Recognizing and Treating Depression in the Elderly

Mark D. Miller, MD

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

In This Article

Factors Associated With Depression in the Elderly

Genetic vulnerability for depressive disorders has long been recognized, although the exact modes of inheritance are unclear. In an elderly person who has had previous bouts of depression, such as during the postpartum period or after stressful transitions (eg, leaving home, losing a family member), there is a greater vulnerability to depression later in life. An elderly patient with a vague history of mild depression but clear diagnoses of depression in first-degree relatives has a 1.5 to 3 times greater vulnerability for depression than the general population.[25,26,27]

There is some evidence that monoamine oxidase (MAO) levels increase with age. The effect of this phenomenon is to metabolize amine neurotransmitters at a faster rate, resulting in a state of relative neurotransmitter depletion, which could increase the risk for depression.[28]

Depression is sometimes seen in patients in the early stages of dementia as a psychological reaction to the broad implications of being aware of losing one's cognitive capacity.[29] Dementia associated with vascular disease frequently has a depressive component resulting from disrupted neuronal systems that are necessary for the maintenance of mood. Depression has long been recognized as a common sequelae following stroke (26% to 61%)[29] and is one of the diagnostic criteria for multi-infarct dementia on the Hachinski ischemia scale.[30,31] The associated depression seems to be independent of any physical disability that results from the stroke.

In addition, improvements in imaging technology have shown an association between patients with "silent strokes" (hyperintensities or periventricular white-matter lesions on MRI) and higher rates of depression. Disrupted neuronal systems are the likely mechanism linking the high incidence of depression and atherosclerotic cardiac and cerebrovascular diseases.[31]

Zubenko and Moosey[32] reported that patients with Alzheimer's disease who were also depressed had more hallmark pathologic damage (plaques and tangles) in the norepinephrine-rich locus ceruleus region of the brain at autopsy than Alzheimer's-disease patients who were not depressed. These findings suggest that Alzheimer's-disease patients show a biological risk for depression secondary to the degenerative process. Similarly, patients with Parkinson's disease, Huntington's disease, and multiple sclerosis also show a biological risk for depression because of subcortical degenerative processes.[33]

A thorough history and physical examination along with screening laboratory tests should be standard procedure when evaluating depression in the elderly. Individuals in this age group are more at risk than those in younger age groups for metabolic derangements, some of which are associated with depression. Cyanocobalamine or vitamin B12 deficiency,[34] thyroid imbalance in either direction,[35] and electrolyte disturbances are examples of metabolic disruptions that can show in associated mood changes. Delirium can also result from metabolic derangements, and it may present with mood changes that may be missed if it is accompanied by psychomotor retardation rather than agitation.[36]

Many medications are associated with depression, including antimicrobials, antihypertensives, antineoplastics, neuroleptics, steroids, hormones, and other miscellaneous medications. A temporal association between the onset of depressive symptoms and institution of a new medication should prompt the reconsideration of the new medication and a switch to a different class. For example, some patients are vulnerable to depression while taking beta-blockers for the treatment of hypertension. The substitution of an angiotensin-converting enzyme inhibitor might resolve the depressive symptoms.

Alcoholism and other substance abuse too often go unrecognized in the elderly, who may have maintained their consumption level as they aged but became unable to metabolize or withstand the agent's depressive effects on the central nervous system. The co-occurrence of substance abuse with other psychiatric diagnoses in anxiety and depressive disorders is well recognized. Alcoholism is also an associated risk factor for suicide.[37] A family history of alcoholism in first-degree relatives conveys an increased risk for depression.

Bereavement is an obvious stressor commonly seen among the elderly. The stress of losing a spouse outranks all others on the Holmes/Rahe scale for depression,[38] although grieving over the loss of any significant person can, in itself, precipitate depression. Symbolic losses include loss of health, appearance, work-related prestige, financial strength, or cognitive abilities.

Depressive symptoms associated with bereavement are too often overlooked by health care personnel as "normal" for the grieving elder. Zisook and Schucter[39] showed that widows often display depressive symptoms 2 years after their loss. Increased substance abuse among the bereaved can also contribute indirectly to depression.

Uncomplicated bereavement and major depression can have many symptoms in common[40] and might be treated with the same therapies. Research has documented the benefit of nortriptyline in ameliorating the vegetative symptoms of depression, although the intensity of the psychological symptoms of grief do not seem to improve as much with nortriptyline alone.[41]The subjective meanings of the loss might require a psychotherapeutic approach for the relief of grief-related depression.[42] The selective serotonin reuptake inhibitor (SSRI) medications are also showing promise as effective agents in this group (Prigerson HE et al, 1996. Unpublished data.). A combined approach is often the most effective, in our experience.

Personality or character traits are formed early in life and remain as interpretive filters of lifelong experience. Certain personality traits or disorders increase the risk for depression. For example, the obsessional businessman who prided himself as a problem-solver may become depressed when he faces a problem he can not fix--even by redoubling efforts (to seek mastery or regain control)--such as an incurable medical problem or the loss of a spouse. Individuals with excessive dependent traits may decompensate and become depressed upon the loss of the organizing personality in their life.[43,44]

The fear or anguish connected with impending death is depressing for some. Often a collusion takes place within families and, at times, health care workers, to avoid talking about the obvious when death approaches. Appropriately trained counselors, nurses, clergy, and medical students, as well as increasing experience with hospice teams, have provided more opportunities for the depressed elderly to confront this issue directly. The physician may be the best person to broach the subject of impending death openly; to allay fears of an undermedicated, painful death; and to encourage the completion of wills and "unfinished business." Properly documented advance directives can be drawn up in order to prevent unwanted, artificial life extension and to help relieve the fear of impending death that can be depressing for some elders.

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