DEPRESSION

DEPRESSION

Depression is the most common mood disorder in the geriatric population. Some symptoms of depression, such as weight loss, sleep disturbance, and fatigue, may be associated with other concurrent medical conditions. These medical issues must be ruled out prior to establishing a diagnosis of depression.

Cognitive disorders may also interfere with the diagnosis of geriatric depression.

Depression significantly contributes to an individual's disability, functional decline, and quality of life. The early diagnosis and management of depression can help to decrease further disability, restore function, and reduce the risk of suicide in the geriatric population.

The prevalence of depression in the elderly is 17-37%, with 11-30% of that population having major depression. The prevalence is higher in the presence of significant medical illness.

The elderly, most commonly those older than 75 years, often contemplate suicide. In older white men, the risk of suicide is 5 times higher than that of any other age group. Depression and significant comorbidity are principal reasons why elderly persons consider suicide.

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) defines major depression as the occurrence of 5 or more of the following   :

§  Depressed mood

§  Diminished interest or pleasure

§  Weight loss or gain

§  Insomnia or hypersomnia

§  Psychomotor agitation or retardation

§  Fatigue or loss of energy

§  Feelings of worthlessness or guilt

§  Diminished energy to concentrate 

§  Suicidal ideation

However, depression in the general population and depression in the geriatric population may differ in some ways. Elderly people with depression are more likely than others to have somatic complaints, to minimize their depressed mood to others (masked depression), and to hide their feelings of guilt.

Hypochondriasis occurs in 65% of the elderly population with depression. Sociologic and demographic factors are not significantly associated with major depression in the elderly.

SCREENING FOR DEPRESSION

A brief screening instrument, the Geriatric Depression Scale (GDS), is beneficial in the rehabilitation setting. The GDS is simple to repeat screenings on multiple occasions to assess any improvement of the patient's depression.

The short-form scale consists of the 15 questions below. Patients are asked to reply "Yes" or "No," and the answers in parentheses are counted as 1 point.

A score of

§  0 - 5 points is normal

§  6 - 10 indicates mild depression

§  11 - 15 indicates severe depression

This screening tool can be helpful as a guide to rehabilitation management in the inpatient and outpatient settings.

RISK FACTORS FOR DEPRESSION

Other risk factors of depression that can be screened in the geriatric patient include poor self-rated health, poor cognitive function, impaired ADLs, 2 or more medical clinic visits in the past month, frequent falls, and a slow walking speed. Passive suicide is also a risk.

Caregivers should be aware of poor nutritional intake, noncompliance with medication, excessive alcohol intake, and taking physical risks because these can be attempts at passive suicide. However, the most common presentation of depression in the elderly involves new medical complaints or an exacerbation of preexisting ones.

The geriatric patient may have a preoccupation with their poor health or physical limitations. The patient may express fatigue, poor concentration, and diminished interest in pleasurable activities. Anxiety, psychomotor retardation, and weight loss in the context of major depression is highly associated with disability.

CONSEQUENCES OF DEPRESSION

The consequences of depression in the geriatric patient are disability, an increased burden on caregivers, poor compliance with medical treatment, increased medical morbidity, higher mortality rates, and higher suicide rates.

In the elderly, depression has been noted to decrease the following: standing balance, walking speed, the ability to rise from a chair, and function in ADLs and IADLs.

Those with depression may have prolonged recovery and overall increased morbidity after surgery. Lower levels of physical performance are strongly predictive of institutionalization; further subsequent disability; and, possibly, death.

Many factors contribute to depression in the geriatric patient. Medical conditions that may lead to depression include malnutrition, Cushing disease, hyperparathyroidism, hypothyroidism, systemic lupus erythematosus, hepatitis, HIV infection, cancer, stroke, Alzheimer disease (AD), Parkinson disease, and Huntington disease.

Arthritis, circulatory problems, speech disorders, or skin problems are related to more significant depression. About 50% of patients with Parkinson disease and 20-25% of patients with stroke have depression, especially those with cortical and lacunar infarcts.

Cerebrovascular lesions in the frontal lobe may promote depression because the frontal lobe integrates sensory, emotional, and neuroendocrine functions that are often impaired in depression.

