Treatment of depressive disorders may involve psychopharmacology, psychotherapy, or both. Studies have shown that for mild depression, psychotherapy was more effective than placebo. For major depressive disorder (illness), psychopharmacologic treatment was more effective than psychotherapy alone. The most effective treatment with better long-term outcomes has been achieved with psychopharmacologic treatment combined with psychotherapy.

Treatment of a depressive disorder must begin with a comprehensive evaluation of the older person to rule out associated medical or physical conditions that may present as depressive illness or complicate the treatment of depression. A minimum evaluation of the older depressed patient should include a careful physical examination and laboratory studies including a complete blood cell count with differential; electrolyte determination; glucose, blood urea nitrogen, calcium, phosphorous, total protein, and serum albumin levels; liver function tests; and thyroid function tests. An electrocardiogram should be obtained. Current medications, (prescribed, over-the-counter medications, and those medications borrowed from neighbors and friends) should be reviewed.

Psychopharmacologic Treatment

The psychopharmacologic treatment of depressive disorders has advanced. Pharmacologic options now include cyclic antidepressants, monamine oxidase inhibitors, and the newer serotonin reuptake-inhibiting antidepressants. The selection of a specific antidepressant is determined by the older person’s symptoms and the side effect profile of the medication. The presence or absence of sleep problems, significant complaints of decreased energy, and the presence of cognitive difficulties are important considerations in the selection of specific medications.

Additional considerations in the treatment of depression are the presence of associated medical illnesses and medications prescribed for their treatment. The choice of an antidepressant medication in this case will be based on both the side effect profile of the antidepressant and the avoidance of potential drug-drug interactions. Because of the physiologic changes of aging (decreased renal blood flow, decrease in total body water, decrease in total lean body mass, decrease in microsomal enzyme activity, and an increase in total body fat), the doses of antidepressants used in the elderly are usually one third to one half the dose prescribed in younger patients.

The approach to the titration of an antidepressant is based on the caveat of starting with a lower dose and slowly increasing it, monitoring the older person for therapeutic response, and side effects. This approach has been summarized as “starting low and going slow(ly).” In some cases, older patients will require antidepressant doses similar to persons in their 30s and 40s. Obtaining blood levels of antidepressants in nonresponding elderly, depressed patients can be helpful in determining whether to increase the prescribed antidepressant or to move to the addition of lithium carbonate to augment the antidepressant effect of the initial medication. Unless the older person has had a history of successful treatment with a monoamine oxidase inhibitor in the past, monoamine oxidase inhibitors are not the first treatment of choice. As noted earlier, electroconvulsive therapy is the treatment of choice for the delusionally depressed older patient and the cachectic, profoundly withdrawn or actively suicidal elderly patient. Although a large body of literature exists on depressive illness, further studies on the efficacy of psychopharmacologic treatment of depression, particularly in the frail, US, ethnic, minority elderly are indicated.

Psychotherapeutic Treatment

Psychological development continues throughout the life cycle. Chronological age may or may not be comparable to the person’s development age. The physician and poet, William Carlos Williams, described the older patient’s mobilization to “reach for what can be added in later life.” Gould stated that elders in contact with their inner core presented with the inevitable hazards of late life faced these developmental stressors with greater strength and were able to bounce back. Their sense of meaning resided within them and was not an external sense of meaning based on power and status. The maintenance of self-esteem may be adaptively accomplished by the elder. The psychosocial perspective of self-esteem noted that several strategies were used by older persons to defend against the erosion of their self-esteem (Table 4).

The psychotherapeutic treatment of depressive illness in the elderly should be based on the biopsychosocial model conceptualized by Engle. The therapist needs to be sensitive to the intrapsychic processes of the older person and facilitate the patient’s recognition and understanding of these psychological processes. The biological sphere has an increased effect due to the physiologic changes of aging and the associated development of physical illnesses. Clarification of the social network and social supports of the older patient as well as the various social interactions of the patient will enable the therapist to assess the extent to which the older patient is at risk to feelings of isolation or alienation. The redefinition of meaningful activity and the establishment of new goals in the context of retirement from work is an important psychological task. A successful redefinition of roles will establish new directions and goals for the older, retired individual.

