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Depression in later life: What GPs need to know

Dr Declan Lyons, Consultant Psychiatrist, St Patrick’s Mental Health Services (SPMHS) and Dr Masashi Terao and Dr Caitriona Lee, Registrars in SPMHS, provide an overview of depression in later life and how to manage it in the GP surgery

Depression in later life

Depression in later life can be challenging to diagnose and it frequently goes undetected and untreated. Older people may be consciously and subconsciously reluctant to volunteer emotional and psychological difficulties or see them as a health issue, and clinicians may be ignorant of the true value in offering adequate treatment for this segment of our population.

Depression in later life

Given the multiple losses experienced by the older population, there is a presumption by society that depression is inevitable and an understandable part of the aging process. However, the clinical implication of failing to diagnose depression has significant consequences for the physical health, social interaction and overall quality of life of the individual.

Epidemiology

Depression of clinical significance occurs in 10 to 15% of people over the age of 65 years, with 2% having major depression (Beekman et al. 1999). In adults with recurrent early onset depression, the recurrence rate is 25.5 per 1,000 person-years as they enter later life.

Epidemiology

The literature lacks reliable estimates of prevalence rates in those over the age of 85 years and the rates reported are likely underestimated. Differentiating depressive symptoms from those of many physical health issues is challenging.

Symptoms and signs of later life

The diagnostic criteria for depression in later life are no different than those that apply in the diagnosis of a younger adult, according to the major classification systems. There are distinct differences in the modes of presentation, however, based on chronological age. Unlike the younger population who report lowering of mood, older people present more commonly with hypochondriacal and somatic symptoms.

Symptoms and signs of later life

Commonly physical symptoms are features such as fatigue, weight loss, pain, poor oral intake and gastrointestinal upset. Moreover, they can typically experience a greater level of anxiety and rumination. An older population can also present with subjective memory loss and cognitive deficits.

Psychomotor changes can be seen in up to 30% of depressed elderly patients with psychomotor slowing or agitation. Indeed, social isolation, increasing alcohol use and self-neglect are also common features.

Psychosis is common in late onset depression. Clinical features commonly seen are persecutory delusions, auditory and visual hallucinations. First-rank symptoms, negative symptoms and thought disorders are uncommon. Importantly, delirium must always be considered which can result secondary to a medical condition or may be drug-induced.

Presentations of later-life depressions

The vulnerability factors for depression in later life include female gender, being widowed or divorced, lower socioeconomic status, insomnia, chronic medical illnesses manifesting pain, and impairments such as mobility difficulties and physical frailty.

Presentations of later-life depressions

Those in residential care and hospital inpatients have a significantly increased risk of depression compared to their community-dwelling peers. Other triggers which are important to look out for are bereavement, sleep deprivation, loss of income/productivity, change in social status and loss of physical and cognitive abilities.

Clinical course and complications

Late life depression can have a considerable impact on quality of life. The clinical course is variable and complications occur frequently. The social isolation that occurs with depression in older adults can result in greater personal vulnerability due, for example, to self-neglect, leading to medical conditions deteriorating and potentially mortality increasing. Ensuring compliance with medications is also a major concern in preventing relapse and recurrence.

Clinical course and complications

It is important to highlight that although society recognises the problem with rates of deliberate self-harm in the younger population, rates of completed suicide tend to rise with age. In fact, completed suicide rates are two-fold higher in later life than the general population and rates have unfortunately been persistently high over recent decades. Men have a higher rate of suicide in later life with ratio of 3:1 in most countries.  Risk factors for deliberate self-harm in the older population include physical illness, loneliness, widowhood and living alone.

When investigating clinical depression in the older adult, it is essential to include a cognitive assessment and blood work-up (glucose, thyroid function, vitamin B12 and folate levels). Depression is a risk factor for Alzheimer’s disease and vascular dementia. The prevalence of depression in those with Alzheimer’s disease is between 30-50%, especially in the initial stages of the condition.

Subtypes

There are various means of classifying late onset depression. Traditionally, major depression and minor depression encompasses dysthymia, brief recurrent depressive disorder and non-dysphoric depression. Biological depression may not present as frequently in older adults as the atypical aforementioned profile of symptoms of anxiety and somatisation but organic factors, especially cerebrovascular disease are relevant aetiological contributors.

Subtypes

As stated earlier cognitive impairment can be associated with depression in later life. Individuals with late onset depression can have attention and executive dysfunction whereas those with recurrent early onset depression may have deficits with memory. When depression is associated with concurrent cognitive deficits, it can be referred to as ‘pseudodementia’. This is transient cognitive impairment with depressive features. Organic causes for an underlying cognitive change must be excluded before the term ‘pseudodementia’ can be used. Some studies have demonstrated that those with pseudodementia are at higher risk for irreversible dementia in the future, with one study reporting an incidence rate of 40% with a three-year follow up (Alexopoulos, 2005), implying a less benign prognosis than previously thought.

Depression due to a medical condition has also been defined. With higher incidence of medical comorbidities in the older population, this term can be applied to many cases of depression. Depression can be a prodromal symptom of neurological illness especially many subtypes of dementia as previously mentioned. There is an abundance of research reporting higher incidence rates of depression in older adults in the presence of medical conditions in particular the 3 Cs; cardiovascular, cancer and central nervous system (stroke, dementia and Parkinson’s disease). The prevalence rate of depression among geriatric patients in a medical hospital is approximately 30%.

Vascular depression is another subtype of late onset depression that has been proposed. Individuals with small vessel disease resulting in ischaemic changes to the frontal subcortical areas is hypothesized to perpetuate depression in later life. Vascular dementia is described to have a collection of clinical features such as apathy, psychomotor retardation, poor executive function and less emotionally intense cognitions such as worthlessness compared to late onset depression without vascular risk factors.

