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April 2008: Awareness key in managing depression in later life

How common is depression in older people?

What screening tools are recommended?

Which patients are at risk of suicide?

How common is depression in older people?

What screening tools are recommended?

Which patients are at risk of suicide?



Depression is second only to heart disease as a cause of disability.1 Patients report persistent sadness, discouragement and loss of self-worth. These feelings are accompanied by reduced energy and concentration, insomnia, decreased appetite and weight loss. In older people, depression is also frequently characterised by excessive concerns about physical infirmity.2

Patients with depression are more likely to suffer from various medical disorders and die prematurely. In those aged over 55 years, depression is associated with a fourfold increase in mortality. Most of these deaths result from heart disease or stroke. In addition, when they have a comorbid disease, patients with depression tend to use medical services more often than patients without.

The good news is that treating depressive symptoms not only alleviates the suffering intrinsic to the disorder,3 but also reduces mortality, for example from cardio- and cerebrovascular illness, presumably by alleviating these conditions or their complications.4

Prevalence

Depression is the most common mental illness in older people and the second most common underlying cause for all GP consultations for people over 70 years of age. The recent Medical Research Council Cognitive Function and Ageing Study (MRC CFAS),5,6 which screened 13,000 people aged over 65 in the community, found that the prevalence of depression was 8.7%, increasing to 9.7% if patients with concurrent dementia were included. The prevalence of depression in those living in institutions was 27.1%, compared with 9.3% in those living at home. Depression was more common in women (10.4%) than men (6.5%) and was associated with functional disability, comorbidity and social deprivation.

Causes

Late-onset depression and early-onset recurrent depression in older age differ in terms of clinical features, aetiology, neuroanatomical substrates and prognosis. Late-onset depression is associated with somatic symptoms; cognitive, especially executive function deficits (ie planning, abstract thinking, initiating appropriate actions, inhibiting inappropriate actions and selecting relevant sensory information); cerebral structural abnormalities, such as white matter changes; vascular disease (‘vascular depression') and possibly with a worse overall prognosis.7

Late-onset depression is therefore more likely to be caused by intervening (vascular) illness affecting the brain in old age, while early-onset recurrent depression may result in part from genetic predisposition. Therefore, the later in life the onset of depressive symptoms, the more likely that there is comorbid cerebrovascular illness, which may in itself be amenable to treatment or prevention.

Psychological or social factors, ongoing problems or acute life events are common in old age and may play a role. The direction of causality is often not clear; for example, social isolation may have precipitated depression, but it is worth considering whether it was the depression that resulted in social isolation. Low mood should not be dismissed as a normal consequence of ageing.8

Old age is a time of loss – of status and position in society, wealth, opportunity, health, friends and companions. Poor self-esteem and lack of capacity for intimacy often follow suit. In this vulnerable state, severe stressors such as a serious loss, physical illness, the early stages of cognitive impairment, a difficult relationship or financial problems can trigger a depressive episode. Furthermore, depression can exacerbate medical problems, slowing down convalescence and leading to apathy and self-neglect.

Diagnosis

Older patients with depression may present with the following signs:

• Poor grooming
• A dishevelled appearance
• Dressed in sombre colours
• A dejected facial expression
• Crying
• Fidgety, agitated, restless
• Not engaging with interviewer
• A slowness of movement, with few gestures and a hunched posture.

Patients may report low energy and fatigue, specific physical symptoms and memory loss, or mention a financial, personal or family disaster. GPs should enquire about sleep and appetite disturbance, as these are common in patients with depression.9,10

Patients' thoughts often circle around issues of loss and abandonment, worthlessness, guilt, suicidal thoughts and hopelessness. The patient may have poor concentration, a short attention span and thought blocking, occasionally bordering on confusion.

Several depression screening tools are available. The Geriatric Depression Scale (GDS) is most commonly used (see table 1, attached).15,16 It is simple and reliable, enabling the scale to be used with patients who are physically ill and/or have moderate cognitive impairment. For clinical purposes, a score of more than five points is suggestive of depression and should warrant a follow-up interview.

Scores of more than 10 almost always suggest depression.