Niederehe noted that psychotherapeutic intervention in the elderly was more likely to be based on psychodynamic and socioenvironmental principles. As late-life depression has been associated often with risk factors such as stressful life events, family conflict, and the absence of social resources (family support and relations with confidants), these factors partially influence the specific therapeutic intervention selected. Niederehe also noted that the significant clinical literature that existed on the value of various psychosocial treatments in the elderly were predominantly theoretical articles, description of techniques, and reports of individual treatment cases. He found few articles that met acceptable methodological standards for psychotherapy outcome research and encouraged further work in this area.

Recently published practice guidelines for major depressive disorder in adults by the American Psychiatric Association suggest specific criteria for US psychiatrists and other mental health professionals to use in the selection of a behavioral, psychodynamic, or group psychotherapy approach to the psychotherapeutic treatment of depression. Because of the potential for relapse, the continuation of antidepressant medication beyond a 9-month period of treatment will need to be discussed with the patient in the context of his or her prior history of depressive illness and response to treatment. It is recommended that the full therapeutic dose of medication that produced a therapeutic response should be continued for a minimum of 16 to 20 weeks after remission of symptoms has been achieved.

Although controversial in the US, electroconvulsive therapy is the most effective treatment for major depressive disorder. In 50% of patients nonresponsive to anti-depressants, electroconvulsive therapy has produced a satisfactory response.

Conclusion

This article reviewed the epidemiologic data on the prevalence of major depressive disorders in community resident elderly and compared international prevalence rates of depressive symptoms (4.4% to 12.6%). The prevalence rate for major depressive disorder among US residents aged 55 years and older was reported to range from 0.81 % to 1.9% among community residents and from 12% to 42% among the medically ill elderly.

Specific factors associated with a report of depressive symptoms were identified from the literature: poor physical health due to medical illness; physical disability; single marital status due to being widowed, divorced, or separated; a restricted support networks resulting in social isolation; bereavement; poverty; and education ≤4 years.

The importance of recognizing alternative presentations of depressive disorder in the elderly was emphasized. Three presentations of late-life depression were described: masked depression, pseudodementia, and delusional depression. Four types of depressive illness in the older US residents were reported by the literature: major depressive disorder, dysthymia, depressive symptoms secondary to medical illness that did not met DSM-IV criteria for a depressive disorder, and a mixed depression anxiety syndrome.

Specific concerns for the treatment of depressive disorder with psychopharmacology and psychotherapy were discussed. Antidepressant medications were needed to facilitate the biochemical readjustment of neurotransmitter levels. Psychotherapy facilitated the reactivation of prior effective, psychological coping capacities, and reworked the destructive thought patterns associated with major depressive disorder for a patient with an uncomplicated major depression. The importance of considering the social network and social roles of the elder person was emphasized. The importance of continuing an antidepressant at the full therapeutic dose for a minimum of 16 to 20 weeks after remission of symptoms was emphasized. Finally, the effective role of electroconvulsive therapy in the treatment of late-life depressive disorders was described.

Depressive disorder untreated can last 7 to 14 months and longer than 2 years. In the elderly, a pathological grieving process that has progressed to an episode of depressive illness may last 5 years or longer. Studies of the outcome of depressive episodes among psychiatric patients have shown rates of relapse that ranged from 5% to 52%. Some 15% to 67% of patients with depressive disorder with >2 years of follow-up were found across 12 studies to have continued symptoms and a chronic course.

Suicide

It is important to emphasize that in the US population, suicide rates are high among adolescents and higher among the elderly. Rates of completed suicide increase for white men throughout the life cycle and peak between ages 80 to 90. Rates of completed suicide by white women peak at ages 50 to 59. The divorced, white man who views his life accomplishments negatively and uses alcohol to medicate his dysphoric symptoms is the elder who completes a suicide—more usually with a firearm.

