1. health and fitness
2. disorders
3. mental disorder
4. depression

ASSESSMENT OF DEPRESSION
IN THE ELDERLY
Alina Rais, M.D.
Associate Professor of Psychiatry
Medical Director
Geriatric Psychiatry Center
University of Toledo
Department of Psychiatry
Demographic of Aging
1900 – Only 4% were 65 and older
 2000 – Increased by 13% in elderly
population
 2050 – Projected increase of 22% in
elderly population

US Population: age 65 and over
80
70
60
50
40
Millions
30
20
10
0
1900
1930
1960
1990
2025
2045
Mental Health in the Elderly

Elderly people have greater risk of
mental illness

15-25% of elderly in the USA suffer
from symptoms of mental illness

Age 65 and older – highest suicide risk
MENTAL HEALTH IN THE ELDERLY
Only 41% of the patients in community
mental health are elderly
 Only 2% seen in hospital and private
setting
 Only 1.5% of the direct costs for
treating mental health are allocated for
the elderly

One of the most common mental
illnesses in the elderly is Depression
Syndrome which includes the
following symptoms:
Physical
Emotional
Cognitive
The NIH Consensus
Depression:
 Affects 6 million people or 1 in 6
 Is not a normal fact of aging
 Is associated with functional disability
and suicide
 Can alter the course of a general
medical condition
The NIH Consensus
(Cont.)
Depression:
 Increases morbidity and mortality
 It is a recurrent illness
 Occurs more frequently in nursing
homes
Suicide in the Elderly

Elderly suicide up by 9% in the last
decade

White males over 65 account for 81% of
all suicides
Profile for Highest Suicide Risk
White male over 60
 Divorced/single/widow
 Poor social support
 Unemployed
 Medical problems
 History of alcohol abuse
 High school education
 Access to guns

Depression: Underrecognized and
Undertreated in the Elderly
70
Patients Percent (%)
60
50
40
Depression
30
20
10
0
Told
Counseling Medication
Physician
ECT=electroconvulsive therapy
ECT
Maddux RE, Delrhim KK, Rapaport MH. CNS Spectr. Vol 8, No 12 (Suppl 3), 2003.
Health Services Utilization in Depressed
Elderly Patients
Number Over 1 Year
20
15
10
Depressed
Not Depressed
5
0
Visits
Laboratory
Tests
Radiological
Procedures
Consultations
Total
*P,.001 after controlling for comorbidity, type of insurance, and the use of antidepressants
ΥP=.008.
N=3,481 primary care patients >65 years of age
Adapted from: Luber MP, Meyers BS, Williams-Russo PG, et al Depression and service utlization in
elderly primary care patients. Am J Geriatr Psychiatry 2001:2:169-176
Maddux RE, Delrahim KK, Rapaport MH. CNS Spectr. Vol 8, No 12 (Suppl 3). 2003.
Number of Suicides
Rates of Completed Suicide
80
70
60
50
40
30
20
10
0
Male
Females
1014
2024
3034
4044
5054
6064
7074
8084
Total
In the United States, 1994
Per 100,000
Adapted from: Hirschfeld RM, Russell JM. Assessment and treatment of suicidal patients. N Engl J Med. 1997;13:910-913.
Prevalence of Late Life
Depression









Elderly women are at increased risk
Twice as many in women compared to men of same age
Might be a subsyndromal presentation like dysthymia,
dysphoria
DSM IV – not age sensitive
6%-9% of patients in primary setting
17%-37% diagnosed with minor depression
10-15% of patients in acute care
30%-45% of patients in nursing homes
13% of residents in nursing homes who experience first
episode of depression
Other Consequences of DepressionPsychiatric
Increased use of alcohol and sedatives
 Reduced cognitive function

– Depressive “Pseudodementia”
– Excess disability in Alzheimer’s disease and
stroke

