Depression remains the most common mental disorder in the elderly. It is often underdiagnosed and consequently, undertreated, creating much suffering for the patient and family.
General practitioners play a pivotal role in identifying depression in an elderly patient. This may be complicated by confounding factors such as pain, physical illness, bereavement, adverse effects of medication and loneliness. Furthermore, the relationship between depression and cognition is complex. Attention and short-term memory are often disproportionately impaired during depressed states. Variable performance and “I don’t know” and “I can’t do it” answers are not uncommon, raising the possibility of a ‘pseudodementia’.
The usual features of depression occur in the elderly although the report of saddened mood is often less in this population. Heightened anxiety, loss of interest and pleasure, somatic preoccupation, fatigue, sleep disturbance, loss of appetite and weight are commonly reported symptoms. Whilst hallucinations are less common on psychotic depression, mood-congruent delusions of poverty and guilt may occur.
It is not uncommon for the elderly patient to intellectualise their underlying depression, stating “I do feel depressed but that is because of…” hence explaining away any need for treatment. Just because it is explainable though, does not mean it should not be treated.
In fact, depression is highly treatable. A holistic approach to treatment often confers best results. This includes consideration of psychotropic medications, addressing stressors, reducing social isolation, scheduling activities and supporting carers.
There should be a low threshold to consider antidepressant therapy for the depressed elderly patient. The presence of psychotic symptoms may indicate the need for adjunctive antipsychotic medication. Consideration of efficacy and tolerability is critically important in the choice of antidepressant. In particular, caution should be given to agents resulting in oversedation, postural hypotension, anticholinergic side-effects, cognitive dulling and confusion. The general rule of “start low and go slow” should apply. Electroconvulsive therapy (ECT) should be considered in severe cases, particularly where there is evidence of psychotic features, treatment resistance and acute risk factors such as escalating suicidality, inadequate oral intake or catatonia. Transcranial magnetic stimulation (TMS) may be another treatment modality.
Unfortunately, whilst depressive episodes are usually treatable, the recurrent nature of this mood disorder leaves its key challenge in maintaining the patient’s wellness and preventing future relapses. Careful consideration of prophylaxis and protective factors is critical in this regard.
In the general practice setting, there should be a low threshold to consider the possibility of a depressive disorder in older patients. Referral to an old age psychiatrist may be indicated when there is diagnostic uncertainty, failure of response to treatment, intolerable adverse effects with standard treatment, complex comorbidity or increasing concerns about the patient’s risk.
At Epworth Camberwell, an Old Age Psychiatry service is being established to guide the multidisciplinary management of elderly patients with mental illness. This aims to expand the existing psychiatric service to specifically tailor the mental health needs of our ageing population.
AUTHOR | Dr Lyn-May Lim
Dr Lim is a general adult and old age psychiatrist at the Epworth Clinic. She is the inaugural director of the Old Age Psychiatry service at Epworth HealthCare.
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