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ASSESSMENT OF DEPRESSION IN THE ELDERLY. Alina Rais, M.D. Associate Professor of Psychiatry Medical Director Geriatric Psychiatry Center University of Toledo Department of Psychiatry. Demographic of Aging. 1900 – Only 4% were 65 and older 2000 – Increased by 13% in elderly population

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Alina Rais, M.D.

Associate Professor of Psychiatry

Medical Director

Geriatric Psychiatry Center

University of Toledo

Department of Psychiatry

demographic of aging
Demographic of Aging
  • 1900 – Only 4% were 65 and older
  • 2000 – Increased by 13% in elderly population
  • 2050 – Projected increase of 22% in elderly population
mental health in the elderly
Mental Health in the Elderly
  • Elderly people have greater risk of mental illness
  • 15-25% of elderly in the USA suffer from symptoms of mental illness
  • Age 65 and older – highest suicide risk
mental health in the elderly5
  • Only 41% of the patients in community mental health are elderly
  • Only 2% seen in hospital and private setting
  • Only 1.5% of the direct costs for treating mental health are allocated for the elderly
One of the most common mental illnesses in the elderly is Depression Syndrome which includes the following symptoms:




the nih consensus
The NIH Consensus


  • Affects 6 million people or 1 in 6
  • Is not a normal fact of aging
  • Is associated with functional disability and suicide
  • Can alter the course of a general medical condition
the nih consensus cont
The NIH Consensus (Cont.)


  • Increases morbidity and mortality
  • It is a recurrent illness
  • Occurs more frequently in nursing homes
suicide in the elderly
Suicide in the Elderly
  • Elderly suicide up by 9% in the last decade
  • White males over 65 account for 81% of all suicides
profile for highest suicide risk
Profile for Highest Suicide Risk
  • White male over 60
  • Divorced/single/widow
  • Poor social support
  • Unemployed
  • Medical problems
  • History of alcohol abuse
  • High school education
  • Access to guns

Depression: Underrecognized and

Undertreated in the Elderly

Patients Percent (%)

ECT=electroconvulsive therapy

Maddux RE, Delrhim KK, Rapaport MH. CNS Spectr. Vol 8, No 12 (Suppl 3), 2003.


Health Services Utilization in Depressed

Elderly Patients

Number Over 1 Year

*P,.001 after controlling for comorbidity, type of insurance, and the use of antidepressants


N=3,481 primary care patients >65 years of age

Adapted from: Luber MP, Meyers BS, Williams-Russo PG, et al Depression and service utlization in elderly primary care patients. Am J Geriatr Psychiatry 2001:2:169-176

Maddux RE, Delrahim KK, Rapaport MH. CNS Spectr. Vol 8, No 12 (Suppl 3). 2003.


Rates of Completed Suicide

Number of Suicides

In the United States, 1994

Per 100,000

Adapted from: Hirschfeld RM, Russell JM. Assessment and treatment of suicidal patients. N Engl J Med. 1997;13:910-913.

prevalence of late life depression
Prevalence of Late Life Depression
  • Elderly women are at increased risk
  • Twice as many in women compared to men of same age
  • Might be a subsyndromal presentation like dysthymia, dysphoria
  • DSM IV – not age sensitive
  • 6%-9% of patients in primary setting
  • 17%-37% diagnosed with minor depression
  • 10-15% of patients in acute care
  • 30%-45% of patients in nursing homes
  • 13% of residents in nursing homes who experience first episode of depression
other consequences of depression psychiatric
Other Consequences of Depression-Psychiatric
  • Increased use of alcohol and sedatives
  • Reduced cognitive function
    • Depressive “Pseudodementia”
    • Excess disability in Alzheimer’s disease and stroke
  • Elevated nonsuicidal mortality
    • In nursing homes – increased 59%
    • In MI patients-hazard ratio 5.74
    • In stroke, COPD




risk factors in development of late life depression biopsychosocial illness model
Risk Factors in Development of Late Life Depression(Biopsychosocial Illness Model)
  • Biological Risk Factors

- Female > male

- Changes in neurotransmitter activity

- Dysregulation of the HPA (hypothalamic,

pituitary axis)

