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Basic treatment of depression in the elderly

By admin 26th January 2016

Consultant Psychiatrist Dr John O’Donovan of Saint John of God Hospital stresses that depression is not a natural end point of getting older and can be treated well following an accurate diagnosis.

Depression in older patients is a common clinical problem affecting at least 3 per cent of community-dwelling older patients and up to 10 per cent of older adults in residential care.

Clinically, it’s characterised by pathological sustained sadness, absence of pleasure in response to normally pleasurable activities, easy fatigue and a constellation of other symptoms including sleep disturbance (both insomnia and hypersomnia can be present), psychomotor changes such as agitation or retardation, feelings of worthlessness or guilt, reduced concentration and recurrent thoughts of death or suicide.

Depression in older adults may present atypically and more often than not will be complicated by comorbidity, polypharmacy and of course the normal challenges of ageing, of which isolation, grief and poverty require special attention. It’s important to identify depression in this population, as available treatments are safe, straightforward and effective.

Diagnostic criteria
The DSM-5 criteria for diagnosis of depression requires that symptoms be present for two weeks and are present on a near continuous basis. The two core symptoms are depressed mood and anhedonia. One or other or these symptoms ‘must’ be present.

Depressed mood is a very innocuous sounding symptom and does not adequately convey the mood alteration in severe depression, which may result in self-loathing, profound guilt, ideas of worthlessness, futility and death. It can be an unbearable emotional state for a patient such that death by suicide can seem a rational end.

Anhedonia describes the loss of pleasure in normally pleasurable activities and as with depressed mood exists on a continuum, and it’s important to ask about even partial anhedonia. A total of five symptoms out of nine are required for a diagnosis of depression and one of the five must be either depressed mood or anhedonia.

Pic: Getty Images

The other seven symptoms are listed below.
1. Significant weight loss when not dieting or weight gain (e.g. a change of more than 5 per cent of body weight in a month);
2. Insomnia or hypersomnia nearly every day;
3. Psychomotor agitation or retardation nearly every day;
4. Fatigue or loss of energy nearly every day;
5. Feelings of worthlessness or excessive or inappropriate guilt;
6. Diminished ability to think or concentrate, or indecisiveness;
7. Recurrent thoughts of death, recurrent suicidal ideation.

There are a couple of other caveats, which are broadly speaking that symptoms cause functional impairment and they are not better accounted for by an alternative explanation, such as substance misuse or a different psychiatric illness.

Applying the DSM-5 criteria to the older patient
It is interesting to consider how the above criteria apply to an older patient. Older patients are often stoic and reluctant to complain about emotional distress. This co-exists with long-standing social beliefs defining old age as a time of illness, reduced functional ability, loss and unhappiness. But it is important to challenge these beliefs, and generally speaking more so for patients than doctors. Depressive comments from older patients indicate depression. Depression is not a natural consequence of ageing.

Anhedonia is generally best gauged by asking about normal pleasurable activities such as watching television, sporting occasions, meeting family members such as children and grandchildren and whether these activities still currently provide a normal response, and that the response is not attenuated.

Caution needs to be exercised in analysing the biological features of depression in the elderly. Sleep, physical energy, appetite and fatigue are especially prone to be disturbed due to a multitude of common problems in later life, such as heart failure, nocturia, malnutrition, medication effects and nearly all serious physical illnesses.

Feeling worthless or guilty is a very sensitive symptom that really is age independent, but poor concentration or indecisiveness can be related to cognitive problems such as early dementia or delirium, and thinking about dying is not always pathological in older patients, particularly so if they have an incurable or terminal illness.

Figure 1. Click to enlarge

The proviso for functional impairment can also be troubling. For example, if a patient is severely functionally impaired due to combined arthritis, left ventricular failure and early cognitive decline requiring full nursing care, how then does one determine functional decline?

The answer is, of course, that there may not be measurable functional decline, but there may still be profound depression and a ‘tick box’ approach to symptoms does not work well in older patients.

Each individual symptom needs to be considered as whether it’s truly due to depression or an alternative cause and this must ultimately come to a diagnostic decision as to whether depression is the problem or not.

