Depression in the Elderly: Part II- Late Onset in Life-
Dementia and Depression
Clinicians have known that depression usually exacerbates the normal decline in concentration and memory that accompanies aging. The same thing appears to be true for certain medications taken by older people for common late-life illnesses. These medications may initiate or worsen a preexisting depression. A common example of this is some hypertensive medication, which can cause low energy, listlessness, lack of initiative and excessive fatigue, all potential symptoms of depression.
The following is an updated list of medications that can cause or worsen depression. One of these medications, benzodiazepine, is taken by approximately one-third of older people in nursing homes. In fact, 40% of all benzodiazepine prescriptions are written for elderly people. In his latest book, Dr. Carl Salzman, one of the leading experts in medications for older adults, states that benzodiazepines "are probably overprescribed or inappropriately prescribed" in the elderly. (Salzman, C. (2001) Psychiatric Medications for Older Adults: The Concise Guide. New York: The Guilford Press).
Medications That Can Cause or Worsen Depression
Alpha-methyldopa* Anabolic steroids
Benzodiazepines Calcium channel blockers
Cimetidine, ranitidine and other H2 blockers Clonidine*
HMG-Co A inhibitors L-dopa
Non-steroid antiinflammatory Drugs Opiate analgesics
Progesterone* Propranolol and other beta blockers
Those drugs marked with a star are medications to take cautiously when depression is in the picture. To be sure, this is a topic to be discussed with a treating physician. It is also worth noting that herbals and certain over-the-counter supplements can have the same effect i.e. enhancing depression. It should be further noted that not all people who take these medications would show adverse effects. Reaction to medications appears to be idiosyncratic, best predicted by prior reaction to the same medication. As individuals age, the pharmacokinetics and pharmacodynamics of medication reactions change with concomitant changes in body physiology. Monitoring of medications taken, especially in the elderly (but true of all medications and age groups), during the first four weeks is of paramount importance. One can look for changes in expression, bearing, attitude, sleep, energy, thoughts (cognitive impairment), behavior and physical well-being as well as other behavioral changes. Changes in these areas should be reported to the treating physician immediately. At the same time, sudden stopping of many medication can bring on withdrawal symptoms including increased anxiety, restlessness, agitation, unsteadiness, seizures (especially after high doses of benzodiazepines), worsening of sleep etc. Information exchange between doctor and patient is essential, with significant others having to be the source of information.
A challenging question becomes how to tell the difference between depression and dementia. While the answer to this question should be left to the treating clinician, there are important distinctions that may be helpful when reporting to the treating health provider. First, and most obvious, is that in dementia reasoning ability of the individual is obviously impaired, while the depressed individual’s reasoning is preserved. Secondly, the depressed individual shows good orientation to time, place and space while the demented person evidences impairment. Thirdly, the demented individual usually tries to cover up any memory impairment, while the depressed individual constantly complains about inability to remember. The demented individual will usually make up a reason for the memory lapse or dismiss it, while the depressed persons memory functioning will not be as bad as the complaints would suggest. One must also be aware that depression can also be a feature of dementia and may vary from mild depression to severe emotional liability.
One of the most frequent email questions we receive has to do with agitation in individuals who evidence dementia. A check of the literature indicates there are a number of suggested treatments for this behavior including behavioral modification techniques and pharmacological treatments. The latter include typical neuroleptics such as haldol, trilafon, mellaril as well as the atypical neuroleptics (risperdal, zyprexia, seroquel), antidepressants (desyrel, SSRI antidepressants), anticonvulsants (depakote, tegretal) and other medications such as buspar. Dosage levels and adverse medication factors are important considerations that must not be taken lightly.
In all cases, close collaboration with your treating physician is an essential ingredient to successful resolution of illness presented to the clinician. While there may not be a successful cure for the illness, the doctor may be able to treat the symptoms present, thus making the quality of life somewhat better. The vast majority of the Western civilization is now living out its natural lifespan to become vulnerable to diseases strongly determined by aging. Some of these diseases are markedly improved with drugs and operations, but others like Alzheimer’s disease are improved by palliative means, but are not postponed indefinitely, with present medications. The question remains whether these latter diseases are soluble. Medical research is the art of unraveling the unsolvable. Time will tell. In the meantime, all of us need to take advantage of the available methods to try to deal with illness.