Elevated nonsuicidal mortality
– In nursing homes – increased 59%
– In MI patients-hazard ratio 5.74
– In stroke, COPD
External/Underlying factors (examples):
Preclinical dementia
Poverty
Low social support
Medical illness
Increased Risk for Incident Physical Illness
Vascular disease (stroke, coronary artery disease)
Cancer?
Osteoporosis?
Hip fracture
Depression
Health behaviors:
Poor medication adherence
Non-adherence to visual or hearing aids?
Smoking and physical inactivity
Poor participation in rehabilitation
Features of the depressed state:
Executive-type cognitive deficits
Poor appetite, causing low body mass index
Psychomotor retardation
Apathy and motivational deficit
Sleep disturbance
Decreased pain threshold
Sequelae of disability:
Increased negative life events
Loss of perceived control
Low self-esteem
Social activity restriction
Strained interpersonal relationships
Physical
Disability
Risk Factors in Development of Late Life
Depression
(Biopsychosocial Illness Model)

Biological Risk Factors
- Female > male
- Changes in neurotransmitter activity
- Dysregulation of the HPA (hypothalamic,
pituitary axis)
- Dysregulation of thyroid function
- Decreased secretion of growth hormone
Risk Factors in Development of
Late Life Depression
(Biopsychosocial Illness Model)
(Cont.)
Desynchronization of circadian rhythms
with sleep cycle disturbance
 Physical aspects of medical illness
 Polypharmacy

Psychological Risk Factors

Decreased social support

Decreased functionality

Placement in a nursing home

Life events, i.e. retirement
Psychological Risk Factors
(Cont.)

Changes in financial status

Bereavement

History of mental illness

Decreased self-esteem

Diagnosing depression in the elderly could
be challenging

Elderly population received 20-30% of all
prescribed medications

Experience decline of cognitive and
functional capacity
Barriers in Diagnosing Depression
in Elderly Patients





Most of this group of patients are seen in
primary care settings
Despite extensive education, still the family
doctors fail to diagnose depression
Different syndrome presentations ( not classical
symptoms of depression, sad less depression)
Stigma
Lack of recognition of depressive symptoms by
patient and family (seen as part of getting old)

When evaluating the elderly depressed patient,
we need to:
–
–
–
–
–
–
Identify any prior psychiatric illness
Identify comorbid illnesses
Baseline medical history
Overall cognitive capacity
Identify current stressors
Evaluate medication that might contribute to
depression
– Receive objective information from family/caregiver
Different Presentation of
Depression
Classic form of major depressive disorder
that meets the DSM IV-R criteria
 Mask depression (somatic complaints,
anxiety)
 Subsyndromal presentation (minor
symptoms, dysthymia)
 Depression due to medical condition
 Vascular depression

Diagnosis

MDD
– Criteria for Depression DSM IV-TR
 2 week period with 5 or more of the following with 1
being either depressed mood or loss of interest/pleasure
– Depressed mood most of the day/every day (subjective or
objective)
– Diminished interest/pleasure – anhedonia
– Weight loss or gain >5% in a month or change in appetite
– Insomnia or hypersomnia nearly every day
– Psychomotor retardation or agitation (objective)
– Loss of energy nearly every day
– Worthlessness or guilt nearly every day
– Decreased concentration
– Suicidality/passive death wish
 Symptoms cause clinically significant distress or
impairment
 Symptoms are not better accounted for by another psych
illness
 Symptoms are not due to the direct physiological effects
of a substance or GMC
Minor Depression
Subsyndromal presentation
 It is now introduced as a DSM IV category
 Much more seen in community samples
 It is considered to represent a spectrum:

– Prodromal/residual symptoms of MDE
– Occurs in patients with underlying medical
condition and dementing processes
– The consequences on functional capacity are
substantial
Proposed Diagnostic Criteria


