The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) enumerates a total of nine criteria for the diagnosis of major depressive disorder; two are required and another five of the remaining seven are necessary to make the diagnosis.

Studies summarized in the first section of this article have reported on the presence of four types of depressive disorders in the elderly. These include a major depressive disorder, dysthymic disorder, depressive symptoms associated with medical illness that do not meet the DSM-IV criteria for a major depressive disorder (termed secondary depression), and a mixed depression anxiety syndrome.

Ruegg et al described three presentations of late life depression: masked depression, pseudodementia, and delusional depression. In masked depression, the older patient presents with multiple somatic complaints such as headache, gastrointestinal upset, and fatigue. The presence of depressive symptoms is “masked” or hidden by the patient’s somatic complaints. The term “pseudodementia” describes a clinical presentation of depression that falsely mimics a dementing illness. The older person complains of difficulty concentrating or remembering, and withdraws from his or her environment. Factors facilitating the differentiation between depression and dementia are summarized in Table 2.

The third presentation of depressive disorder in the elderly is delusional depression.- After the age of 60 years, persons with a first episode of depressive illness are more likely to experience delusions. Sixty percent of all older women and 50% of all older men experience delusions. The most frequent delusions are somatic (delusion of cancer) or persecutory (being spied on), or delusions of guilt or sin. Less frequent delusions are delusions of poverty, nihilism (the world does not exist), or jealousy. Medical illnesses with symptoms mimicking a delusional depression include Binswanger’s disease, tumor, stroke, Alzheimer’s disease, and subfrontal white matter lesions. An organic personality disorder due to frontal convexity damage can produce a pseudodepression characterized by withdrawal, absence of motivation, psychomotor retardation, and a discrepancy between verbal and motor behavior. The most effective treatment for the delusion-ally depressed, older patient is electroconvulsive therapy. Electroconvulsive therapy has a significantly better outcome than the use of antidepressant and antipsychotic medications for the treatment of delusionally depressed patients.

Krishnan summarized findings from magnetic resonance imaging studies (MRI) of late-onset depressed patients. Caudate nuclear volume and metabolism were diminished. The lateral ventricles were enlarged due to leukoencephalopathy, and putamen volume was markedly diminished compared with nondepressed controls. The T1 relaxation times of the hippocampus on MRI, an indirect measure of water balance, and possible atrophy, were decreased in late-onset depressed patients compared with controls. These findings document changes in the caudate nuclei and deep frontal white matter that can affect the basal ganglia neural pathway and the limbic neuronal pathway, which are involved in mood regulation. These data suggest an organic basis for affective illness.

Description Of The Us Elderly Population

In Germany in the 1880s, Otto von Bismark defined age 65 years as the eligible age for starting social welfare benefits. In the 1930s, the US social security legislation defined persons aged 65 years as being of retirement age. When we speak of older people in the United States, we refer to the birth cohorts who are age 65 and older in the year of interest.

The population of older persons in the United States will become increasingly more culturally and racially diverse in the 21st century. The percentage of African-American and Hispanic-American elders will continue to increase. By 2040, these populations of ethnic elders combined will exceed the proportion of European-American persons age 85 and older. The old-old are the fastest growing segment of these ethnic elders. Studies to determine the presentation of psychiatric disorders and the correlation of serum levels of psychoactive medication with psychiatric symptoms among ethnic elders are another focus of needed research.

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