- Dysregulation of thyroid function

- Decreased secretion of growth hormone

risk factors in development of late life depression biopsychosocial illness model cont
Risk Factors in Development of Late Life Depression(Biopsychosocial Illness Model)(Cont.)
  • Desynchronization of circadian rhythms with sleep cycle disturbance
  • Physical aspects of medical illness
  • Polypharmacy
psychological risk factors
Psychological Risk Factors
  • Decreased social support
  • Decreased functionality
  • Placement in a nursing home
  • Life events, i.e. retirement
psychological risk factors cont
Psychological Risk Factors (Cont.)
  • Changes in financial status
  • Bereavement
  • History of mental illness
  • Decreased self-esteem
Diagnosing depression in the elderly could be challenging
  • Elderly population received 20-30% of all prescribed medications
  • Experience decline of cognitive and functional capacity
barriers in diagnosing depression in elderly patients
Barriers in Diagnosing Depression in Elderly Patients
  • Most of this group of patients are seen in primary care settings
  • Despite extensive education, still the family doctors fail to diagnose depression
  • Different syndrome presentations ( not classical symptoms of depression, sad less depression)
  • Stigma
  • Lack of recognition of depressive symptoms by patient and family (seen as part of getting old)
When evaluating the elderly depressed patient, we need to:
    • Identify any prior psychiatric illness
    • Identify comorbid illnesses
    • Baseline medical history
    • Overall cognitive capacity
    • Identify current stressors
    • Evaluate medication that might contribute to depression
    • Receive objective information from family/caregiver
different presentation of depression
Different Presentation of Depression
  • Classic form of major depressive disorder that meets the DSM IV-R criteria
  • Mask depression (somatic complaints, anxiety)
  • Subsyndromal presentation (minor symptoms, dysthymia)
  • Depression due to medical condition
  • Vascular depression
  • MDD
    • Criteria for Depression DSM IV-TR
      • 2 week period with 5 or more of the following with 1 being either depressed mood or loss of interest/pleasure
        • Depressed mood most of the day/every day (subjective or objective)
        • Diminished interest/pleasure – anhedonia
        • Weight loss or gain >5% in a month or change in appetite
        • Insomnia or hypersomnia nearly every day
        • Psychomotor retardation or agitation (objective)
        • Loss of energy nearly every day
        • Worthlessness or guilt nearly every day
        • Decreased concentration
        • Suicidality/passive death wish
      • Symptoms cause clinically significant distress or impairment
      • Symptoms are not better accounted for by another psych illness
      • Symptoms are not due to the direct physiological effects of a substance or GMC
minor depression
Minor Depression
  • Subsyndromal presentation
  • It is now introduced as a DSM IV category
  • Much more seen in community samples
  • It is considered to represent a spectrum:
    • Prodromal/residual symptoms of MDE
    • Occurs in patients with underlying medical condition and dementing processes
    • The consequences on functional capacity are substantial
proposed diagnostic criteria
Proposed Diagnostic Criteria
  • 1) Presence of low mood and/or loss of interest in all activities most of

the day, nearly every day, and

  • 2) At least two additional symptoms from the DSM checklist:
    • Significant weight loss when not dieting or weight gain (e.g., a change in more than 5% of body weight in 1 month), or decrease or increase in appetite nearly every day
    • Insomnia or hypersomnia nearly every day
    • Psychomotor retardation or agitation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
    • Fatigue or loss of energy nearly every day
    • Feelings of worthlessness or excessive or inappropriate guilt) which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
    • Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
    • Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
proposed diagnostic criteria cont
Proposed Diagnostic Criteria (Cont.)
  • The symptoms cause clinically significant distress or impairment in social and occupational functioning
  • 17 item Hamilton Rating Scale for Depression (Ham-D) score of >10, or Geriatric Depression Scale Score of >12
  • Duration of at least 1 month

Duration subtypes:

a. Duration from 1-6 months

b. Duration from 6-24 months

c. Duration >24 months

proposed diagnostic criteria cont29
Proposed Diagnostic Criteria (Cont.)
  • The symptoms may be associated with precipitaing events (e.g., loss of significant other)
  • Organic criteria:

- objective evidence from physical and neurological examination and laboratory tests; and/or history of cerebral disease, damage, or dysfunction, or of systemic physical disorder known to cause cerebral dysfunction; including hormonal disturbances and drug effects

- a presumed relationship between the development or exacerbation of the underlying disease and clinically significant depression

- the disturbance occurs exclusively to the direct psychological effect of alcohol or a substance use

- recovery or significant improvement of the depressive symptoms following removal or improvement of the underlying presumed cause

proposed diagnostic criteria cont30
Proposed Diagnostic Criteria (Cont.)