1) Presence of low mood and/or loss of interest in all activities most of
the day, nearly every day, and
2) At least two additional symptoms from the DSM checklist:
a.
Significant weight loss when not dieting or weight gain (e.g., a change
in more than 5% of body weight in 1 month), or decrease or increase
in appetite nearly every day
b. Insomnia or hypersomnia nearly every day
c.
Psychomotor retardation or agitation nearly every day (observable by
others, not merely subjective feelings of restlessness or being slowed
down)
d. Fatigue or loss of energy nearly every day
e.
Feelings of worthlessness or excessive or inappropriate guilt) which
may be delusional) nearly every day (not merely self-reproach or guilt
about being sick)
f.
Diminished ability to think or concentrate, or indecisiveness, nearly
every day (either by subjective account or as observed by others)
g. Recurrent thoughts of death (not just fear of dying), recurrent suicidal
ideation without a specific plan, or a suicide attempt or a specific plan
for committing suicide
Proposed Diagnostic Criteria (Cont.)
The symptoms cause clinically significant
distress or impairment in social and
occupational functioning
4) 17 item Hamilton Rating Scale for Depression
(Ham-D) score of >10, or Geriatric Depression
Scale Score of >12
5) Duration of at least 1 month
Duration subtypes:
a.
Duration from 1-6 months
b.
Duration from 6-24 months
c.
Duration >24 months
3)
Proposed Diagnostic Criteria (Cont.)
6)
7)
The symptoms may be associated with precipitaing events (e.g.,
loss of significant other)
Organic criteria:
- objective evidence from physical and neurological examination
and laboratory tests; and/or history of cerebral disease, damage,
or dysfunction, or of systemic physical disorder known to cause
cerebral dysfunction; including hormonal disturbances and drug
effects
- a presumed relationship between the development or
exacerbation of the underlying disease and clinically significant
depression
- the disturbance occurs exclusively to the direct psychological
effect of alcohol or a substance use
- recovery or significant improvement of the depressive symptoms
following removal or improvement of the underlying presumed
cause
Proposed Diagnostic Criteria (Cont.)
8) Exclusion criteria:
There has never been:
an episode or mania or hypomania;
a chronic psychotic disorder, such as
schizophrenia or delusional disorders.
Previous history of major depressive
episode is not an exclusion criterion.
Depression and Medical Illness


Medical illness greatly increases riskf or depression
Risk to particularly high in
–
–
–
–
–
–
–


Ischemic heart disease (e.g., MI, CABG)
Stroke
Cancer
Chronic lung disease
Arthritis
Alzheimer’s disease
Parkinson’s disease
Mechanisms of depression vary
Medical Illness may confuse the diagnosis of depression
in medical patients
Depression Due to Medical
Condition
Older age of onset
 Organic features on MSE
 Lower incidence of family hx of depression
 Less likely to have SI/HI
 More likely to improve at discharge
 Higher morbidity and mortality in CAD, MI
and CVA
 Atypical presentation

Medications Associated With
Depression and Anxiety
Anticancer
Cimetidine, cyclotherine, other, levodopa,
ranitidine
Anticholinergic
Amopine, benztropine, hycosamine,
probanthine
Anti-inflammatory/ anti-infective
Baclofen, disulfirma, ethambutol, fenoprofen,
indomethacin, naproxen, phenylbutazone,
sulfonamides
Cardiovascular
Bethanidine, clonidine, diuretics, guanethidine,
hydralazine, methyldopa, propranolol,
reserpine, thiazide
Hormones
Anabolic steroids, corticotrophin, estrogen
hormone blocker, glucocorticoids, oral
contraceptives
Psychotropics
Benzodiazepines, neuroleptics
Stimulants
Caffeine, nicotine
Sympathomimetics
Appetite suppressants, ephedrine,
pseudoephedrine
Withdrawal from:
Alcohol, amphetamines, cocaine, hypnotics,
sedatives
M
a
d
Maddux RE, De;rajo, LL. Ra[a[prt <J. CMS S[pectr/ Vp; 8, No 12 (Suppl 3). 2003.
Drugs Linked to Depression/Anxiety









Beta-blockers
Other antihypertensives
Reserpine
Digoxia
L-Dopa
Steroids
Benzodiazepines
Phenobarbital
Neuroleptics
“Masked” Depression








Terminal insomnia, often with ruminations
Decreased appetite and weight loss
Extreme fatigue vs. anxiousness, restlessness
Increased, frequently delusional, preoccupation
with bodily functions, pain and weakness
Expression of fears and anxiety without reason
Low self-esteem or self-concept
Increased isolation, loss of interest and pleasure
Hopelessness, suicidal ideation
– All in context of “not feeling well physically”
– Depression is felt to be “secondary”
Clues to Depression in Primary Care

Help-seeking, persistent complaints
Pain
Arthritis
Weight Loss
Insomnia
GI Symptoms
Multiple diffuse symptoms
Headache
• Frequent calls and visits
• High utilization of services
•Treatment refusal, non-compliance
Additional Clues in Nursing Home
Apathy, withdrawal, isolation
 Failure to thrive
 Agitation
 Delayed rehabilitation

Additional Clues in Hospitalized
Patients
CABG, hip fracture, MI, stroke, arthritis
 Delayed recovery
 Treatment refusal
 Discharge problem