Among ethnic elders, the rates of completed suicide among Chinese-American men and Japanese-American men age 85 and older exceed the rates of white men by 20% and 60%, respectively (Table 3). The single, poor Asian male who was unable to establish a family or to bring his family to the United States because of the Asian Exclusion laws and who has isolated himself from mainstream American culture is at high risk to complete a suicide.

The ratio of suicide attempts to completed suicide in younger age US cohorts is estimated at 20:1. The ratio of suicide attempts to completed suicides in the US elderly is estimated at 4:1. Clues to suicidal ideation among the elderly include statements such as “You’d be better off without me,” behaviors of giving away prized possessions, and indefinite plans for the future. Specific questions should be asked to elicit the presence of suicidal ideation and the presence of a plan for a suicidal act. Such a direct approach will enable the older person to reveal the extent of his or her despair. Because thoughts of suicide usually are associated with fantasies of rescue, the elder may view the therapist positively and anticipate help in avoiding acting on his or her suicidal thoughts. We must remember that the elderly, while representing only 13% of the US population, complete 39% of the deaths by suicide that occur in the United States each year.

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.

Major depressive disorder occurs throughout the life cycle. Longitudinal data suggest a changing pattern in the age of onset in the United States. In more recent birth cohorts, the rates of major depression were higher and the age of onset was younger. The lifetime prevalence rates for major depression per 100 population were determined in five US cities by the Epidemiologic Catchment Area Survey (ECA). The rates varied from a low of 2.9% in Baltimore to a high of 5.8% in New Haven. The mean lifetime prevalence rate in adults ages 18 and older for depression was reported as 4.4%. Weissman and Klerman reported data from international studies that found higher lifetime prevalence rates of depression in two nations: Canada (8.6%) and New Zealand (12.6%). Lower rates were observed in urban cities in Taiwan (0.9%) as well as in rural areas in Korea (1.0%). The lifetime prevalence rate of depression in Seoul, Korea was 3.4%. The rate of depression in Puerto Rico was established as 4.6%, a rate similar to the US mainland. Risk factors associated with major depressive disorder included female gender (rates in women were two to three times those of men), a positive family history of depression, urban residence, and a history of divorce and separation. These data are reported for international community surveys of mixed age populations.

The identification of major depressive disorder in the elderly is a complex task. Because of the number of medical illnesses and the number of prescribed medications being taken, the older person may experience changes in neurovegetative signs and changes in mood as the result of their illness and medications. Affective disorders (depression and dysphoria) may present in the elderly with cognitive impairment or somatic complaints, termed “masked depression.”

In a 1972 study of a stratified random sample of Durham County, North Carolina residents aged 65 and older, 14.7% were identified by the older American Resources and Services (OARS) Depression Scale as having substantial depressive symptoms. Thirty-three percent of this sample was black. Dysphoric symptoms were found in 4.5% of these community resident elderly. Some 3.7% had symptoms of major depression, but did not meet the full criteria for a diagnosis of depression. Only 1.8% met criteria for a diagnosis of major depression, and 1.9% had a secondary depressive disorder. Community residents with secondary depressive disorder who met the criteria for a diagnosis of depression had significant dysphoric symptoms and had evidence of cognitive dysfunction or a thought disorder. Only 1% of these older, depressed community residents was receiving therapy from a trained counselor. Factors associated with depression in this sample included being white and widowed, having impairment in social economic resources, having a history of alcohol abuse more often than nondepressed community residents, and having a greater tendency to use pain medications. Of the 14.7% of the sample with depressive symptoms, 44% had impaired physical health.

In a later survey of community residents age 55 and older completed in Kentucky in 1981, the Center for Epidemiologic Studies Depression Scale (CES-D) was used to screen the sample for the presence of depressive symptoms. Using a cutpoint of 29 (rather than the usual cutpoint of 16), 13.7% of men and 18.2% of women were identified as having symptoms of depression. Factors associated with symptoms of depression included older age, education of ≤4 years, income <$4000 per year, housing with ≤two rooms, being widowed, separated, or divorced, and poor health. The strongest association with depression in this sample was physical health. This finding was consistent with data from two prior studies.

