Depression in the Elderly

M H WalkerM H Walker

Prevalence

Controversial w.r.t. younger peopleControversial w.r.t. younger people Instruments for younger people not Instruments for younger people not

appropriateappropriate DSM IV depression has low prevalenceDSM IV depression has low prevalence High prevalence of depressive symptomsHigh prevalence of depressive symptoms Perhaps 10-15% of >65s have significant Perhaps 10-15% of >65s have significant

depressive symptomsdepressive symptoms

Incidence

Biphasic distributionBiphasic distribution

Age

5030

Diagnosis

Instruments for younger people not Instruments for younger people not appropriate – e.g. DSM, HAM-D, appropriate – e.g. DSM, HAM-D, MADRAS – all these have physical MADRAS – all these have physical elements, e.g. weight loss, which are likely elements, e.g. weight loss, which are likely to have a physical cause in the elderlyto have a physical cause in the elderly

Instruments for the Elderly

Geriatric Depression Scale – 30,15 and 4Geriatric Depression Scale – 30,15 and 4 BAS (and BASDEC)BAS (and BASDEC) Research:Research:

CARE (and SHORTCARE)CARE (and SHORTCARE) GMS-AGECATGMS-AGECAT CAMDEXCAMDEX

Geriatric Depression Scale (15) Yesavage et al 1983

Are you basically satisfied with your life?Are you basically satisfied with your life? Have you dropped many of your activities and interests?Have you dropped many of your activities and interests? Do you feel that your life is empty?Do you feel that your life is empty? Do you often get bored?Do you often get bored? Are you in good spirits most of the time?Are you in good spirits most of the time? Are you afraid that something bad is going to happen to you?Are you afraid that something bad is going to happen to you? Do you feel happy most of the time?Do you feel happy most of the time? Do you often feel helpless?Do you often feel helpless? Do you prefer to stay at home rather than going out and doing new things?Do you prefer to stay at home rather than going out and doing new things? Do you feel you have more problems with memory than most?Do you feel you have more problems with memory than most? Do you think it is wonderful to be alive now?Do you think it is wonderful to be alive now? Do you feel pretty worthless the way you are now?Do you feel pretty worthless the way you are now? Do you feel full of energy?Do you feel full of energy? Do you feel that your situation is hopeless?Do you feel that your situation is hopeless? Do you think that most people are better off than you?Do you think that most people are better off than you?

Institutions

Prevalence high in hospitalPrevalence high in hospital Prevalence about 50% in residential homes Prevalence about 50% in residential homes

using the BASusing the BAS Prevalence not higher than the community Prevalence not higher than the community

in sheltered accommodation (Walker et al in sheltered accommodation (Walker et al 1998 – actually non-significantly lower)1998 – actually non-significantly lower)

The Vascular Connection

Depression known to be common after Depression known to be common after strokestroke

High proportion (up to 100% - Coffey et al High proportion (up to 100% - Coffey et al 1989) of people with first ever depressive 1989) of people with first ever depressive episode > 60 y.o. have hyperintensities on episode > 60 y.o. have hyperintensities on MRI scanMRI scan

Concept of “vascular depression”Concept of “vascular depression”

Prognosis

Traditionally poorTraditionally poor Unfortunately this appears to be true Unfortunately this appears to be true Vascular changes may underlie thisVascular changes may underlie this BUT many people respond to treatment and a recent BUT many people respond to treatment and a recent

meta-analysis suggests there is no worse response to meta-analysis suggests there is no worse response to modern antedepressants at older ages (Entsuah et al modern antedepressants at older ages (Entsuah et al 2001)2001)

Higher rate of dementia – esp. if first episode >65 Higher rate of dementia – esp. if first episode >65 y.o.y.o.

BUT many do not develop dementiaBUT many do not develop dementia

Disease and Disability

Physical illness and disability are the Physical illness and disability are the strongest associations with depression in the strongest associations with depression in the elderlyelderly

Illness and disability are also the strongest Illness and disability are also the strongest (-ve) prognostic factors (Murphy 1983)(-ve) prognostic factors (Murphy 1983)

High prevalence of depression in the High prevalence of depression in the general hospitalgeneral hospital

Suicide and the elderly

Suicide is more common in the elderly (esp. Suicide is more common in the elderly (esp. men)men)

Parasuicide (suicide attempt) is less Parasuicide (suicide attempt) is less common in the elderlycommon in the elderly

Elderly suicides often go unreported and/or Elderly suicides often go unreported and/or unrecognisedunrecognised

There has usually been evidence of There has usually been evidence of depressiondepression

Treatment - principles

The elderly may have co-existing medical The elderly may have co-existing medical conditionsconditions

The elderly are likely to be taking other The elderly are likely to be taking other medicationmedication

Prolonged untreated depression in the Prolonged untreated depression in the elderly may have adverse physical effectselderly may have adverse physical effects

Treatment - practice

Tricyclic drugs have many adverse effects which Tricyclic drugs have many adverse effects which are a particular problem for the elderly – e.g. are a particular problem for the elderly – e.g. confusion, postural hypotension, urinary retention, confusion, postural hypotension, urinary retention, cardiaccardiac

Minimize the potential for interactionMinimize the potential for interaction Beware of hyponatraemiaBeware of hyponatraemia ECT can provide rapid relief, but generally ECT can provide rapid relief, but generally

another form of treatment will be required for another form of treatment will be required for maintenancemaintenance

Psychotherapy

Traditionally not suitable for the elderlyTraditionally not suitable for the elderly This is now being challengedThis is now being challenged CBT well-established for the elderlyCBT well-established for the elderly Outcome remains worse than in younger Outcome remains worse than in younger

people (on average) – but prognosis is people (on average) – but prognosis is worse in generalworse in general