This decision is very much a global impression, which takes into account alteration from normal functional performance, personality, and collateral information from spouse or carers and simultaneously rules out the common mimics.

How to distinguish between delirium, depression and dementia
Delirium, dementia and depression can look identical on a single cross-sectional assessment and teasing them out at the bedside with limited time can be a difficult task.

Delirium will tend to have a clinical triad of poor attention, sleep wake cycle disturbance and an underlying physical problem of some type and will, of course, tend to begin more abruptly and fluctuate more widely during a 24-hour cycle.

The distinguishing features of dementia tends to be the primacy of cognitive problems leading to progressive functional decline and, unlike delirium, this is a slow process, which evolves over months and years. Time course and clinical setting can also be useful diagnostic pointers as outlined in Figure 1.

Taking the history
Core questions that should always be asked are a combination of open and closed questions about mood such as “how are you feeling?” and “Are you feeling sad or unhappy recently?” and specific questions about anhedonia such as “Are you enjoying things?”, or perhaps more effectively to ask about favourite interests, company and hobbies and find out if they are still enjoying these to the same extent.

Questions about self-esteem such as “Are you feeling confident?” and guilt “Are you worried that you have let anyone down?” are all important topics to explore, as are beliefs about the future such as “How does the future seem to you?” All of these questions relate to the core emotional aspects of depression including sadness, futility, self-esteem, guilt and the person’s belief about the future.

Vegetative features need to be interpreted with an appropriate knowledge of the person’s physical state and clearly if the core emotional aspects of depression are not present, vegetative features need to be interpreted cautiously.

Finally, thoughts of dying and suicide must always be asked about and can usefully be sub-divided into an increased level of risk as seen in Figure 2.

At the lowest level are fleeting thoughts of not being present or of death presenting an escape with no true plan or intent of suicide. This is quite a common presentation in even significant depression.

The next level is considering harm to oneself and perhaps turning over different scenarios and plans.

As the plans become more specific and definite, the risk elevates and patients may think about different methods over a long time before actually escalating to actions such as overdose, cutting, hanging, drowning etc.

Figure 2. Click to enlarge

Older patients are statistically far less likely to self-harm than younger patients and any suicidal act in an older patient should be treated as a true suicidal attempt until proven otherwise.

Prior history of depressive episodes should also be enquired about, family history of depression and critically any episodes of mania in the patient or in the patient’s family.

The presence of a prior manic episode immediately alters the diagnosis from that of depression into bipolar disorder, which means a significantly different treatment approach with use of mood stabilisers rather than antidepressants.

Substance misuse needs to be enquired about with the commonly abused substances being alcohol and benzodiazepines.

Severity of depression and treatment
The best guide for severity of depression is functional impairment. Mild depression causes minimal impairment of function, moderate depression will impair function significantly and severe depression will have near total functional impairment, where basic tasks such as getting dressed, eating and drinking may be neglected. Severely depressed older patients may require hospitalisation and full nursing care until their depression is treated.

Physical illness and depression in later life
Important things to look out for during the physical examination are evidence of acute physical illness, thus suggesting a delirium, and hypoactive delirium can be very hard to distinguish from depression with psychomotor retardation.

Certain physical illnesses are strongly associated with depression including pancreatic cancer, Cushing’s syndrome, Parkinson’s disease, stroke, dementing illnesses and of course any illness resulting in chronic pain or significant functional disability.

In practice, the most common confounding physical illnesses are dementia, stroke disease, cardiac disease, arthritis and Parkinson’s, and as the population ages it is now increasingly the case that the older depressed patient will have several physical illnesses and be on multiple pharmaceutical agents.

Treatment
The purpose of the history and examination is to establish a clear diagnosis, identify any immediate or urgent problems (delirium, acute illness, suicide risk) and plan effective treatment.

Depression in later life is not uniform, and each patient will present his or her own particular set of circumstances and require individualised treatment with a different balance of biological treatments, social interventions and psychological interventions.

Antidepressant use in the elderly patient
Antidepressant medication is a safe and effective treatment for depression in the elderly.

However, no single anti-depressant is clearly superior to others in terms of efficacy.

