Depression in Later Life

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Depression in Later Life: A Diagnostic and Therapeutic Challenge Richard B. Birrer, M.D., M.P.H., St. Joseph’s Healthcare System, Inc., Paterson, New Jersey Sathya P. Vemuri, M.D., Yuma, Arizona Am Fam Physician. 2004 May 15;69(10):2375-2382. This article exemplifies the AAFP 2004 Annual Clinical Focus on caring for America’s aging population. Depression in elderly persons is widespread, often undiagnosed, and usually untreated. The current system of care is fragmented and inadequate, and staff
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  Depression in Later Life: A Diagnostic and Therapeutic Challenge Richard B. Birrer, M.D., M.P.H., St. Joseph’s Healthcare System, Inc., Paterson, New Jersey Sathya P. Vemuri, M.D., Yuma, Arizona  Am Fam Physician.  2004 May 15;69(10):2375-2382. This article exemplifies the AAFP 2004 Annual Clinical Focus on caring for  America’s aging population.   Depression in elderly persons is widespread, often undiagnosed, and usually untreated. The current system of care is fragmented and inadequate, and staff at residential and other facilities often are ill-equipped to recognize and treat patients with depression. Because there is no reliable diagnostic test, a careful clinical evaluation is essential. Depressive illness in later life should be treated with antidepressants that are appropriate for use in geriatric patients. A comprehensive, multidisciplinary approach, including consideration of electroconvulsive treatment in some cases, is important. The overall long-term prognosis for elderly depressed patients is good. Depression is not a normal part of aging. 1  The lack of connection between health care and mental health providers has created a fragmented system of care for depressed elderly patients that is often inadequate. 2  Concurrent medical problems and lower functional expectations of elderly patients often obscure the degree of impairment. 3  Typically, elderly patients with depression do not report depressed moods but instead present with less specific symptoms such as insomnia, anorexia, and fatigue. Elderly persons sometimes dismiss less severe depression as an acceptable response to life stress or a normal part of aging. Depression costs $43 billion annually in the United States, in direct and indirect costs — about the same as coronary heart disease. 2   Epidemiology MAJOR DEPRESSION  Nearly 5 million of the 31 million Americans who are 65 years or older are clinically depressed, and 1 million have major depression. 4  The prevalence of depression in the total U.S. population is 1 percent (1.4 percent in women, 0.4 percent in men), and the rate approaches 12 to 30 percent in patients who live in long-term care facilities. 5  Depression has been identified in 17 to 37 percent of elderly patients treated in primary care settings; of these patients, about 30 percent have been diagnosed with major depression. 1   Approximately 3 percent of healthy elderly persons living in the community have major depression, 6  and 75 percent initially present to a primary care physician. 4  Recurrence may be as high as 40 percent. Suicide rates are nearly twice as high in depressed patients as in the general population. 5  Sixty-three percent of persons who commit suicide are white, elderly men, and 85 percent of them have an associated psychiatric or physical illness. 7  Approximately 75 percent of elderly persons who commit suicide had visited a primary care physician within the preceding month, but their symptoms were not recognized or treated. 7  – 9  Depression is the most common diagnosis in older persons who commit suicide; in younger persons who commit suicide, the most common diagnoses are substance abuse and psychosis, alone or in combination with a mood disorder . 1  Risk factors for depression in elderly persons include a history of depression, chronic medical illness, female sex, being single or divorced, brain disease, alcohol abuse, use of certain medications, and stressful life events. 4  Up to 15 percent of widowed adults have potentially serious depression for a year or longer after the death of a spouse. 4  Unlike younger persons with depression, elderly persons with depression usually have a medical comorbidity. 9,10  Major depression is more common in medically ill patients who are older than 70 years and hospitalized or institutionalized. 4  Severe or chronic diseases associated with high rates of depression include stroke (30 to 60 percent), coronary heart disease (8 to 44 percent), cancer (1 to 40 percent), Parkinson’s disease (40 percent), Alzheimer’s disease (20 to 40 percent), and dementia (17 to 31 percent). 4   TABLE 1 Geriatric Depression Scale View Table  MINOR DEPRESSION Minor depression is a clinically significant depressive disorder that does not fulfill the duration criterion or the number of symptoms necessary for the diagnosis of major depression. 