It is crucial not to take a patient's negative world view on trust, as it may be intensely coloured by depression or may even be delusional. Changes in attitude and ability, as well as an increase in exploratory activity after recovery, often make all the difference to patients' lives.

Depression can affect judgment, possibly related to cognitive bias, and can cause problems with information processing and delusional thinking. Patients with major depression often have limited insight.

GPs should always ask about suicidal intent.11 Many patients may not contemplate suicide actively but would welcome death by heart attack or accident. Some make impulsive suicidal gestures to convey their despair to others without a definite plan to die. Patients who are determined to die and make active plans when and how to carry out the act are at greatest risk.

Risk factors for suicidal behaviour include:12-14

• Male gender
• Being divorced or widowed
• Older age
• Unemployment
• Alcoholism
• Poor response to treatment
• A history of past attempts
• A family history of suicide.

Treatment

The 2004 NICE depression guideline is currently under review.17 NICE and SIGN have both published guidelines for bipolar disorder, which are relevant for a subgroup of older patients with depression.18,19 Although none of the available guidelines focus on old age, they do cover older patients.

The guiding principle of the NICE depression guideline is stepped care.

41185263It is based on the ICD-1020 distinction between mild, moderate and severe depressive episodes (see table 2, left).17 However, the NICE guideline states that ‘some symptoms may have greater weight than others in establishing severity.'17,21

The NICE guideline recommends considering family and previous history as well as the degree of associated disability when assessing the severity of depression. In the absence of clear definitions, GPs should examine potential benefits and costs with the patient, and in milder cases discuss the option of watchful waiting with the patient rather than active treatment.

There appears to be no difference in efficacy between antidepressant classes in older people. However, tricyclic antidepressants are associated with greater gastrointestinal and neuropsychiatric side-effects compared with newer drugs.22 It is advisable to start tricyclics at lower doses than in younger patients. SSRIs are recommended as first-line treatment and local protocols should be followed. Some rare SSRI side-effects, such as gastric bleeding, may be more common in the elderly and those already taking NSAIDs.23 The UK general practice database shows no evidence that antidepressant drugs exacerbate suicidal behaviour in older people.24

Unfortunately, a systematic review of ten brief psychosocial intervention trials in old age depression found that only two trials met validity criteria25 and a recent meta-analysis of nine trials of (cognitive behaviour and psychodynamic) psychotherapy in older patients with depression did ‘not provide strong support for psychotherapeutic treatments in the management of depression in older people.'26

More encouragingly, a number of primary care studies have supported the use of collaborative care models in reducing depressive morbidity and its consequences, including mortality.3,4 For example, this could involve a community psychiatric nurse delivering a facilitated self-help programme, with close liaison with primary care professionals and old age psychiatrists according to a defined protocol.3 Availability of psychopharmacology expertise seems essential to this approach.

Although evidence is only slowly accumulating for older patients, continuing treatment with antidepressants seems to be particularly important in this group of often relapsing and chronic illnesses.

Referral

GPs successfully treat most patients with depression. However, referral to secondary services may be indicated if the first (or sometimes the second or third) line of treatment fails.

The successful management of treatment-resistant depression requires persistence and continuous motivation of the patient.27 Generally, a psychiatric team manages patients in an outpatient setting. Patients are usually only admitted to hospital for depression if they are acutely suicidal, psychotic or physically unwell, for example because they have ceased to eat or drink.28

Conclusion

Primary care has a significant role to play in educating patients about depression, its consequences and the therapeutic and preventive measures that can be taken. GPs should not only liaise with mental health trusts and aim for collaborative care of older patients with depression, but also with health planners and administrators in primary care trusts so that adequate attention is given to depression services.

While depression can cause much suffering for patients and their families, in terms of the chances of recovery and the improvement of quality of life, it is one of the most rewarding illnesses to treat.

Authors

Dr Alessia Gargiulo
State DMS
specialist registrar in geriatrics and staff doctor in old age psychiatry

Professor Klaus P Ebmeier
State Exam Med MD FRCPsych
specialist in general psychiatry and honorary consultant old age psychiatrist, Warneford Hospital, Oxford

Depression in later life Tab2depression Table 1: The Geriatric Depression Scale (GDS) Key points

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