Depression is a heterogeneous disorder that can begin early in life and have recurrent episodes later in life, or the first onset may occur late in life. This article will address the late onset in life depression.
Depression with late onset in life is more commonly associated with underlying brain abnormalities, which may not be diagnosed until years after first signs of depression. Brain imagery techniques now show that these individuals have enlarged ventricles and an increase intensity of white matter in their brain. Epidemiological studies indicate a high incidence of subsequent dementia and a more chronic course of the depressive symptoms in these individuals.
In general, the elderly show a greater incidence of two types of depression, other than major depression: dysthymia and subsyndromal depression.
Dysthymia is a chronic depression with mild to moderate symptoms that last at least two years or longer and occur often with brief periods of normal mood. Interestingly, major depression and dysthymia can occur concurrently. Lifting the major depression via medication may still leave the dysthymia. This may account for the fact that there are individuals though "cured" of their major depression still have bouts of depression in the form of sadness, melancholia, feeling blue etc.
Subsyndromal depression may be a precursor for major depression and be related to physical disabilities, medical illness, and high use of health-care services. Stressful later life events may precipitate depression.
According to the DSM-IV, major depression is defined as depressed mood or a mark loss of interest that is experienced most of the day, nearly everyday, for two weeks or longer. In addition, at least five of the following eight symptoms must be present during the same two week period, representing a change from previous function:
Since five of the eight symptoms are necessary for a diagnosis of depression, one can understand why depression manifests itself differently in different people. It would depend on the particular symptom and which end of the spectrum the symptoms manifests themselves.
In the elderly, the diagnosis of depression can be overlooked because of the presence of medical illness, use of medications and non-disease issues. It should be carefully evaluatated by a competent professional. Its presence may also indicate an underlying medical condition. When depression is identified by the General Practitioner, it is sometimes treated in a cavalier fashion. It is often called a lack of will power. When medication is prescribed, non-therapeutic or high doses are suggested which could have an iatrogenic effect.
The following have been identified as risk factors for depression:
As was previously mentioned, there are a number of non-disease specific factors that are related to depression and illness in the elderly. These include the following:
Acute illness related to an abrupt loss of function, a disability and also fear of death.
Chronic disease involving progressive loss and dependency, feelings of lack of control and the inevitability of death.
Hospitalization which is seen as loss of control, deprivation, infantization and immobilization.
Damage to body image, which is the result of amputation, cancer with surgical loss and myocardial infarction.
Loss involving death of spouse, family member or friends.
Pain of a chronic nature, severity of pain and anticipation of the pain.
With such a wide spectrum of etiological causes of depression, caretakers must be alert to changes in mood in the individuals under their care and report it to health professionals. Medical professionals need to consider depression in the elderly as a primary cause of presenting condition and not only attribute it to state factors that the patient will get over with time.
For further information on the topic of depression in the elderly, we recommend the following free publications available from the Federal Government at the address listed below:
"Depression: What you need to know".
"If you’re over 65 and feeling depressed".
"Helping the depressed person get treatment".
"What to do when a friend is depressed".
This material can be obtained by writing to:
DEPRESSION Awareness, Recognition & Treatment (D/ART)
Public Education Campaign
5600 Fishers Lane, Room 14C-02
Rockville MD 20875
Telephone # 800-421-4211
For more technical information, we suggest the following recent publications:
Lebowitz BD., Pearson JL., Schneider LB., et al. Diagnosis and treatment of depression in late life: Consensus statement update. Journal of the American Medical Association 1997; 279:1186-1190.
Riger SK., Studenski S., Duncan PN, et al. Pharmaceutic treatment of geriatric depression: key issues in interpreting the evidence. J Am Geriatr Soc 1998; 46:106-110.
For our other articles in this series see:
Organizations that Help with Info About Depression
Depression in the Elderly-Part III
FOR AN INFORMATIVE AND PERSONAL ARTICLE ON PRACTICAL SUGGESTIONS WHEN SELECTING A NURSING HOME SEE OUR ARTICLE "Selecting a Nursing Home"
Harold Rubin, MS, CRC, ABD, Guest Lecturer
updated March 19, 2001
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