Recognizing and treating depr... Health Article

Why it's so hard to diagnose; issues to consider when deciding about treatment.

Depression is sometimes viewed as a normal part of aging. It shouldn't be. Rates of depression vary widely, depending on elderly individuals' overall health and whether people still live independently.

Although estimates differ depending on how depression is defined, about 1% to 5% of elderly people living in the community suffer from depression, compared with about 12% of the elderly who are hospitalized, and about 14% of those who require health assistance at home. Various studies have found that 29% to 52% of elderly people living in nursing homes are depressed, as are 39% to 47% of those being treated for cancer, heart attack, or stroke.

An inborn genetic susceptibility to depression may be triggered by the challenges of old age, such as the loss of a spouse and close friends, co-existing medical problems, and increasing disability, cognitive impairment, and social isolation. Unfortunately, the problem often goes undiagnosed. Left untreated, depression increases the likelihood of disability, placement in a nursing home, or death from any cause. Suicide risk also increases with age, and white men over age 85 have the highest suicide rate in the United States.

Depression in the elderly can often be treated effectively, but when depressive symptoms arise it can be challenging not to mistake them for symptoms of another medical disorder.

Stealth symptoms

Although some elderly people with depression develop the "classic" symptoms listed in the Diagnostic and Statistical Manual of Mental Disorders (4th ed.), such as persistent sadness and despair, others may seek help for less typical symptoms that might initially suggest other types of medical problems. Particularly common are somatic symptoms such as heart palpitations, restlessness, fatigue, tremors, body aches and pains, nausea or vomiting, dizziness, shortness of breath, fainting, heavy perspiration, or facial flushing. Patients may also report cognitive problems, such as an inability to concentrate or remember things. Any mood disturbance may show up as anxiety, irritability, or preoccupation with death.

It's not entirely clear why symptoms of depression in the elderly may differ from those in younger adults. Co-existing medical problems, medication side effects, and the natural aging process may all contribute. Stigma likely also plays a role. Some researchers believe that elderly people, having grown up in an era when emotional problems were stigmatized even more than they are now, may be more apt to report physical complaints.

It's therefore important for the clinician to assess all physical health problems and medications, to determine whether these might be contributing to depressive symptoms in someone who is elderly. In some people, treating an underlying medical problem will alleviate depression, but other patients will require medications, psychotherapy, or both to address their mood disorder. Following are some of the most common co-existing medical problems.

Cardiovascular disease. Depression seems both to predispose people to vascular disease and to worsen outcomes. For example, about 25% of people who have a heart attack or undergo cardiac catheterization suffer from depression beforehand, while about 20% of people who suffer a stroke develop major depression afterwards. And in one study, elderly people who were depressed were four times as likely to die within four months of a heart attack as those without depression.

According to the vascular depression hypothesis, blood vessel pathology disrupts normal communication pathways in the brain, contributing to symptoms. Elderly people with vascular depression tend to experience greater disability and cognitive impairment than other people with depression. They also may be less insightful, and more likely to feel apathetic, agitated, or guilty.

Psychosis. About 3.6% of elderly people in the community, and 20% to 45% of those who are hospitalized, develop psychotic symptoms when they become depressed. Certain types of delusions, such as those involving bodily symptoms or feelings of persecution, guilt, or nihilism, suggest that the person may suffer from both psychosis and depression.

Dementia. About 17% of people with Alzheimer's disease also have major depression, and the prevalence is even higher in people with other types of dementia. Symptoms of depression may also precede the development of dementia or Alzheimer's. Further complicating matters, when depression and cognitive impairment develop simultaneously, the deficits may be mistaken for dementia — a problem known as "pseudodementia." Although cognitive function may improve after the depression is treated, many of those affected will still have some form of intellectual impairment that may progress with time.

Depression is not so easy to distinguish from early dementia in practice, but doing so may improve quality of life in important ways. If depression goes undiagnosed and untreated, for example, it may speed disability. It may also hasten death.

Other causes. Elderly people with hypothyroidism and those with deficiencies in the B vitamins may experience exhaustion or cognitive impairment that suggests depression. In such cases, appropriate medical treatment may alleviate symptoms.