These associations were confirmed by an analysis of the ECA sample of community residents aged 60 and older from Piedmont, North Carolina; 19% were diagnosed as having mild dysphoria, 4% had symptomatic depression, 2% had dysthymia, and 1.2% had a mixed depressive anxiety syndrome. Only 0.8% of this sample of older community residents had a diagnosis of major depression. The elderly with symptomatic depression reported poor physical health (3%), the loss of a loved one (25%), reported social phobias, and having experienced social isolation. Community residents with major depression and dysthymia were more likely to report poor physical health, subjective memory problems, subjective negative events, and difficulty with their support networks. The association of illness, disability, isolation, bereavement, and poverty with depression was confirmed by a study of Medicare recipients who resided in the Bronx, New York. Thus, epidemiologic studies of community resident elders in several US cities found a prevalence rate of major depression ranging from 0.8% to 1.8% and a rate for dysthymic disorder of 2%.

The rates of depressive symptoms among medically ill patients has been found to be higher. Stewart et al found 12% of severely medically ill inpatients had depressive illness. In 1967, Schwab et al studied a sample of hospitalized, medically ill patients. Using a clinic interview, depression screening instruments, and the medical record in order to determine the diagnosis, 22% of this sample was found to be depressed. Using the Zung Self-Rating Depression Scale, 42% of the sample of randomly selected outpatients was identified as depressed by clinical examination with only 30% screening positive for depression. Rates of depression among veterans ranged from 13% to 38%.

These data demonstrate that the rate of major depressive disorder is higher among medically ill patients, ranging from 12% to 42%, compared with the rates for various samples of community resident elderly (Table 1). The rate of major depression among medical patients is usually reported as 26%. The association between poor physical health, poverty, impaired support network, bereavement, ≤4 years of education, and an increased report of depressive symptoms and depressive disorders is important in the assessment of the older patient.

Risk from SSRIs highest in those over 80, says study

The latest generation of antidepressants may have a nasty side effect in older patients, says a new Canadian study.

Selective serotonin reuptake inhibitors, or SSRIs, a class of antidepressants that includes Prozac and Paxil, increase the risk of upper gastrointestinal (GI) bleeding in elderly patients, according to research.

Lead author Dr. Carl van Walraven, an assistant professor of medicine at the Ottawa Health Research Institute in Ontario, says that the risk appears to be greatest in those over the age of 80. He suggests that doctors should keep this risk in mind when prescribing antidepressants to older patients.

But another expert says that there’s little clinical evidence that links SSRIs to gastrointestinal bleeding.

Blood cells called platelets play a critical role in stopping bleeding by clumping together to form a clot. In order to stop bleeding, platelets absorb serotonin from the blood.

“The channel that is used for doing that is blocked by SSRIs,” says van Walraven.

The researchers examined data that kept track of 317,824 patients 65 and older in Ontario who received a prescription for an antidepressant between 1992 and 1998. The patients were followed until they stopped taking the drug, experienced an upper gastrointestinal tract bleed or died, or until the study ended.

The overall rate of GI bleeding among all the study participants was 7.3 per 1,000 people followed for one year. Among the entire group studied, the use of SSRIs didn’t significantly increase the risk of GI bleeding.

But when the researchers broke the group down into categories by age groups, they found that the risk for patients in their 80s taking SSRIs increased to 12.3 per 1,000.

The data available for this study, from a Canadian provincial drug benefits database for seniors, was limited to patients age 65 and older. Potentially, says van Walraven, the same effect could exist in younger patients, but based on how the rate of GI bleeding dropped along with age, the effect would be insignificant.

“If we studied people less than 65, we would expect the bleeding rates to be much, much lower,” he says.

“The most important aspect of these data is that for particular subgroups, the risk of gastrointestinal bleeding should be considered when prescribing pharmacotherapy for depression,” says van Walraven. “Those specific subgroups would be: very old, i.e., those greater than 80, and those with previous gastrointestinal bleeding… We believe that in those groups alone … the bleeding rates between traditional antidepressants like [tricyclic antidepressants] and the newer antidepressants are clinically significant,” he says.