8) Exclusion criteria:

There has never been:

an episode or mania or hypomania;

a chronic psychotic disorder, such as schizophrenia or delusional disorders. Previous history of major depressive episode is not an exclusion criterion.

depression and medical illness
Depression and Medical Illness
  • Medical illness greatly increases riskf or depression
  • Risk to particularly high in
    • Ischemic heart disease (e.g., MI, CABG)
    • Stroke
    • Cancer
    • Chronic lung disease
    • Arthritis
    • Alzheimer’s disease
    • Parkinson’s disease
  • Mechanisms of depression vary
  • Medical Illness may confuse the diagnosis of depression in medical patients
depression due to medical condition
Depression Due to Medical Condition
  • Older age of onset
  • Organic features on MSE
  • Lower incidence of family hx of depression
  • Less likely to have SI/HI
  • More likely to improve at discharge
  • Higher morbidity and mortality in CAD, MI and CVA
  • Atypical presentation
medications associated with depression and anxiety
Medications Associated With Depression and Anxiety

Maddux RE, Delrahim KK, Ra[a[prt <J/ CMS S[ectr/ V

Maddux RE, De;rajo, LL. Ra[a[prt <J. CMS S[pectr/ Vp; 8, No 12 (Suppl 3). 2003.

drugs linked to depression anxiety
Drugs Linked to Depression/Anxiety
  • Beta-blockers
  • Other antihypertensives
  • Reserpine
  • Digoxia
  • L-Dopa
  • Steroids
  • Benzodiazepines
  • Phenobarbital
  • Neuroleptics
masked depression
“Masked” Depression
  • Terminal insomnia, often with ruminations
  • Decreased appetite and weight loss
  • Extreme fatigue vs. anxiousness, restlessness
  • Increased, frequently delusional, preoccupation with bodily functions, pain and weakness
  • Expression of fears and anxiety without reason
  • Low self-esteem or self-concept
  • Increased isolation, loss of interest and pleasure
  • Hopelessness, suicidal ideation
    • All in context of “not feeling well physically”
    • Depression is felt to be “secondary”
clues to depression in primary care
Clues to Depression in Primary Care
  • Help-seeking, persistent complaints

Pain GI Symptoms

Arthritis Multiple diffuse symptoms

Weight Loss Headache


  • Frequent calls and visits
  • High utilization of services
  • Treatment refusal, non-compliance
additional clues in nursing home
Additional Clues in Nursing Home
  • Apathy, withdrawal, isolation
  • Failure to thrive
  • Agitation
  • Delayed rehabilitation
additional clues in hospitalized patients
Additional Clues in Hospitalized Patients
  • CABG, hip fracture, MI, stroke, arthritis
  • Delayed recovery
  • Treatment refusal
  • Discharge problem
chronic pain and depression
Chronic Pain and Depression
  • Study of more than 1000 patients found depression in 1% of patients with one or no pain complaints
  • 12% in patients with 3 or more such complaints
depression and neurodegenerative brain disease
Depression and Neurodegenerative Brain Disease
  • Alzheimer’s Dementia
  • Vascular Dementia/Cerebrovascular Disease
    • Apathy
    • Nondysphoric Depression
  • Parkinson’s Disease
vascular depression
Vascular Depression

Cerebrovascular disease can:

- predispose

- precipitate

- perpetuate

- a depressive syndrome

risk factors of vascular depression
Risk Factors of Vascular Depression
  • Male gender
  • Older age
  • Diabetes Mellitus
  • Smoking
risk factors of vascular depression cont
Risk Factors of Vascular Depression (Cont.)
  • Atrial fibrillation
  • Left Ventricular Hypertrophy
  • Higher systolic blood pressure
  • Angina Pectoris
  • Congestive Heart Failure
cerebrovascular evidence in late life depression
Cerebrovascular Evidence in Late Life Depression
  • Genetic and early life stressors less important
  • Diffuse brain dysfunction
  • Cortical atrophy
  • Diffuse hypometabolism
cerebrovascular evidence in late life depression cont
Cerebrovascular Evidence in Late Life Depression (Cont.)
  • Deep white and gray matter hyperintensities on MRI
  • Small vessel disease postmortem
  • Relation between stroke and depression
localization of brain disease in depression
Localization of Brain Diseasein Depression
  • Hyperintensities in:

- left hemisphere deep white matter

- left putamen

localization of brain disease in depression cont
Localization of Brain Disease in Depression (Cont.)
  • Lesions of:
  • - caudate
  • - frontal lobe
  • - basal ganglia
brain function evidence
Brain Function Evidence
  • Hypoactivity of the caudate and frontal regions including

- dorsolateral frontal region

- inferior orbitofrontal region

- medial anterior cingulate

summary of vascular mechanisms of late life depression
Summary of Vascular Mechanisms of Late-Life Depression
  • Small lesions disrupt critical pathways:

- frontostriatal, circuitry and limbic

hippocampal connections

- damage of the catecholamine neurons by

white matter lesions in the pons

- Disruption of the orbital frontal cortex control

over the serotonergic raphe nuclei

symptoms and presentation
Symptoms and Presentation
  • Increased psychomotor retardation
  • More prominent cognitive impairment
  • Poor performance on neuropsychological tests
symptoms and presentation cont
Symptoms and Presentation (Cont.)
  • Less agitation and guilt
  • Increased disability
  • Older age of onset
  • Executive dysfunction and apathy
two major behavioral symptoms in late life
Two Major Behavioral Symptoms in Late-Life