Chronic Pain and Depression

Study of more than 1000 patients found
depression in 1% of patients with one or
no pain complaints

12% in patients with 3 or more such
complaints
Depression and Neurodegenerative
Brain Disease
Alzheimer’s Dementia
 Vascular Dementia/Cerebrovascular
Disease

– Apathy
– Nondysphoric Depression

Parkinson’s Disease
Vascular Depression
Cerebrovascular disease can:
- predispose
- precipitate
- perpetuate
- a depressive syndrome
Risk Factors of Vascular
Depression
Male gender
 Older age
 Diabetes Mellitus
 Smoking

Risk Factors of Vascular
Depression (Cont.)
Atrial fibrillation
 Left Ventricular Hypertrophy
 Higher systolic blood pressure
 Angina Pectoris
 Congestive Heart Failure

Cerebrovascular Evidence in
Late Life Depression
Genetic and early life stressors less
important
 Diffuse brain dysfunction
 Cortical atrophy
 Diffuse hypometabolism

Cerebrovascular Evidence in
Late Life Depression (Cont.)
Deep white and gray matter
hyperintensities on MRI
 Small vessel disease postmortem
 Relation between stroke and depression

Localization of Brain Disease
in Depression

Hyperintensities in:
- left hemisphere deep white matter
- left putamen
Localization of Brain Disease
in Depression (Cont.)
• Lesions of:
- caudate
- frontal lobe
- basal ganglia
Brain Function Evidence

Hypoactivity of the caudate and frontal
regions including
- dorsolateral frontal region
- inferior orbitofrontal region
- medial anterior cingulate
Summary of Vascular
Mechanisms of Late-Life
Depression

Small lesions disrupt critical pathways:
- frontostriatal, circuitry and limbic
hippocampal connections
- damage of the catecholamine neurons by
white matter lesions in the pons
- Disruption of the orbital frontal cortex control
over the serotonergic raphe nuclei
Symptoms and Presentation
Increased psychomotor retardation
 More prominent cognitive impairment
 Poor performance on
neuropsychological tests

Symptoms and Presentation
(Cont.)
Less agitation and guilt
 Increased disability
 Older age of onset
 Executive dysfunction and apathy

Two Major Behavioral
Symptoms in Late-Life
- Apathy
- Executive Function
Apathy
A state of reduced motivation.
Types of Apathy
Motor apathy
- Tendency not to initiate motor activity
 Motivational apathy
- Absence of motivation to initiate new activities
 Emotional apathy
- Absence or reduction of emotional interest
 Cognitive apathy
- Absence of generative ideation

Conditions Associated with
Syndrome of Apathy
Alzheimer’s Disease
 Vascular Disease
 Brain Damage
 Partially treated depression
 Psychotic depression
 Schizophrenia
 Drug-induced (neuroleptics, SSRI’s, marijuana,
amphetamine or cocaine withdrawal)
 Other: apathetic hyperthyroidism, lyme dz, chronic
fatigue, testosterone deficiency, sleep apnea, etc.

Executive Dysfunction
Decreased:
• attention
• initiation
• organization
• planning
• abstract thinking
Screening for Depression

Evidence-based literature is somewhat
sparse and at times conflicting

Majority of physicians would rely on
individual judgment when assessing
depression in the elderly
Overview of Currently Used
Depression Scales in Geriatric
Patients

When using screening instruments in
elderly patients it is important to consider
the cognitive level
– Visual auditory deficits
– Function level

The validity of certain depression
screening instruments is significantly
decreased in patients with MMSE lower or
equal to 15
Geriatric Depression Scale (GDS)










30 questions that indicate presence of depression
Yes/No format
Might be more appropriate for elderly patients
Sensitivity 92%
Specificity 89%
Valid measure of depression in elderly patients
Validity decreases in nursing home patients and appears
to be dependent on the degree of cognitive impairment
Can be used in inpatient and outpatient
Very reliable for phone screening
Available for minorities
Depression Scale for People with
Dementia (Cornell Scale for
Depression in Dementia or CSDD)
Best validated scale for patients with
dementia
 Use information from both patients and
outside informant
 Better validated for patients with mild and
moderate dementia than with severe form
 Could depict depression in patients with
Alzheimer's.

