Recognizing and Treating Depression in the Elderly

Mark D. Miller, MD

Medscape Psychiatry & Mental Health eJournal. 1997;2(2) 

In This Article

Clinical Presentation

In addition to the hallmark DSM-IV symptoms of major depression outlined in Table I,[17] the most notable difference between the clinical presentation of depression in the elderly and in younger age groups is the high prevalence of somatic complaints. Depressed elderly individuals often present with a chief complaint of increased arthritic, abdominal, or headache pain that usually has a core of real pathology but is now perceived by the patient as intensely exacerbated.

Today's elderly are frequently unfamiliar with the manifestations of "depression" or may be unclear about its meaning. Many elderly depressed patients define their problem as an inability to do their usual housework or a lack of motivation rather than a focus on sadness or low mood, particularly if they see no legitimate reason to be sad. These same patients, described as alexithymic (lex = to know, thymos = to feel; thus, "an inability to know one's feelings"), will often show a complete remission of symptoms when appropriately treated for depression.[18] They may still not comprehend the syndrome of major depression; they just know that they now feel improved. Primary care physicians or ancillary health care staff might consider the use of depression-rating scales to help make the correct diagnosis (Table II).

Obtaining a corroborating history from confidants or family members is highly recommended. The clinician may have to infer a diagnosis based on the family's description of marked changes consistent with depression. For example, family members might describe their elderly mother as having been active in church affairs and walking regularly for fitness, but now she appears to them as dulled; she declines invitations and sits watching television for hours, with no particular interest in what she watches. This marked change in activity coupled with pervasive negativity and listlessness should raise the possibility of depression in the mind of the clinician even if the patient denies feeling sad.

Educational efforts are often required for patients and families when managing depression at any age, but particularly so with depression in the elderly. Treating geriatric depression often requires addressing the concerns of family members as well as managing the patient. Family stressors can include the need to take time off to escort an ill parent to appointments and to otherwise perform double-duty with their own immediate family needs. Finally, there is the specter of old interpersonal conflicts with parents that can potentially be rekindled by the demands of caregiving.

In addition to a somatic focus, anxiety symptoms and irritability are also commonly seen in geriatric depression. Particularly in the elderly, patients with agitated depression can present with symptoms of pacing or hand wringing and sometimes with an obsessional focal point such as worry over adequate finances or the perceived threat of cancer.[19]

Psychotic symptoms can also accompany depression in the elderly. These are usually negativistic delusions (false beliefs), such as "I feel that I'm dying," or a guilt-ridden perception that punishment is deserved. Hallucinations are rarely involved in psychotic depression, nor are the more bizarre delusions seen in schizophrenia (eg, feeling under the control of radio waves).[20] The rapid onset of visual hallucinations suggests the possibility of delirium.[21]

The prevalence of bipolar disorder or manic depression in the general population is 1%.[22] The diagnosis is usually made by the third or fourth decade of life, and exacerbations can be seen throughout later life, either as frequent mood swings or hovering at one pole of the bipolar spectrum with chronic symptoms, sometimes despite optimal treatment.

Mania or severe depression can present for the first time late in life. In retrospect, a history can sometimes be pieced together that is highly suggestive of a "bipolar spectrum." That is, these individuals were prone to periods of overactivity, recklessness, or foolhardy spending that may have been undiagnosed hypomania, but because their behavior never clearly crossed lines of social taboos, treatment was never considered. These individuals may have suffered from unrecognized depressions as well. For a variety of reasons, such as the stress of an intercurrent medical illness, a course of prednisone, or a cerebrovascular event, the heretofore smoldering symptoms may appear as classic symptoms of bipolar disorder for the first time in later life. It should also be noted that organic causes of mania--such as poststroke, secondary to head trauma, or drug-induced--do exist (Table III).[23,24]


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