And moderating the dose of SSRIs probably won’t work, he adds. “The dosage that is required for effectiveness as far as the depression is concerned is probably going to still affect the platelets as well,” speculates van Walraven.

But Dr. Andrew Farah, who lectures on SSRIs and is familiar with the study, says that he’s never seen an increased rate of GI bleeding among his patients on SSRIs.

Farah, the medical director at High Point Regional Behavioral Health in High Point, N.C., suspects that patients are more likely to develop upper GI bleeding from other medications.

“The reality is that the population that’s over 65, a high percentage of them are going to have arthritis, so … [what] they’re going to be exposed to is [a] non-steroidal anti-inflammatory drug [NSAID],” Farah says. And NSAID is “the No. 1 cause of a GI bleed,” he adds.

“Also, anybody with arthritis tends to be at higher risk of depression. Chronic pain itself is a risk factor for depression,” he adds. “So it’s not uncommon that they would be given one of the newer antidepressants along with the arthritis medication.”

However, van Walraven said that they found no evidence of drug interactions between SSRIs and NSAIDs.

But he cautions, “People who are taking SSRIs shouldn’t immediately stop taking those drugs just because of the study.”

He adds that although people should be aware of this potential side effect, it applies to only a small subgroup. “If they think that it might affect them, they should discuss it with their physician,” he says.

What To Do

The prescribing information for Indianapolis-based Eli Lilly & Company’s Prozac and Philadelphia’s SmithKline Beecham Pharmaceuticals’s Paxil, two of the better-known SSRIs, mentions rare reports of impaired platelet function. However, there is no clear laboratory evidence that either drug is directly responsible for the effect.

General Principles of Pharmacologic Intervention

A thorough history, physical examination, and basic laboratory studies are important to fully evaluate the patient and rule out medical and medication-related causes of insomnia and depression. Additionally, the selection of the appropriate antidepressant medication (selective serotonin reuptake inhibitors, tricyclic antidepressants [TCAs], monoamine oxidase inhibitors, or atypical antidepressants), adequate dosages, and a sufficient trial period are imperative in the treatment of depression in the elderly. In seniors, an adequate antidepressant trial is longer than that for younger adults, with a complete response often seen after six to 12 weeks. Nuances related to medication therapy in the geriatric population should be clearly expressed by pharmacists in recommendations and educational communications. The impact of aging and medical conditions associated with aging on the pharmacokinetic profile of a medication and the increased risk of associated side effects must be understood with regard to geriatric dosage guidelines, disease-drug contraindications (eg, TCAs and cardiac conduction defects), and drug interactions (eg, CYP450 inhibition and possible toxicities).

When sleep medication is deemed the best course of treatment after careful consideration of nonpharmacologic interventions (eg, sleep hygiene, stimulus-control therapy, and sleep-restriction therapy) in the elderly, short-acting nonbenzodiazepine hypnotics (zolpidem or zaleplon) are recommended. These medications reduce both sleep latency, due to their quick absorption and onset, and the risk of daytime sleepiness the following day, due to their short half-life. Caution should be exercised when a longer-acting hypnotic is prescribed in a geriatric patient since associated side effects may be particularly pronounced in seniors. Longer-acting hypnotic agents may be associated with changes in sleep architecture such as a reduction in delta or deep sleep, morning hangover with excessive daytime sleepiness, impaired motor coordination, and visuospatial problems that may contribute to an increased risk of injury. In an attempt to prevent rebound insomnia, a very gradual taper is recommended when termination of treatment is warranted.

Conclusion

When caring for older patients, it is important to make the distinction between pathological changes and normal aging. Remaining cognizant of this helps to avoid not only dismissing a treatable pathology as merely an accompaniment to old age but also treating a natural aging process as a disease while overlooking the possibility of iatrogenic effects.

Insomnia may be a symptom of medical and psychiatric conditions, changes in lifestyle, or medications, among other precipitating factors. When an elderly patient presents with complaints of insomnia, the clinician should assess for possible depression since many seniors do not seek help for or verbally express symptoms of this condition, which is common among them and is associated with morbidity and mortality. By raising awareness that insomnia, a symptom of depression for many people, may be reported more readily than depressive symptoms, pharmacists may become involved in identifying those at risk for depression and in facilitating the appropriate evaluation, intervention, and education of patients and their families and caregivers.

