1. Use rating scales with care
The usefulness of rating scales in diagnosing older people with depression is doubtful.Symptoms such as fatigue, loss of appetite and sleep disturbance may be caused by physical illness rather than depression – so many older people score above cut-off points on rating scales. Also, older people with cognitive impairment – even if incipient – may give unreliable scores. But if the patient is free of these conditions, a scale such as PHQ-9 can be used in the same way as in younger adults. Go to pulsetoday.co.uk/tools-and-resources to download a copy of the PHQ-9.
2. Look out for anhedonia and pessimistic thinking
When considering a diagnosis of depression, pay particular attention to the core mood symptoms of anhedonia, sadness and pessimistic thinking (self-blame, inappropriate guilt, feeling life is not worth living). Gentle scrutiny about the persistence of these symptoms – how much of the day and how many days a week they are experienced – and severity in terms of impact on everyday living, should identify whether these symptoms are a significant change from normal. If so, depression is likely.
3. Identify red flags, such as weight loss and psychosis
Features to worry about in the context of depression are:
- weight loss
- persistent failure to eat and drink
- significant suicidal ideation.
In patients with these symptoms you should exclude plausible causes, such as a UTI producing hallucinations or poor compliance with medication, and then urgently refer to
4. Refer patients with persistent symptoms
As well as urgent referral for red flags, consider referral to a psychiatrist if the patient:
- does not respond adequately to first-line treatment
- has chronic symptoms even with some response to treatment
- has persistent significant impairment in everyday living
- has cognitive impairment which persists or worsens with treatment.
5. Investigations should just be used to exclude differentials
Sadly there are no investigations that positively support a depression of diagnosis, so their role remains one of exclusion. A regular physical health check and blood screen with an MSU if indicated should be performed, but no other investigations are normally carried out, even in secondary care. Neuroimaging is restricted to unusual presentations, such as focal neurological signs, or where dementia is suspected.
6. Consider antidepressants early in older people
In theory, management of depression in older people should follow the same stepped-care approach advocated by NICE for all adults – watchful waiting for mild depression, supportive counselling or formal psychotherapy for moderate depression, and antidepressants for severe depression. But in practice, access to psychological therapies is particularly difficult for older adults and so antidepressants are likely to be prescribed earlier. Severity is determined by duration of illness and degree of functional impairment.
7. Give lower doses to the frail elderly
Antidepressants are unequivocally beneficial in older people with moderate and severe depression – where the illness persists for months or there is significant impact on daily functioning. In physically healthy older people, use full doses as for younger adults. Use lower doses in the frail elderly and those with severe co-morbidity since these patients are sensitive to side effects.
8. Treat with antidepressants for life
The maxim ‘the dose that got you well, keeps you well’ applies to older adults as well as younger. Relapse and recurrence rates are high in older people with depression. So once a patient is well they should remain on antidepressant treatment for life.
9. Dysphasia and dyspraxia can help distinguish depression from dementia
Memory problems are frequently reported in older people with either depression or dementia. Cognitive impairment – amnesia, executive dysfunction and impaired concentration – is characteristic of depression in older people. Dysphasias and dyspraxias are not features of depression but are common in early dementia. Dysphasias are difficult to assess briefly, but drawing tests – for example clock drawing – can identify dyspraxia. Failure on these tests strongly suggests dementia, so referral is appropriate.
10. Avoid antidepressants for depression in dementia
In patients with established dementia, depression co-occurs more commonly than chance. In most of these patients depressive symptoms are mild and do not persist, so watchful waiting is appropriate. Antidepressants are ineffective in most people with depression in dementia, but persistence of symptoms for more than three months or severe symptoms such as impact on food and fluid intake or significant social withdrawal, should prompt referral to a psychiatrist. Prescription of antidepressants may be warranted in such cases.
Dr Alan Thomas is clinical senior lecturer in old age psychiatry at Newcastle University and honorary consultant at Gateshead Health NHS Foundation Trust
This topic will be covered at the British Geriatrics Society’s Autumn Meeting on 28–30 November 2012 in Harrogate. For more details and to register, visit bgsevents.org