Certain drugs may also cause side effects in the elderly that mimic the symptoms of depression. These include beta blockers, used to treat high blood pressure, and benzodiazepines, used as tranquilizers, as well as many others. In such cases, reducing the dose or switching to a new medication may help.

Medication options

The American Psychiatric Association (APA) recommends that selective serotonin reuptake inhibitors (SSRIs), such as citalopram (Celexa) and fluoxetine (Prozac), be used as first-line depression therapy for elderly people mainly because these drugs have less dangerous side effects than other antidepressants and are less likely to interact with other medications.

That said, SSRIs may interact with certain antihistamines, anticonvulsants, or other antidepressants. And analysis suggested that SSRIs may increase risk of gastrointestinal bleeding in the elderly.

Other medication options include old mainstays, such as lithium, and newer types of antidepressants with varied mechanisms of action, such as bupropion (Wellbutrin), mirtazapine (Remeron), venlafaxine (Effexor), and duloxetine (Cymbalta). And while the older antidepressants — tricyclics and monoamine oxidase inhibitors (MAOIs) — are seldom used in the elderly nowadays (mostly because of concerns about side effects), they may help some individuals who have not responded to other drugs.

Regardless of the medications used, the following advice applies when treating elderly patients with depression.

Start low. Because elderly people often have co-existing medical problems, and because they metabolize some drugs more slowly and are more at risk for drug interactions compared with younger people, the APA advises starting at a low dose, generally about half the normal starting dose for adults. The dose can very slowly and gradually be increased to recommended levels.

Consider alternatives. Try a drug for two to six weeks at the recommended dose to see if symptoms subside. If the drug doesn't work, or if side effects become bothersome, adjust the dose or consider another medication. Other options are to augment the initial medication with a second drug or to consider electroconvulsive therapy.

Maintain treatment. As many as 38% of elderly people who experience an initial bout of depression will suffer a recurrence in three to six years. For this reason, maintenance therapy is vital. Recommendations about how long to continue taking a drug after remission vary, from six months to two years — or even indefinitely.

Electroconvulsive therapy

Antidepressant medications don't work for everyone. Older people may quit taking antidepressants or repeatedly miss doses because of side effects, memory problems, or difficulty keeping track of complicated drug regimens. They are also more likely than younger patients to have medical complications, or psychosis in addition to depression. For all these reasons, electroconvulsive therapy (ECT) is another option to consider.

ECT remains one of the most effective treatments for depression that is severe or accompanied by psychosis. It can be used safely in elderly patients, including those with cardiac pacemakers and implanted defibrillators.

ECT is administered along with sedatives or general anesthesia and can be given unilaterally (to one side of the brain) or bilaterally. Initially, six to 12 treatments, given two to three times a week, may be necessary to bring the depression under control. If the patient relapses, or has treatment-resistant depression, ECT may be given periodically over six months, with treatments gradually becoming less frequent.

Once again, maintenance therapy is important to prevent recurrence of depression. This may involve maintenance ECT, follow-up medications, or some combination.

Psychotherapy

Psychotherapy alone may help older patients whose depression is mild or has occurred because of a stressful life change, such as losing a spouse or starting retirement. Combining psychotherapy with medication may be helpful for those with more severe depression.

Cognitive behavioral therapy aims to correct ingrained patterns of negative thoughts and behaviors. The patient is taught to recognize distorted, self-critical thoughts, and then work with the therapist to transform negative automatic thinking while recognizing events that are beyond anyone's control. The aim is to enable a patient to learn how to cope better with problems and change harmful ways of thinking.

Interpersonal psychotherapy concentrates on identifying and practicing ways to cope with recurring conflicts. A patient may learn, for example, how to deal with the grief over a recent loss or handle a major life change.

Depression develops for many reasons in people who are elderly. While it may take some time to determine the best treatment strategy for a particular individual, the reward is often a better quality of life — whether that means being able to spend time with grandchildren or other loved ones, taking up a new hobby, or going on an extended road trip. Pleasure and happiness shouldn't have an age limit.

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For more references, please see www.health.harvard.edu/mentalextra.