Depression in elderly often ignored

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Older people may suffer from a wide range of psychiatric problems in late life. Those who are suffering from physical illness are especially vulnerable. Though these conditions tend to be under- diagnosed and under-treated, their outlook with appropriate management is often excellent.

Depression in late life is an example of such a condition.

DEPRESSION

Depression is common and disabling in old age, especially in people who are suffering from a physical illness at the same time or are in institutional care. In spite of this, it is often missed, ignored, or not managed adequately. Yet the associated health and social care costs are high.

Many people wrongly assume that depression is a normal part of the aging process and that treatment is inappropriately excessively risky or not likely to be effective. These assumptions are false. The majority of older people are not clinically depressed, and those that are, respond as well to medication and psychological treatment as do younger depressed patients.

PREVALENCE

The prevalence of depression in older people varies widely depending on the sample selection and the diagnostic criteria used, but most studies put the prevalence at from three to 11 per cent in the elderly population living in the community.

In the hospitalized elderly the prevalence is higher, especially amongst elderly people in long-term institutional care where the rate is over 20 per cent.

CAUSES

Most community studies find significantly higher rates for depression in women than in men. Depression is more common in physically ill than in healthy older people. The main risk factors appear to be the severity of the physical illness, the degree of disability, co-existing cognitive (mental) impairment and a positive past psychiatric history.

Although illness in general is a risk factor, serious illnesses such as Parkinson's disease have been associated with a particularly high likelihood of developing depression. However, depression in elderly medical patients is frequently overlooked by medical staff. The management of depression in physically ill elderly patients is essentially the same as for depression in general.

Poverty, bereavement and social isolation often precipitate depression in old age. The importance of physical illness has already been discussed.

Individuals who are separated, divorced or widowed show more depressive illness than single or married subjects.

CLINICAL FEATURES

Depression often presents in less typical fashion in old age with low mood being less prominent or even absent. Older patients tend to have an increase in body complaints, sleep disturbances and agitation.

A person with more serious depression may suffer from loss of appetite, difficulty in sleeping, loss of interest and enjoyment in social activities, a lack of energy and loss of concentration. Movement and thinking may become slowed. However, in some cases the opposite occurs and the person becomes extremely agitated and anxious.

Severely depressed people may "wish to die" and have feelings of guilt and worthlessness. They may suffer from hallucinations and delusions that someone is trying to poison them.

SCREENING

Given that depression in older people is common, disabling, often persistent, and eminently treatable, it is worth "screening" for it.

Several useful "screening questionnaires" have been developed specifically for use in older people, and the results are reliable. Early treatment can then be started.

TREATMENT

Research studies suggest that only a small minority of older people with depression receive treatment.

Although their general practitioners were aware of the depression in the majority of cases they are not treating them for it. This suggests that all too many general practitioners wrongly think such cases are not treatable or believe drug treatment is highly toxic or ineffective. However, it must also be recognized that many older patients with depression will deny the results of screening tests and refuse to admit that they may be in need of treatment and object to having to take more drugs.

This is unfortunate, because treatment of depression in old age is clearly efficacious. Antidepressant drugs are undeniably more hazardous in old age but are successful, by and large, if correctly prescribed. Also, the newer antidepressants that are now available have fewer side effects and are safer than the older generation of drugs. However, antidepressant drugs may take as long as 10-12 weeks to show clinical improvement in the patient.

Electroconvulsive therapy (ECT) remains an important treatment option in very severe or treatment-resistant depression in old age. It is particularly indicated when depressive delusions are present, and when the suicide risk is considered to be high. The electric shock is administered under a general anesthetic. The treatment is effective and safe and may be lifesaving. The only side effect may be a mild, temporary memory loss. It relieves severe depression faster than drugs.

Psychotherapy, whether individual or in a group, is also most useful. Ideally, it is combined with antidepressant drugs.

OUTLOOK

The outlook is good for most sufferers, provided they get appropriate treatment and advice. The main risk is suicide.