Depression, Morbidity, and Suicide Risk

Why is it so important to assess the risk for depression in a senior with insomnia who may not feel comfortable with the subject or who feels stigmatized by self-reporting a depressed mood? As mentioned earlier, a depressive disorder is among the most common causes for sleep disturbances in the elderly. Furthermore, depression is one of the most common psychiatric disorders among the elderly, with clinically significant depressive symptoms appearing in 30% of institutionalized seniors and in 8% to 15% of community-dwelling elderly. It has been shown that patients with any medical diagnosis were twice as likely to develop depression than were patients without a medical diagnosis. Depression increases mortality in hospitalized patients, increases medical morbidity, worsens the outcomes of medical disorders, increases the perception of poor health and the use of medical services, and increases the economic burden on the health care system.

It must not be overlooked that depression is the psychiatric disorder most likely to raise the risk of successful suicide in the elderly (TABLE 3). Statistics reveal that suicide rates in the United States are highest in people 70 and older. Suicide in white men is 45% more common in those ages 65 to 69 than in those ages 15 to 19. It is about 85% more common in those ages 70 to 74 and greater than three and one half times more common in men older than 85 than in men in the 15-to-19 age group. While suicide attempts are rarer in older people than in younger people, they are more lethal as a result of more careful planning, more lethal self-destructive acts, and fewer indications of the intent. Younger patients are more likely to seek or respond to suicide interventions than are the elderly. Although mood disorders are more prevalent in women than men across the spectrum of age, successful suicide is disproportionately higher in males, especially in elderly men.

Diagnostic Questioning and the Geriatric Depression Scale (GDS)

Unless specific questions are asked, depression may go unrecognized, as it is well known that as many as 70% of seniors who commit suicide were seen by their primary care physicians within the last few weeks of their lives. Presentation of depression in the elderly varies as compared with that in the younger population. Rather than psychological complaints, somatic complaints often predominate in the clinical scenario. Although older patients often do not report a dysphoric mood, apathy and withdrawal are common. Loss of self-esteem is prominent, and guilt is less common. The inability to concentrate, with a resultant impairment of memory and other cognitive functions, is commonly seen. In addition to a review of systems, health care practitioners can question elderly patients regarding: sleep disturbance, appetite changes, trouble concentrating, lack of energy, and loss of interest. Whenever possible, in addition to ongoing primary care, referral for consultation with an experienced geriatric psychiatrist and/or psychologist is helpful in diagnosing and managing depressive disorders.

Senior care pharmacists may find the Geriatric Depression Scale (GDS) helpful in identifying depressed geriatric patients for referral for a full evaluation. The GDS may also be used subsequently by the pharmacist as an outcomes measure of antidepressant therapy in the management of depression.

The notion that aging is a multifactorial process is commonly accepted. Many of the age-related changes that occur in a senior’s nervous system have an impact on the function of sleep. In the elderly, sleeping difficulties often occur in conjunction with depression. Because depression raises the risk of suicide in this population, it is important for pharmacists to question their elderly patients about sleeping difficulties.

Sleep Difficulties Increase With Aging

Complaints of sleep difficulty increase with age, tend to be more common in women than in men, and occur in about 50% of community-dwelling elderly people. The loss of sleep associated with sleep disturbances directly affects quality of life and often contributes to increased risk of chronic fatigue, falls, and accidents. Insomnia, a complaint of poor quality of sleep, results in a sense of nonrestorative sleep. Through both objective and subjective reporting, it has been shown that elderly adults, as compared to younger adults, have longer sleep latency (time to fall asleep), lower sleep efficiency (amount of sleep given the length of time in bed), a higher number of nighttime awakenings, awaken earlier in the morning than they would like, and need more daytime naps. In fact, the sleep pattern is altered in elderly individuals, with a significant decrease in delta sleep, REM sleep, and total sleep time.