Montgomery/Asperg Depression
Rating Scale (MADRS)
Observer rated assessment
 Based on clinical interview
 Does not assess somatic symptoms that
are important in geriatric population
 Not very well validated in geriatric patients

Zung Self-Rating Depression Scale
Self assessment scale
 Uses graded answers (never, sometimes,
always, usually which might be
problematic for geriatric patients)
 High false positive results in normal
elderly
 High false negative results if patients has
somantic problems62

Beck Depression Inventory (BDI)
Developed by Beck, Steer & Brown
 Assesses the intensity of depressive
symptoms
 5-10 minutes to administer
 Highly reliable regardless of the population
tested
 Available in Spanish

Hamilton Rating Scale for
Depression
Goal standard of observer-rated
depression scale
 Requires training to complete
 Takes 20-25 minutes to administer
 Valid for all ages
 Can be used in both clinical and research
 Assesses the severity of depression

Screening Measures for Depression in Children,
Adolescents, Adults, and the Elderly
Measure
Spanish Version
No of Items
Time to Complete
Psychometric
properties/cutoff
ELDERLY
Beck Depression
Inventory (BDI)
Yes
21
5 to 10
Alpha:
0.76/above 15
Center for
Epidemiological
Studies
Depression Scale
(CES-D)
Yes
20
5 to 10
Sensitivity: 92%
Specificity:
87%/above 15
Cornell Scale for
Depression in
Dementia
NO
19
10 with patient, 20
with caregiver
Sensitivity: 90%
Specificity:
75%/above 12
Geriatric
Depression Scale
(GDS)
Yes
30
10 to 15
Specificity:
100%/above 13
Sensitivity: 92% to
97%
Geriatric
Depression Scaleshort
Yes
15
5 to 10
Specificity: 64.8%
to 81%/above 5
Zung Depression
Rating Scale
No
20
5 to 10
Specificity:
63%/above 49
Medications Useful in Treating Depression
Medication
Doses Ranger
Uses
Precautions
Selective Serotonin Reuptake
Inhibitors
Citalopram
Fluoxetine
Paroxetine
Sertraline
Trazodone
10-40 mg/day
10-40 mg/day
10-40 mg/day
25-100 mg/day
25-150 mg/day
Depression, Dysthymia, anxiety
Common to all SSRIs
Common to all SSRIs
Common to all SSRIs
When sedation is desirable
GI upset, nausea, vomiting,
insomnia
Tricyclic Antidepressants
Desipramine
10-100 mg/day
Anticholinergic effects,
hypotension, sedation,
cardiac arrhythmias
Nortriptyline
10-75 mg/day
Adjunctive pain
management/
neuropathic pain
naturopathic
pain
High efficacy for depression if
patient can tolerate side effects
Other Agents
Buproprion
75-225 mg/day
Irritability, insomnia
Mirtazapine
Nefazodone
7.5-30 mg/day
50-200 mg/day
More activating,
lack of cardiac effects
Useful for insomnia
Useful for insomnia
Vanlafaxine
25-150 mg/day
Useful in severe depression
2.5-20 mg/day
Give before 1PM
Ofen rapid onset
may augment antidepressants
2.5-15 mg/day
Give before 1PM
Same as above
Psychostimulants
Methylphenidate
Dextroamphetamine
Sedation, falls, hypotension
Sedation, hypotension
Sedation, hypotension
*Warning, do not use in
liver disease
Hypertension may be a
problem; insomnia
Tachycardia, irritability,
tremor, excitation,
insomnia
Similar, but possibly
More over-stimulation
Psychosocial Interventions for
Depression
Social support to reduce isolation; referral to senior
centers, home care, and visiting nurse services; pet
therapy and visitation; volunteer jobs as indicated
 Psychotherapy: supportive psychotherapy, cognitivebehavioral therapy, interpersonal therapy, group therapy
 Family counseling
 Substance abuse interventions as indicated
 Bereavement counseling and services as needed
 Health promotion and maintenance: good nutrition, light
physical exercise, attention to chronic medical
conditions, establish a regular daily routine

Conclusion

When diagnosing depression in geriatric
patients, there are 5 essential objectives:
– Determine etiology and diagnosis
– Provide disease specific management
– Manage behaviors and target symptoms (symptoms
that are the most distressing)
– Prevent secondary complications (side effects of
medication)
– Rule out dementing process/medical illness
– Support the families