatch-to-batch discrepancies in chemical compositionand quality, even in a single product from the samemanufacturer.Be sure to encourage patients to inform you of any alternativeor complementary products they may be taking sothat the potential for side effects and drug interactions canbe minimized.