Treatment

When addressing the management of depression in later life, the essential treatment goals are attainment of remission and prevention of future relapse. However, in clinical practice perhaps a more realistic goal is to aim to reduce symptoms by at least 50%. Most depression in later life is seen and treated at the level of primary care. Additionally, it is encouraging that by successfully identifying and treating late life depression, medical co-morbidities can be improved.

The biopsychosocial model was developed by Engel in 1977 (Engel GL, 1977) and many clinicians instinctively employ this framework, to emphasise a holistic approach in patient care and formulating care plans. What are the biological, psychological and social factors that interplay on presentation and how can they be meaningfully addressed (genetic factors, symptomatology, personality and behavior, cultural, familial, diet, etc.)?

  • Biological

    The treatment for biological symptoms is largely the same as for young adults. For example, the management of unipolar depression would involve SSRIs as first-line agents, going on to SNRIs (Venlafaxine, Duloxetine), Tricyclics, atypical antidepressants, and Mono Amine Oxidase-Inhibitors. Augmentation of depressive symptoms with mood stabilisers such as Lithium or antipsychotics are also in several treatment guidelines (Maudsley, National       lnstitute of Clinical Excellence). Electroconvulsive therapy has no absolute contraindications and is indicated in refractory depression, some even benefiting from maintenance ECT. Factors to consider however in prescribing for an older population are drug interactions, pharmacokinetics, pharmacodynamics, and/or dosages. The elderly population may have several co-morbid medical conditions resulting in polypharmacy out of necessity. The hepatic first-pass effect may be reduced as hepatic volume and perfusion decreases, increasing the bioavailability of medications. Decreases in lean body mass will increase the volume of distribution (Vd) of lipophilic drugs and decrease Vd for hydrophilic drugs. Drugs such as Lithium are better kept at a subtherapeutic level to avoid nephrotoxicity, and Venlafaxine is rarely used at the recommended maximum dose of 375mg due to potential adverse effects of increasing blood pressure, and sweating. All in all, physiological changes make psychopharmacology challenging, however the “prescribe low and go slow” dictum holds true for elderly patients.

  • Psychological

    There is a misconception that elderly patients don’t respond to or cannot engage in psychotherapeutic approaches. Available evidence suggests that cognitive behavioral therapy, supportive psychotherapy, problem-solving therapy and interpersonal psychotherapy have had efficacy in late-life depression either alone or in combination with psychopharmacology. Listening to and demonstrating empathy to patients in distress is a powerful form of supportive psychotherapy, even if there is a significant age disparity between patient and therapist. For those presenting with certain triggers/stressors in milder depression, or for those who are “psychologically minded”, psychotherapy models such as CBT can play a crucial role in treatment.

  • Social

    In relation to the social factors, there is a misconception that ageing is synonymous with deteriorating physical and mental health with a resultant poor quality of life? Jonathan Swift expressed the ambivalence of many an individual reaching later life when he stated: “Every man desires to live long but no man wishes to be old.” Ikigai (生き甲斐) is a mysterious Japanese word that roughly translates as “life’s purpose” or “the joy of living”, which is sometimes used casually in Japanese society. It emphasises the unique balance of going with life’s flow and enjoying the small things in life. Centenarians in the Japanese island of Okinawa, the longevity hotspot in the world are a living testament to this. Retirement is a fluid experience as many continue to work past their 70s and 80s because they feel fulfilled by helping, serving others and activity is valued. Their sense of community is strong, as is solidarity across the generations. Anti-oxidant and Omega-3 rich foods are the main dietary staples but in relation to key social factors, human interaction, which uniquely challenges us cerebrally is felt to be the most robust anti-aging activity in Okinawan society. 

Recovery and remission

It is widely recommended that a first episode of depression should be treated for at least six to nine months, after full remission.

Recovery and remission

If antidepressants are stopped soon after recovery, one in two patients will experience depressive symptoms within three to six months. Unfortunately, more than 50% of those who had one episode of major depression will have a second episode, and more than 80% of those who had two episodes may have three. NICE guidelines recommend that patients who’ve had two or more episodes and consequential functional impairment adhere to medications for at least two years.

The decision to continue medications for longer needs to be decided individually, weighing up past psychiatric history, other medical co-morbidities and risk factors along with the impact of relapse on the patient and family members. The risk factors stated above are known to increase the chance of relapse, making concordance to pharmacotherapy crucial among many. Some patients do however challenge the idea of taking maintenance medications when they are in remission and feeling well. Within consultation some may even confess that they have reduced the dose or discontinued medication entirely due to concern about potential or actual side-effects. It is important to reassure patients that antidepressants are effective in treatment and remission, are not addictive, do not lose efficacy over time and do not cause new long-term adverse effects.

If discontinuing medications is a priority for individuals who have gained good response or symptomatic remission, then it needs to be done gradually and under medical supervision. Needless to say, the non-medication part of recovery is equally important, ensuring people who have recovered are equipped with routines, activities and supports which maintain wellness, and that they are aware of relapse indicators and contingency plans, if needs be.

References

References

The full original article originally appeared in the Irish Medical Times in 2019. 

Alexopoulos, G. S. (2005). Depression in the elderly. The lancet, 365 (9475), 1961-1970.

Beekman, A. T., Copeland, J., and Prince, M. J. (1999). Review of community prevalence of depression in later life. The British Journal of Psychiatry, 174 (4), 307-311.

Engel GL. The need for a new medical model: a challenge for biomedicine. Science, 1977

Cambridge Textbook of Effective Treatments in Psychiatry, First Edition.

The Maudsley Prescribing Guidelines in Psychiatry, 13th Edition

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