Because of frequent nocturnal awakenings involving wandering and confusion, sleep in institutionalized elderly people living in nursing homes is extremely disturbed. The fragmented sleep seen in these elderly people may be such that in a 24-hour period, not a single hour may be spent fully awake or fully asleep.

Providing both emotional and physical restoration, sleep is essential to life. There is a wide interindividual variability in the amount of sleep required per night, ranging from three to 10 hours.

Insomnia and Depression

It is well documented that insomnia is frequently comorbid with various psychiatric disorders, and researchers have indicated that sleep disturbances may be an early sign or the cause of some psychiatric disorders. While chronic insomnia may trigger depression, the converse has also been shown; that is, depression is a common, prominent cause of insomnia. Depressive and anxiety disorders are among some of the most common causes for sleep disturbances in an elderly individual. The actual relationship between insomnia and depression has been studied in older adults. One British study looked at whether sleep disturbances predict depression in seniors 65 and older. Livingston et al reported that a current sleep disturbance was the strongest predictor of future depression in nondepressed older adults. In another study, Roberts and colleagues looked prospectively at Californians 50 and older and found a variety of factors associated with developing depression one year later: sleep problems, psychomotor agitation, mood disturbance, low self-esteem, and loss of feeling and pleasure. Even though the etiology of sleep disturbances in the development of depression is unclear and sleep problems in older adults may not always be related to depression or result in a future depressive episode, it is important to emphasize that further assessment should be done to rule out all medical, psychiatric, or iatrogenic causes of insomnia. Health care professions should suspect that insomnia lasting more than three weeks may be a symptom of a medical or psychiatric disorder.

While reviewing epidemiologic studies, Ford and Cooper-Patrick found that people in the general population may find it easier and less stigmatizing to report symptoms of insomnia more accurately than symptoms of depression such as poor concentration, fatigue, and depressed mood. Additionally, Ohayon and colleagues reported that a large proportion of individuals with concomitant insomnia and depressive symptoms may seek treatment only for insomnia.

Only 38% see depression as a health problem.

Depression is still mostly a “hidden” disease, as cancer used to be. In spite of more publicity about the condition in the past few years, and more and better drug therapies, only 38% of Americans age 65 and older believe that clinical depression (depression that continues for months on end) is a major health problem (see chart). Older adults who suffer from clinical depression are in fact more likely than younger adults to want to “handle” it themselves. During any one-year period, 10% of Americans suffer from depression.

Costly Disease

Americans spend $150 billion a year for treatment that includes costs of hospitalization and drugs. Depressed seniors have 50% higher healthcare costs than nondepressed seniors.

Depression and Seniors

Symptoms of depression occur in 15% of people past age 65 who live at home. Clinical depression strikes three of every 100 seniors, and twice as many women as men are diagnosed with the condition. Unfortunately, almost 70% of seniors know little or nothing about depression, its causes and treatment options.

The incidence of major or minor depression among seniors ranges from 5% in primary care clinics to 25% in nursing homes. About 13% of nursing home residents develop a new episode of major depression over a one-year period.

Suicide is a major issue. Elderly white men are at highest risk of committing suicide — those with severe, untreated depression have a suicide rate as high as 15%. For seniors who live at home, compliance with treatment is a major issue. It is estimated that 70% of patients take only 25% to 50% of their prescribed medication.

Another serious problem is recurrence of symptoms. Up to 40% of all sufferers experience recurrent depression. Antidepressant medication should be maintained for six months after remission from a first episode and 12 months or longer after a second or third episode.

Depression in late life is a treatable disorder and is not a part of the normal aging process, points out Ira R. Katz, M.D., a professor of psychiatry at the University of Pennsylvania Medical Center. Primary-care doctors, however, often overlook or misdiagnose depression in older people (those over age 75), said Dr. Katz. Of those older persons who are depressed, only one in six will be properly diagnosed and treated. More than 80% of these people could be treated effectively with antidepressants or other forms of therapy. Methods to prevent depression include staying active socially and maintaining a high level of physical fitness.