Depression in Older Patients

Depression can occur in any patients as they age, even without a prior history of depression. Older individuals can present with mood symptoms that can seem to be part of the normal aging process, but it is important to assess for the possibility of a masked depression. Of note, there is an increased risk of suicide in older patients with depression, particularly older white men who are isolated.

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.

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.

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