11  Minor depression, which is more common than major depression in  elderly patients, may follow a major depressive episode. It also can be a reaction to routine stressors in older populations. Fifteen to 50 percent of patients with minor depression develop major depression within two years. 11  The prevalence of minor depression in the general population ranges from 2.5 to 9.4 percent but significantly increases (to about 47 to 53 percent) in clinical settings. 2,12   About 30 percent of nursing home residents have minor depression, and the female-to-male ratio is 1.3:1.0, compared with a 1.4:0.4 ratio for major depression. 5  Untreated, the natural course of minor depression is one to two years. Patients with minor depression are less likely to require hospitalization or to commit suicide than patients with major depression, but 51 percent of patients with minor depression report more disability days than persons with major depression. 12  Persons with minor depression also are more likely to have a concomitant anxiety disorder. Pathophysiology/Pathogenesis There is evidence of a genetic basis for depression in persons of all ages. 11  There also is substantial evidence that a history of depression is a risk factor for depression later in life. Elderly persons with depression have higher rates of cognitive impairment, cerebral atrophy, enlarged ventricles, leukoencephalopathy, and deep white-matter changes. Left frontal lesions, left lesions of the basal ganglia, and cortical and subcortical atrophy also are common. 13  Medical comorbidity is frequent. Evaluation The Diagnostic and Statistical Manual of Mental Disorders , 4th ed., 11  gives nine criteria for depression: depressed mood, sleep disturbance, lack of interest or pleasure in activities, guilt and feelings of worthlessness, lack of energy, loss of concentration and difficulty making decisions, anorexia or weight loss, psychomotor agitation or retardation, and suicidal ideation. The presence of at least five of these criteria, occurring nearly every day during the same two-week period, or a score of more than 10 on the Beck Depression Inventor y 14  or 10 or more on the Geriatric Depression Scale 15  supports the diagnosis of depression in elderly patients ( Table 1 ) . Laboratory tests should include electrocardiography, urinalysis, general blood chemistry screen, complete blood count, and determination of thyroid-stimulating hormone, vitamin B 12 , folate, and medication levels. TABLE 2 Medications That May Cause Depression  View Table   Alcohol or substance abuse, certain medications, and physical disorders are associated with depression ( Tables 2  and  3 ) . Depression must be distinguished from dementia in elderly patients because these conditions share some of the same features ( Table 4 ) . Older patients, particularly women, may have vegetative symptoms and cognitive dysfunction. 4  Some features that suggest depression include frequent office visits or use of medical services; persistent reports of pain, fatigue, insomnia, headache, changes in sleep or appetite, and unexplained gastrointestinal symptoms; and signs of social isolation and increased dependency. Delayed recovery from a medical or surgical condition, refusal of treatment, and resistance to discharge from a hospital also may be signs of depression. Treatment Depression is treatable in 65 to 75 percent of elderly patients. 5  Effective management requires a biopsychosocial approach, combining pharmacotherapy and psychotherapy. 16,17  Therapy generally results in improved quality of life, enhanced functional capacity, possible improvement in medical health status, increased longevity, and lower health care costs. Improvement should be evident as early as two weeks after the start of therapy, but full therapeutic effects may require several months of treatment. Recovery from a severe depressive episode usually takes six to 12 months. Studies show that older patients with depression benefit most from aggressive, persistent treatment. 17  Thus, therapy for older patients should be continued for longer periods than are typically used in younger patients. 1   PHARMACOTHERAPY Pharmacotherapy for acute episodes of depression usually is effective and free of complications. Underuse or misuse of antidepressants and prescribing inadequate dosages are the most common mistakes physicians make when treating elderly patients for depression. Only 10 to 40 percent of depressed elderly patients are given medication. 17   TABLE 3 Physical Disorders Associated with Depression View Table  Medication is appropriate not only for primary depression but also for depression associated with medical conditions such as cancer, heart and pulmonary diseases, arthritis, stroke, and parkinsonism. However, the physician must consider carefully how the metabolism of the drug may be affected by physiologic changes resulting from aging and other medical problems. 9,18  
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