|
|
|
|
|
IN THIS ARTICLE
OTHER TOPICS   The End of Stress, now available at amazon.com
|
Depression in the Elderly Rafi Kevorkian, M.D. Dr. Kevorkian is a Fellow, Division of Geriatric Medicine, St. Louis University School of Medicine. Dr. Kevorkian reports no commercial conflict of interest. Depression in the elderly is prevalent, persistent, disabling and sometimes fatal. All of us, seniors and caretakers alike, are burdened by the myth that depression is a natural result of aging. Yes, psychiatric needs of seniors are different from those of younger persons, and the causes leading to a change in personality are different. But what's important is that many elder individuals who are depressed often go unnoticed or are not offered treatment. It is estimated that there are 2 million people over the age of 65 in the U.S. who are depressed. Because medicine can be too focused on chronic medical illness, physicians, as a result, do not have enough time to discuss issues regarding emotional health. As our population ages, it is imperative that society and physicians become more sensitive to emotional health concerns in order to improve the total well being of elders. Assessment Assessment of depression in the elderly begins with an emphasis on risk factors that are typically more relevant to older patients: severe life events, ongoing stresses, spousal bereavement, care giving burden and loss of independence by medical illness.1 The five D's of depression in the elderly are:
Family history of depression is an important risk factor for late life depression.5 A survey done by the National Mental Health Association in 1996 showed that 58% felt depression was a normal part of the aging process, and 49% attributed depression to personal weakness. Although depression is more common in younger patients, 20% of suicides are in older patients (highest in any age group),6 specifically older white men, who also had a greater rate of success of suicide. These men tended to live alone, were widowed, had chronic medical illnesses and saw their primary medical doctor a few weeks prior to suicide. Again, it is important to pay attention to the life stresses to raise awareness for suicide. It has been shown that 50 to 70% of all medical visits by the elderly have, as a major component, emotional distress or dysfunction. These patients were less likely to have greater social contacts. They had an increasing feeling that their health was poor. As a result, they had more doctor visits and medical costs. A study of outpatients showed that only 9% of doctors used routine questioning or screening for depression.7 The diagnosis of depression was made 33% of the time by formal criteria. Fifty-eight percent of doctors asked about suicide. One-third of doctors offered 5 minutes of counseling. Seventy-two percent gave medicines and 38% referred to a psychiatrist. In the presence of chronic medical illness, physicians are less likely to discuss depression but are very receptive to patient requests for medication. Older patients tended to have depression without sadness. It has been shown that 5 to 10% of nursing home patients are depressed, as well as 11% of inpatients and 12 to 22% of nursing home patients.8 Loss of independent functioning has been associated with depression and the treatment of depression can improve function even when no change occurs in the medical condition that caused disability. It is also important to treat depression because, otherwise, medical burden is increased. Medical Causes Infection, hormonal changes and conditions (e.g., diabetes), cancer (high rate with pancreatic cancer), brain diseases, dementia, chronic pain and cetain medications can cause depression. Pain is made worse by depression and chronic pain worsens depression. Some medications that have caused depression include corticosteroids, interferon, sedatives, calcium channel blockers, tamoxifen, clonidine, cimetidine and digitalis. It has been shown that dementia causes apathy and loss of initiative. Since elderly patients are often dependent on caregivers, family members and doctors need to ask caregivers about their observations. Have they noticed crying spells, insomnia, weight loss, rapid emotional swings, psychomotor slowing and poor spirits? Mildly demented patients may refuse medical treatment or food and may express the desire not to live. Prompt investigation should be carried out for depression if that occurs. Assessment Tools There are several questionnaires that doctors can use to screen patients and assess depression. What's important is not which test is better but whether the screen is able to identify a depressed person. For seniors, the most commonly used screen is the Geriatric Depression Scale (GDS):9 Answer Yes or No to the following:
At a minimum all patients should be asked if they are sad. Men are less likely to report mood problems and doctors are less likely to recognize mood problems in men. It has been consistently observed that chronic medical illness contributes to late life depression as much as do bereavement and death of a loved one. There is strong evidence that disability and lack of social contact also provoke late life depression.10 However, negative life events and ongoing difficulties have not been consistently shown to cause depression. It is useful to remember that not everyone gets depressed as they age. Indeed, for some, advanced age may improve self-esteem and maturation may protect these seniors from the impact of psychosocial risk factors. Chronic Medical Illness and Depression As mentioned previously, chronic medical illness contributes to depression in late life. Although there are no controlled studies, 20% of patients with heart disease at time of cardiac catheterization were depressed, 33% developed depression over 12 months after a myocardial infarction and 17% of heart transplant patients were depressed.11 It has been noted that 25% of cancer patients are depressed, although no long-term studies of the same patients have been done.12 Depression also occurs among patients with neurologic disease -- 25 to 50% of stroke patients were noted to be depressed.13 There was a peak at 3 to 6 months after the stroke for depression. Some patients had a spontaneous remission of their depression 1 to 2 years after their stroke.14 In one study, the drug sertraline reduced some of the symptoms, but not depression, as compared to the non-treated group, and in another study more depression with stroke was seen than with physical illnesses with similar disability.15 It has been hypothesized that strokes in certain locations of the brain may lead to depression. Studies estimate that 10% of Alzheimer's disease patients and 20% of Parkinson's patients were depressed.16 According to researchers, depressed patients with Alzheimer's disease had aggression ad agitation 20% of the time, delusions 16% of the time, apathy 28 % of the time, problem behavior in 19 % of the time as well as sleep disturbance.17 In cases of change in behavior, clinicians need to consider possible medical causes such as hypothyroidism, urinary tract infections, constipation and pain. The Cornell Scale for Depression in Dementia18 can be used in these patients. A score greater than 12 indicates depression. The Cornell Scale for Depression in Dementia (CSDD): Ratings should be based on symptoms and signs occurring during the week prior to interview. No score should be given if symptoms result from physical disability or illness. Scoring System A = unable to evaluate 0 = absent 1 = mild or intermittent 2 = severe
Suicide Prevention In a study from Sweden, patients 85 years or older were asked about mood.19 Sixteen percent of the patients who were undemented had thoughts of taking their life or thought that life was not worth living in the preceding month. These patients tended to have more than three physical disorders (e.g., cardiac disease, peptic ulcer disease) and had mental disorders. In this study group, women were twice as likely as men to have these thoughts. Elder patients have a greater determination to die, give fewer warnings, use more violent and deadly methods to commit suicide, do more planning, have greater resolve and complete suicide at a higher rate. Suicide is the 13th leading cause of death in elders in the U.S.20 The incidence is 62/100,000 in white men -- guns were used 71% of the time. Treatment There are many medical and non-medical options for the treatment of elderly depression. It is not known whether treating depression can actually reduce the death rate. Behavior (i.e., talk) therapy has been shown to be equally effective in management of depression in younger and older individuals. A literature review for 1995 to 2001 produced 33,167 subjects with a mean age of 72.21 Ninety-seven studies reported on antidepressants and 12 on electroconvulsive therapy. Eleven studies compared tricyclic antidepressants versus therapy with selective serotonin reuptake inhibitors (SSRIs). Eight of the studies showed equal efficacy and three showed that tricyclics were better. All types of antidepressants were tolerated well. Side effect profile was similar for all classes of antidepressants, although in some studies SSRIs had a better side effect profile (Table 1). Table 1. Antidepressants and their side effects.  Click to see full sized image  Click to see full sized image Treatment of the frail elderly must be monitored closed because they are more prone to side effects from antidepressants.22 In demented patients, some studies showed SSRIs and tricyclics, as compared to placebo, were equally effective but most showed no benefit. If patients are not responding to treatment, switching to a different class of antidepressant has been shown to be efficacious. Electroconvulsive therapy (ECT), electric shock to the brain that produces a seizure, is the first choice in persons who are suicidal or who have severe weight loss, and ECT has been shown to be more effective than antidepressants.23,24 In a few studies, estrogen25 and methylphenidate26 demonstrated possible benefits. Psychotherapy in addition to medical therapy is better than medical therapy by itself.27 Finally, stimulation of the vagus nerve is being used experimentally to treat depression, as is electromagnetic brain stimulation. Conclusion Older depressed adults are less likely to be recognized or diagnosed because they don't look like younger depressed patient, because of the myth that depression is a natural component of aging and, finally, because the caregiver has not asked enough questions about the senior citizen's social and medical situations. Late life events -- disability, chronic medical illness, bereavement and dementia -- increase the elderly patient's risk of depression. All types of antidepressants are effective and when failure occurs electroconvulsive therapy (ECT) should be considered. If the primary physician is unable to provide counseling, the patient should be referred for those services.
