The symptoms of depression can be the same for older patients as younger adults. However, older patients with depression can often deny feeling sad or depressed. Here are some clues to indicate that an older patient might have depression.

• unexplained or aggravated aches and pains
• feelings of hopelessness or helplessness
• anxiety and worries
• concentration problems
• lack of motivation and energy
• slowed movement and speech
• irritability
• loss of interest in socializing and hobbies
• neglecting personal care

It can be easy to think of a patient’s presenting symptoms as a normal part of aging, for example it is common for people to experience trouble with concentration and difficulty maintaining sleep as they get older. Even feelings of guilt and worthlessness can appear to be a reaction to losing a loved one or retiring, respectively. One important factor is looking at the level of impairment to help determine if a more serious process is occurring.

Depression can occur co-morbidly with dementia and the two disorders each increase the risk of the other, but the cognitive concerns that occur with each are different. Persons with depression commonly report trouble concentrating and being motivated. Persons with dementia present with short-term memory loss and word finding difficulties, and may not be aware of the cognitive challenges. The cognitive decline seen in dementia is mostly a slow process whereas the cognitive decline seen in depression is more rapid. Here is a helpful chart to distinguish between depression and dementia.

One very important thing to be aware of is that the suicide risk is high among older patients with depression, particularly in Caucasian males. Research shows that 75% of people who commit suicide have visited their PCPs in the previous month but their symptoms of depression were either not disclosed or not assessed for. This is a serious and potentially preventable problem, and starts with improving psycho-education and awareness of depression in older patients.

It is also important to be aware that medical problems and medications can cause depressive symptoms in older adults. Medical problems that can cause depressive symptoms, either directly or as a psychological reaction to the illness, include Parkinson’s disease, stroke, heart disease, cancer, diabetes, thyroid disorders, vitamin B12 deficiency, dementia, lupus and multiple sclerosis. Medications that can cause of worsen depression include: beta-blockers, sleeping medications, benzodiazepines, calcium-channel blockers, ulcer medications, steroids, cholesterol medications, and pain medications. While the mood-related side effects of prescription medication can affect anyone, older adults are more sensitive because of less efficient metabolism of medication.

Treatment for depression should include treating underlying medical factors, increasing social engagement and therapy. Medication (primarily the SSRIs) can be an important part of the treatment as well, but it is important to utilize the lowest effective dose and monitor closely for side effects, which can include bone loss and increased risk for falls and fractures in elderly patients. Measures to reduce the risk of bone loss, like exercise and calcium and vitamin D supplementation, are important to consider adjunctively.

As mentioned previously, it is important to improve awareness of and assessment for depression in older patients, It not only can be a debilitating condition on its own, but it can also complicate the presentation of other medical problems and limit effectiveness of treatment for those other medical problems.

Risk factors for depression in older patients include:

1. Significant medical problems
2. Retirement and loss of professional identity
3. Decreased independence
4. Decreased physical mobility
5. Memory impairment
6. Loss of close loved ones

While depression is diagnosed in older adults using the same criteria used to diagnose younger and middle-aged adults, symptom presentation can vary slightly.  Older patients may not explicitly report symptoms of sadness. Other clues that depression may be present include: unexplained or aggravated aches and pains; sleep disturbance; feelings of hopelessness or helplessness; anxiety and worries; concentration problems; lack of motivation and energy; slowed movement and speech; irritability; loss of interest in socializing and hobbies; and neglecting personal care.

Both the number of symptoms and the level of impairment from these presenting symptoms are important features in determining whether a diagnosis of major depressive disorder is warranted.

There is a complicated relationship between depression and dementia in older patients. Dementia can be a risk factor for depression and depression can be a risk factor for dementia. Additionally, older patients with depression can have memory and concentration troubles without also having dementia. The cognitive problems seen in depression and dementia are different from each other. Persons with depression commonly report trouble concentrating and being motivated. Persons with dementia present with short-term memory loss and word finding difficulties, and often may not be aware of the cognitive challenges.