International guidelines generally suggest first-line treatment with one of the SSRIs and if this fails moving on to an SNRI or alpha-2 antagonist.

Common side-effects of the SSRIs as a group are nausea, headache and an initial increase in anxiety. These effects can be reduced by starting with low doses and taking them with food, and it’s sensible to warn patients of these side-effects and reassure them that these tend to pass within four-to-five days.

Sexual side-effects for both men and women are also common, occurring in up to 20 per cent of patients taking SSRIs, and need to be enquired about directly as the patient may not volunteer this information due to embarrassment.

Serious side-effects include hyponatremia, prolongation of the QTc and serotonin syndrome (Figure 3).

Serotonin syndrome is characterised by hyperthermia, hyperreflexia with clonus and a delirious state.

The true prevalence of this is unknown and it probably exists as a broad phenotype ranging in severity from mild agitation and confusion to a severe illness, which can result in death.

Prolongation of the QTc is associated with antidepressant use from several classes and is a particular problem with citalopram and escitalopram at higher doses. However, it is not clear that the prolonged QTc translates neatly into higher rates of sudden death from torsades de pointes.

Hyponatremia with SSRI use is a common clinical problem in older patients and is more likely to occur in thin, physically ill, older women on antihypertensives.

The clinical presentation is varied but classically a hypoactive delirium with prominent nausea and myoclonus or tremor.

As a simple rule of thumb, transient nausea, headache and anxiety are very common, self-limiting and do not cause longer-term harm.

Figure 3. Click to enlarge

QTc prolongation is most strongly associated with citalopram and escitalopram and therefore a patient with known or suspected cardiac rhythm problems or a baseline ECG with a prolonged QTc should probably not be prescribed one of those agents.

Hyponatremia can happen within days of starting treatment and should be the first consideration in an older patient who becomes confused within three to seven days of starting antidepressants.

Treatment of SSRI related SIADH is to stop the medication and fluid restrict.

Patients tolerate SSRIs well and there is little to choose between them. Older patients may require longer to respond and a period of between four to six weeks is the correct time to wait.

If patients do not respond to the initial treatment, the correct option is to switch to another agent. This may be another SSRI or an antidepressant from a different class and a common strategy is to switch to an SNRI such as venlafaxine or duloxetine or an alpha-2 antagonist such as mirtazapine.

Once again, these medications should be taken at effective doses for another four-to-six weeks and the patient reviewed.

A patient who does not respond to two adequate trials of two different antidepressant classes may need referral to a specialist for treatment.

Psychotherapy
Psychotherapy of all types is helpful in treating later-life depression and for some patients is the treatment of choice.

Matching the patient to the correct psychotherapy and therapist is important and independent of the type of therapy employed, the skill and experience of the therapist remains a key variable.

It is important also to make sure that the patient is physically and cognitively well enough to engage in the process.

A patient with cognitive impairment and depression may not manage to attend sufficiently to make psychotherapy worthwhile.

Social and other treatments
Very often the most effective treatments in later-life depression are practical. Increased social support at home, meals on wheels, addressing pain through adequate analgesia, making sure that the patient is warm, has enough to eat, has company, is not in physical pain, does not suffer from sensory deprivation and has a sense of purpose in the day and a meaningful future.

Carer burden is an important stress to consider in older patients and treatment of isolation is crucial.

Attendance at a day centre or day hospital for social interaction and communal meals is often the key difference between living at home in the community and crisis admission to a general hospital or residential home setting.

In conclusion, depression in the elderly is a common clinical problem, which can be diagnosed accurately by taking a good history and focusing on the core features of unhappiness and loss of pleasure in life.

It’s important to rule out common mimics such as delirium or dementia and consider the risk of suicide at all stages.

Treatment is broad based and relies on correct use of medication allied to other interventions, which aim to improve the patient’s comfort, purpose and sense of self.

With good treatment, depression remits. Depression is not a natural endpoint of getting older and the treatment of depression in the older person is rewarding for both patient and doctor.

Dr John O’Donovan,
MRCPI, MRCPsych,
Consultant Psychiatrist,
Saint John of God Hospital,
Stillorgan, Co Dublin.