The Assessment of Depression Among Older Adults

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Psychiatric Times, Vol 39, Issue 3,

In this CME article, learn about the best ways to assess depression in the geriatric population.

CATEGORY 1 CME

Premiere Date: March 20, 2022

Expiration Date: September 20, 2023

ACTIVITY GOAL

The goal of this activity is to review the epidemiology, risk factors, and evidence-based assessment of depression among older adults.

LEARNING OBJECTIVES

1. To describe the epidemiology and risk factors for depression among older adults

2. To discuss the assessment of depression among older adults

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This accredited continuing education (CE) activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals seeking to improve the care of patients with mental health disorders.

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(This is part 1 of a 2-part CME activity discussing depression in older adults.
Part 2 appears in the April issue—Ed.)

According to the DSM-5, major depressive disorder (MDD) is a condition that is characterized by the presence of depressed mood or marked loss of interest or pleasure in activities.1 Other symptoms associated with MDD include changes in sleep, energy, concentration, appetite, weight (changes in 5% of total body weight), and psychomotor activity. Additionally, individuals present with feelings of inappropriate guilt or worthlessness and recurrent thoughts of death or suicide. Furthermore, these symptoms should cause clinically significant distress or impairments in social, occupational, or other areas of functioning. Also, these episodes of depression should not be attributable to the psychological effects of substances or medical conditions. To meet the criteria for an MDD, an individual should have depressed mood or marked loss of interest or pleasure in activities, plus 4 associated symptoms. These symptoms should have occurred during the same 2-week period.

The term late-life depression (LLD) is specifically used to describe depression that occurs among individuals 65 years or older who do not have a previous history of depression.2 Table 1 describes the prevalence rates for depression among older adults.3-6

Presentation

The presentation of MDD in older adults differs from the presentation of MDD among younger adults.3,7 Table 2 highlights the differences between MDD in older adults vs younger adults.3,7-9

Psychotic Depression

MDD with psychotic symptoms accounts for approximately 25% to 50% of admissions to inpatient geriatric psychiatry units.10 Nihilistic, somatic, or poverty-based delusions are often seen among older adults with MDD. These individuals also have greater rates of insomnia, somatic symptoms, diurnal variation of mood, and poor insight into their illness.3,10 Among older individuals with MDD, hallucinations appear to occur less frequently than delusions.

The risk factors for the development of psychotic symptoms among older adults with MDD include being single, widowed, or living alone.10 The presence of psychotic symptoms in older patients with MDD is a poor prognostic factor. These individuals present with frequent recurrences of symptoms that result in hospitalizations.3 Age-related deterioration of the cortical areas of the brain, neurochemical changes commonly seen with aging, comorbid medical conditions, social isolation, sensory deficits, cognitive decline, and polypharmacy are all considered possible reasons for the occurrence of psychotic symptoms among older adults with MDD.9

Relationship Between Depression and Dementia

Depression and dementia in older adults have a similar presentation and share an important relationship.11,12 Older adults with MDD are more likely to develop cognitive deficits when compared with their age- and education-matched counterparts without depression.13-15 Approximately 20% to 50% of older adults with depression develop cognitive deficits, including executive dysfunction and deficits in information processing and visuospatial functioning.13-15 Depressive pseudodementia or depression-associated dementia are the reversible cognitive deficits that are often seen during an episode of depression and that tend to improve with the treatment of the depressive episode.2,4

Often, the occurrence of depressive symptoms can be the presenting symptom of dementia in this patient population. It is still unclear from available evidence whether an episode of depression is a prodrome for the onset of dementia, a risk factor for dementia, or an independent event.16 Table 3 describes the symptoms that primarily occur among individuals with depression-associated dementia when compared with a primary dementia.17

Neurobiology

Current evidence indicates that LLD occurs due to the complex interactions among the various biological, psychological, and sociological factors seen among older adults.18 Table 4 describes the various biological, psychological, and sociological factors that result in the development of depression among older adults.19-26

Available evidence indicates that the impact of psychosocial risk factors on depression among older adults can be altered by personal or environmental factors.26 One meta-analysis noted that the important risk factors for the development of depression among older community-dwelling individuals include a prior history of depression, female gender, sleep disturbance, bereavement, and the presence of disability.27

Consequences

As with younger patients, depression among older adults can result in various poor outcomes. Older adults with depression have 1.5 to 3 times greater morbidity when compared with older adults without depression.1 Table 5 describes the medical, social, and societal consequences of depression in older adults.28-37

Assessment

Current evidence indicates that almost 50% of older adults who have MDD go undiagnosed; a major reason for this is that the initial evaluation of these individuals for psychiatric symptoms is often completed by their primary physician rather than a psychiatrist.38,39 Additionally, many of these individuals do not report depressive symptoms; instead, they present with somatic complaints, cognitive difficulties, and/or functional changes.33 Any older adult who presents with these symptoms should always be screened for possible depression.

The assessment of depression among older adults starts with a thorough history, which should be obtained from the patient and, if possible, a knowledgeable informant.3 In addition, these individuals should have a comprehensive medical and psychosocial assessment. There should also be a suicide risk assessment, a cognitive screening, and a functional evaluation.

The use of standardized screening instruments can assist with the diagnosis of depression and the screening for suicide.40 In addition, these instruments can help with assessing the severity of depression, identifying psychotic symptoms, and assessing treatment responses. The common screening tools for depression in older adults are the Geriatric Depression Scale (GDS), the Cornell Scale for Depression in Dementia (CSDD), the Hamilton Rating Scale for Depression (HAM-D), the Montgomery-Asberg Depression Rating Scale (MADRS), and the Zung Self-Rating Depression Scale (SDS). The Brief Psychiatric Rating Scale is the most commonly used scale to detect and rate the severity of psychopathology among older adults with depression and psychotic symptoms. Table 6 discusses the salient features of these rating instruments.40-42

A thorough physical examination is an important part of the assessment, as these individuals have greater rates of medical comorbidities when compared with age-matched controls.37 Table 7 specifies the medical workup for older adults with depression.43-45

Prognosis

Evidence indicates that depression is a chronic and relapsing illness.46 Although approximately 25% of older adults with depression will achieve full remission with or without any treatment, another 25% will never achieve any treatment response.3 The remaining 50% will have a waxing-and-waning course. Poor prognostic factors include the presence of psychotic features, comorbid medical illness, physical disability, and a lack of social supports.3,10 The presence of medical comorbidities is a major risk factor for poor treatment response and poor antidepressant tolerability among these individuals.46

Conclusions

Evidence indicates that depression is not an uncommon condition among older adults. Depression is often underdiagnosed in this patient population and is associated with poorer outcomes, including greater rates of morbidity and mortality. A thorough history should include ruling out medical causes and drug effects; a focused physical examination; and appropriate laboratory studies, including neuroimaging and neuropsychological testing when necessary, as these are important in identifying depression among older adults.

Depression remains a chronic and relapsing illness, with approximately half of the individuals having a waxing-and-waning course. The presence of psychotic symptoms, medical comorbidities, and physical disability, and the absence of social supports, worsen prognosis for depression among older adults.

Dr Tampi is professor and chairman, Department of Psychiatry, Creighton University School of Medicine and Catholic Health Initiatives (CHI) Health Behavioral Health Services, Omaha, Nebraska. He is also an adjunct professor of psychiatry at Yale School of Medicine. Ms Tampi is cofounder and managing principal, Behavioral Health Advisory Group, Princeton, New Jersey.

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