Medications may also lead to depression include

Ø  Benzodiazepines

Ø  Corticosteroids

Ø  Psycho stimulants

Ø  Cimetidine

Ø  Clonidine

Ø  Digitalis

Ø  Estrogen

Ø  Hydralazine

Ø  Progesterone

Ø  Alpha-methyldopa

Ø  Propoxyphene

Ø  Propranolol

Ø  Reserpine

Ø  Tamoxifen

Depression can also stem from elder abuse because of the dependency of the geriatric patient on a caregiver with poor coping skills. Also, if the caregiver or spouse is depressed, the patient may experience similar depressive symptoms.

In addition, many patients receiving home healthcare are not treated for depression because the medical liaison may not recognize the significance of the patient's depressed mood. In the case of physical decline, the home healthcare worker contacts the primary physician, but the reason for the patient's decline may remain undiscovered.

TREATMENT OF DEPRESSION

Depression is not a normal part of aging. Depression is a treatable source of disability and suffering in the geriatric population.

One of the most effective and important mechanisms to combat depression is to emphasize rehabilitation after illness and injury. Often, older people become depressed as a result of injury or illness, and therefore, they need rehabilitation.

Depression has been shown to be a barrier to rehabilitation, so addressing the illness and injury as well as the depression is important to prevent further debility in the elderly.

The earlier treatment begins, the more effective and the greater the likelihood of preventing serious recurrences. Treatment of depressive symptoms may be one of the most effective interventions to reduce physical decline and to increase the number of years during which older people are free of disability.

Medications, electroconvulsive therapy (ECT), and behavioral psychotherapy have all been successfully used to treat depression in elderly patients.

Medications used for depression include tricyclic antidepressants, SSRIs, monoamine oxidase inhibitors (MAOIs), and atypical antidepressants.

Tricyclic antidepressants and SSRIs may increase the risk of falls and should be used cautiously.

Testosterone may also be a good adjunct in a depressed elderly man with low testosterone levels. Although trials have not proven the effectiveness of St John's wort in the treatment of moderately severe depression, many patients are trying alternative medicine, with anecdotal success.

ECT can be a life-saving intervention for severely depressed and suicidal patients. It is also indicated for those who are resistant to drug therapy and in those who are unable to tolerate antidepressant medications.

ECT also improves depression, tremors, rigidity, and bradykinesia in those with Parkinson disease. The neuropsychologist is imperative in the team treating the depressed geriatric patient.

Behavioral psychotherapy, including cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT), may be effective in treating depression.

CBT helps the patient recognize and change negative thinking patterns that contribute to depression.

IPT focuses on improving relationships with other people, which can reduce depressive symptoms.

Group therapy, which focuses on coping skills, information exchange, and mutual support, is also a positive approach in the depressed elderly patient. This counseling technique can reduce the patient's feelings of hopelessness and despair.

Meeting a patient's physiologic needs for adequate nutrition, regular exercise, and uninterrupted sleep can help decrease his or her depression. Depressed people are often sedentary and have no motivation to increase their physical activity.

Exercise activates serotonin and norepinephrine, which can lead to a feeling of euphoria and, ultimately, enhanced mental health. Exercise can also increase physical endurance and functioning, which can improve the patient's quality of life.

Light therapy may be an effective treatment for major and minor depression that has a seasonal pattern. The optimal duration for light therapy is 45-60 minutes daily. Longer light exposure is associated with a better outcome.

Music therapy is often used to treat depression in the geriatric population. It can provide motivation to increase physical activity. The patient plays a musical instrument, which can increase his or her ROM and develop muscle strength and endurance.

Music therapy facilitates relaxation, thereby promoting sleep and decreasing pain, depression, and anxiety. It also promotes social awareness and interaction. Pet therapy, gardening, spiritual practices, reentry into the community, participation in social groups, and recreation can also improve the patient's mental health.

CONCLUSION

Because depression is prevalent in the geriatric population after injury or illness, screening patients for depressed mood is essential for early therapeutic intervention.

The management of depression with medication, psychotherapy, exercise, and other adjuncts can improve the patient's compliance with the rehabilitation program and improve his or her functional outcomes.