- Apathy

- Executive Function


A state of reduced motivation.

types of apathy
Types of Apathy
  • Motor apathy

- Tendency not to initiate motor activity

  • Motivational apathy

- Absence of motivation to initiate new activities

  • Emotional apathy

- Absence or reduction of emotional interest

  • Cognitive apathy

- Absence of generative ideation

conditions associated with syndrome of apathy
Conditions Associated with Syndrome of Apathy
  • Alzheimer’s Disease
  • Vascular Disease
  • Brain Damage
  • Partially treated depression
  • Psychotic depression
  • Schizophrenia
  • Drug-induced (neuroleptics, SSRI’s, marijuana, amphetamine or cocaine withdrawal)
  • Other: apathetic hyperthyroidism, lyme dz, chronic fatigue, testosterone deficiency, sleep apnea, etc.
executive dysfunction
Executive Dysfunction
  • Decreased:
  • attention
  • initiation
  • organization
  • planning
  • abstract thinking
screening for depression
Screening for Depression
  • Evidence-based literature is somewhat sparse and at times conflicting
  • Majority of physicians would rely on individual judgment when assessing depression in the elderly
overview of currently used depression scales in geriatric patients
Overview of Currently Used Depression Scales in Geriatric Patients
  • When using screening instruments in elderly patients it is important to consider the cognitive level
    • Visual auditory deficits
    • Function level
  • The validity of certain depression screening instruments is significantly decreased in patients with MMSE lower or equal to 15
geriatric depression scale gds
Geriatric Depression Scale (GDS)
  • 30 questions that indicate presence of depression
  • Yes/No format
  • Might be more appropriate for elderly patients
  • Sensitivity 92%
  • Specificity 89%
  • Valid measure of depression in elderly patients
  • Validity decreases in nursing home patients and appears to be dependent on the degree of cognitive impairment
  • Can be used in inpatient and outpatient
  • Very reliable for phone screening
  • Available for minorities
depression scale for people with dementia cornell scale for depression in dementia or csdd
Depression Scale for People with Dementia (Cornell Scale for Depression in Dementia or CSDD)
  • Best validated scale for patients with dementia
  • Use information from both patients and outside informant
  • Better validated for patients with mild and moderate dementia than with severe form
  • Could depict depression in patients with Alzheimer's.
montgomery asperg depression rating scale madrs
Montgomery/Asperg Depression Rating Scale (MADRS)
  • Observer rated assessment
  • Based on clinical interview
  • Does not assess somatic symptoms that are important in geriatric population
  • Not very well validated in geriatric patients
zung self rating depression scale
Zung Self-Rating Depression Scale
  • Self assessment scale
  • Uses graded answers (never, sometimes, always, usually which might be problematic for geriatric patients)
  • High false positive results in normal elderly
  • High false negative results if patients has somantic problems62
beck depression inventory bdi
Beck Depression Inventory (BDI)
  • Developed by Beck, Steer & Brown
  • Assesses the intensity of depressive symptoms
  • 5-10 minutes to administer
  • Highly reliable regardless of the population tested
  • Available in Spanish
hamilton rating scale for depression
Hamilton Rating Scale for Depression
  • Goal standard of observer-rated depression scale
  • Requires training to complete
  • Takes 20-25 minutes to administer
  • Valid for all ages
  • Can be used in both clinical and research
  • Assesses the severity of depression

Screening Measures for Depression in Children,

Adolescents, Adults, and the Elderly

Measure Spanish VersionNo of Items Time to CompletePsychometric properties/cutoff


Medications Useful in Treating Depression

Medication Doses Ranger Uses Precautions

psychosocial interventions for depression
Psychosocial Interventions for Depression
  • Social support to reduce isolation; referral to senior centers, home care, and visiting nurse services; pet therapy and visitation; volunteer jobs as indicated
  • Psychotherapy: supportive psychotherapy, cognitive-behavioral therapy, interpersonal therapy, group therapy
  • Family counseling
  • Substance abuse interventions as indicated
  • Bereavement counseling and services as needed
  • Health promotion and maintenance: good nutrition, light physical exercise, attention to chronic medical conditions, establish a regular daily routine
  • When diagnosing depression in geriatric patients, there are 5 essential objectives:
    • Determine etiology and diagnosis
    • Provide disease specific management
    • Manage behaviors and target symptoms (symptoms that are the most distressing)
    • Prevent secondary complications (side effects of medication)
    • Rule out dementing process/medical illness
    • Support the families