Depression is also common in patients with mild cognitive impairment (MCI), occurring in up to 1/3 of patients with MCI. It is therefore important to assess for depressive symptoms in an older patient presenting with early and generally mild signs of cognitive impairment.

It is also important to be aware that medical problems and medications can cause depression in older adults. Medical problems that can cause depression, either directly or as a psychological reaction to the illness, include Parkinson’s disease, stroke, heart disease, cancer, diabetes, thyroid disorders, vitamin B12 deficiency, dementia, lupus and multiple sclerosis.

Medications that can cause or worsen depression include: beta-blockers, sleeping medications, benzodiazepines, calcium-channel blockers, ulcer medications, steroids, cholesterol medications, and pain medications. While the mood-related side effects of prescription medication can affect anyone, older adults are more sensitive because of less efficient metabolism of medication.

The Geriatric Depression Scale is a validated screening tool for assessing for depression in older patients. It is a self-administered screen. A link and copy of the screening tool is included.

https://www.healthcare.uiowa.edu/igec/tools/depression/GDS.pdf

Next week’s e-weekly will address treatment of depression in older patients and how it is different than treatment of depression in younger adults.

First, it is important to identify and address any medical contributions to a person’s depression, including treatment(s) for an underlying medical condition or adjustment of a medication that may be causing affective or cognitive changes as side effects.  Prior to considering psychotropic medication for a patient’s depression, it would be important to determine if psychotherapy or increasing social engagement with family or the community could play a role in the treatment.

Psychotropic medication can be an important part of the treatment of depression, particularly in moderate-severe cases, but it is important to “start low and go slow”, to utilize the lowest effective dose and to monitor closely for side effects. Dementia, cardiovascular problems, diabetes, and Parkinson disease, which are commonly in older patients, can worsen with highly anticholinergic medications, like the tricyclic antidepressants. Because older patients are often on multiple medications, it is important to carefully review for potentially relevant drug-drug interactions.

The selective serotonin reuptake inhibitors (SSRIs) are the first line agents in this population. Possible side effects that are particularly important to monitor for in older patients include bone loss and increased risk for falls and fractures. Measures to reduce the risk of bone loss, like exercise and calcium and vitamin D supplementation, are important to consider adjunctively. There can be an increased risk of developing hyponatremia secondary to a syndrome of inappropriate antidiuretic hormone secretion, so sodium levels should be monitored regularly in older patients taking SSRIs or SNRIs. The best SSRIs to consider in older patients are citalopram escitalopram and sertraline. For citalopram, an appropriate starting dose would be 5-10 mg and increasing in 5mg increments, and for sertraline starting at 25mg and increasing in 25mg increments. Other appropriate medication options are the SNRIs, mirtazapine, and bupropion.

As a group, older patients with depression are more likely than younger patients to show signs of cognitive impairment, including poor concentration, apathy, and poor motivation, as part of their presentation. If these cognitive defects persist even when the depression is treated this may be an indicator of a potential risk of an evolving dementia process.  There are times when an elderly patient may be less likely to respond to antidepressant medications, either with a less robust response overall and with a poor response to a first medication trial (up to 1 in 3).  One option in such a situation is to consider augmenting the antidepressant with a stimulant medication. If prescribed potential side effects need to be monitored carefully – appetite and sleep disturbance, increased irritability, and moodiness when the medication is wearing off. Also this option should generally be avoided in patients with significant histories of (recent) substance abuse and/or concurrent anxiety symptoms as stimulant medications can worsen make anxiety symptoms.

It is our hope that this series on assessing for and treating depression in older patients has been helpful for working with older patients in your practice.

SAVE THE DATE/REGISTER for the 2^nd Annual Critical Issues in Child & Adolescent Health Conference in San Diego,
March 11, 2017
http://cicamh.com/