References 1. Bruce ML. Psychosocial risk factors for depressive disorders in late life. Biol. Psychiatry, 2002, (52) 175-184. return 2. Swendsen JD, Merinkanga Sk, Canino GJ, Kessler RL, Rubiostipec M, Angst J. Comorbidity of Alcoholism with Anxiety and depressive disorders in four geographic communities. Comprehensive Psychiatry, 1998, 39:176-179. return 3. Hasin DS, Tsai W-Y, Endicott J, Mueller TI, Corywll W, Keller M. Five-year course of major depression: Effects of comorbid alcoholism. J Affect Disord, 1996, 41:63-70. return 4. Abrams RC, Rosendahlk E, Card C, Alexopoulous GS (1994): Personality disorder correlates of late and early onset depression. Journal of American Geriatric Society (42) 727-731. return 5. Barry Kl, Fleming MF, Manwell LB, Copland LA, Appel S. Prevalance of and factors associated with currebt and lifetime depression in older adult primary care patients. Fam Med, 1998, 30:366-376. return 6. Conwell Y, Duberstein PR, Caine ED. Risk factors for suicide in later life. Biol. Psychiatry, 2002, 52:193-204. return 7. Williams JW, Rost K, Ciotti MC, Zyzanski SJ, Cornell J. Primary care physicians approach to depressive disorders. Effects of physician specialty and practice structure. Arch. Family Medicine, 1999, (8) 58-67. return 8. Gurland BJ, Cross PS, Katz E. Epidemiological perspectives on opportunities for treatment of depression. American Journal Geriatric Psychiatry, 1990, vol. 4 (Suppl 1): S7-S13. return 9. Yesavage JA, Brink TL, Rose TL, Lum O, Huang V, Adey MB, Leirer VO. Development and validation of a geriatric depression screening scale: A preliminary report. Journal of Psychiatric Research, 1983, 17: 37-49. return 10. Bruce ML. Depression and disability in late life. Directions for future research. American J Geriatric Psychiatry, 2001, (9) 102-112. return 11. Carey RM, Rich MW, Telvelde AJ, Freedlank KE, Saini J, Sieone C et. al. Major depressive disorders in coronary artery disease. American J Cardiology, 1987, (60) 1273-1275. return 12. Evans DL. Depression in the medical setting. Biopsychological interactions and treatment considerations. J Clinical Psychiatry, 1999, (60) Suppl. 4:40-45; discussion 56. return 13. Astrom M, Adolfsson R, Asplunk K. Major depression in stroke patients. A 3-year longitudinal study. Stroke, 1993, (24) 976-982. return 14. Dam H, Pedersen HE, Ahlgren P. Depression among patients with stroke. Acta Psychiatrica Scandanvica, 1989, (80) 118-124. return 15. Robinson R, Bolduc P, Price T. Two year longitudinal study of postroke mood disorders: Diagnosis and outcome at one and two years. Stroke, 1987, (18) 5:837-843. return 16. Starkstein SE, Bryer JB, Berthior ML, Cohen B, Price TR, Robinson RG. Depression after stroke: The importance of cerebral hemisphere asymmetries. J Neuropsychiatric Clin. Neurosciences, 1991, 3:276-285. return 17. Burns A, Jacoby R, Levy R. Psychiatric phenomenon in Alzheimer's disease I,II,III,IV; British Journal of Psychiatry, 1990, (157) 72-76, 76-81, 81-86, 86-94 return 18. Alexopolous GS, Abrams RC, Young RC, Shamoian CA. Cornell Scale for depression in dementia. Biological Psychiatry, 1988, Feb 1:23(3):271-84. return 19. Skoog I, Aevarson O, Beskow j, larsson L, Palssson S, Waern M, et al. Suicidal feelings in a population sample of nondemented 85 year olds. American J Psychiatry, 1996, (151) 1015-1020. return 20. National Center for Health Statistics. Death Rates for 72 selected causes by 5 year groups, race, and sex, United States, 1979-1998. return 21. Salzman C, Wong E, Wright B. Drug and ECT treatment of depression in the elderly, 1996-2001: A literature Review. Biological Psychiatry (52) Number 3, August 1, 2001, pg 265-284. return 22. Thomas DR, Morley JE. Advances in the treatment of depression in the elderly; Supplements to Annals of Long term Care, October 2001, S1-S10. return 23. Manley DT, Oakley SP, Bloch RM, Oakley SR Jr. Electroconvulsive therapy in old-old patients. Am J Geriatr Psychiatry, 2000, 8:226-223. return 24. Philibert RA, Richards L, Lynch CF, Winkour L. Effect of ECT on mortality and clinical outcome in geriatric unipolar depression. J Clin Psychiatry, 1995, 56:390-394. return 25. Schneider LS, Small GW, Clary CM. Estrogen replacement therapy and antidepressant response to sertraline in older depressed women. Am J Geriatr Psychiatry, 2001, 9:393-399. return 26. Lavretsky H, Kumar A. Methylphenidate augmentation of citalopram in elderly depressed patients. Am J Geriatric Psychiatry, 2001, 9:298-303. return 27. Blanchard MR, Waterreus A, Mann AH. Can a brief intervention have a longer-term benefit? The case of the research nurse and depressed older people in the community. Int J Geriatr psychiatry, 1999, 14:733-738. return |
|||||||||||||||||||||||||||||||||||||||||||||||||||||
 |
|
 |
||||||||||||||||||||||||||||||||||||||||||||||||||||
|
NEWS SEARCH CONTENTS MEDITORIAL ASK DISCUSS REGISTER HELP HOME |
||||||||||||||||||||||||||||||||||||||||||||||||||||||
© 2008 interMDnet Corporation. All Rights Reserved. PRIVACY POLICY |
||||||||||||||||||||||||||||||||||||||||||||||||||||||
Successful carotid artery surgery can reduce the risk of stroke. 