BMH Medical Journal

BMH Med. J. 2020; 7(Suppl): Early Online. Geriatrics & Gerontology Initiative: International Workshop on Care of the Elderly

“Mental pain is less dramatic than physical pain, but it is more common and also more hard to bear. The frequent attempt to conceal mental pain increases the burden: it is easier to say “My tooth is aching” than to say “My heart is broken.”
C.S. Lewis

Depression is a malady which occurs regardless of age, but the elderly, face particularly concerning issues. Referred to at times as depression in later life, geriatric depression is vastly different from depression in younger adults. It is often misconstrued that depression is a part of normal aging and therefore considered a phase of life than a medical disorder. The World Health Organization reports that depression affects 7% of older people worldwide. Depression in seniors is linked to greater vascular, medical and environmental factors, while early onset depression typically involves genetics and adverse developmental and social factors. Research reports indicate that seniors often report more physical (headaches, backaches, fatigue) and cognitive difficulties (forgetfulness, poor reasoning, and slowed thinking) than kinds of sadness or despair younger depressed report. As a result, it is often thought by the elderly and their relatives that failing memories, aches, pains and irritability are due to “old age”, and they struggle hitherto unaware that they are battling a treatable illness. The alarming statistic is that upwards of 90% of seniors doesn’t receive adequate care for depression, with 78% not receiving any kind of treatment at all. The financial cost of misdiagnosis or mismanagement of geriatric depression is enormous with research saying it worsens co-existing physical illnesses, hastens mortality and increases the rates of suicide by seniors. And the suicide risk is often grossly undervalued, research shows that among those who attempt suicide, elders are the most likely to die. In adolescence, the ratio of attempted to completed suicides has been estimated to be 200:1, whereas the estimated risk for the adult population is from 12:1 to 33:1. In contrast, this sharply rises to 4:1 in later life

Causes of Depression in Elderly

Many factors contribute to late-life depression, including biologic and psychosocial. The bio psychosocial model of understanding and organizing the cause of psychiatric illness shows that elderly depression, stems from a complex multidirectional interaction of biologic, psychological (including personality based), and social factors.

Biologic Factors

Vascular depression

First described by Alexopoulos and colleagues who observed a characteristic cognitive pattern in depressed patients with vascular disease, and called vascular depression in 1997, this entity is the most important biologic association of late life depression. The known comorbidity of depression, vascular disease, vascular risk factors, and the association of ischemic lesions with distinctive behavioral symptoms support the vascular depression hypothesis. Symptomatically, these patients have more psychomotor retardation and less psychomotor agitation, less guilt, poorer insight, and limited depressive symptoms compared with controls. Cognitively, patients with vascular depression have greater overall cognitive impairment and disability than those with nonvascular depression. Fluency and naming are more impaired in patients with vascular depression.

Several lines of evidence substantiate vascular origins of late life depression. Elevated levels of homocysteine lead to cerebral vascular disease and neurotransmitter deficiency, which then cause depressed mood. Levels of homocysteine may increase due to a multitude of factors, including dietary deficiency of B₁₂, folate, and B₆. Several studies indicate that a large proportion of elderly persons with depression have had either a stroke or other evidence of cerebral compromise. They are characterized by arteriosclerosis, perivascular demyelination, dilated periventricular spaces, and ischemia. Many studies have also found high rates of cerebrovascular disease and white matter hyperintensities (WMH) on MRIs in depressed elderly patients. It is thought that WMH are caused by small, silent cerebral infarctions, WMHs can predispose individuals to depression by disrupting the fiber tracts connecting cortical and subcortical structures, including tracts in the dorsolateral prefrontal cortex and the anterior cingulate cortex. New research that probed the interrelationship of orthostatic blood pressure and WMH, shows an association between the degree of orthostatic systolic blood pressure decrease and WMH volume in depression. Therefore the presence of autonomic abnormalities in late-life depression could partly be associated with the development of and/or worsening of WMH and late-life depression. Further depression may occur more commonly as a symptom in vascular dementia than in Alzheimer dementia.

Medical comorbidity

Late-life depression often arises in the context of medical and neurologic illness. Although almost any serious or chronic condition can produce a depressive reaction, the disorders that are most strongly associated with depression include cardiac conditions and neurologic illness, including cerebrovascular disease, Parkinson’s disease, dementias and tumours. Specific medical conditions that may be associated with geriatric depression include myocardial infarction, coronary heart disease, hyponatremia, diabetes, hypertension and increased BMI especially obesity.

Approximately 20% to 25% of patients with heart disease experience major depression, and another 20% to 25% report symptoms of depression. A report in adults aged 60 years and older who had major depression or dysthymia, shows that the most common coexisting physical health conditions were hypertension (58%), chronic pain (57%), arthritis (56%), loss of hearing or vision (55%), urinary tract and prostate disease (39%), heart disease (28%), and diabetes (23%). Depression rates are elevated in hyper- as well as hypothyroidism, suggesting that endocrine dysregulation may cause late life depression. Further drugs like methyldopa, benzodiazepines, propranolol, reserpine, steroids, anti- Parkinsonian agents, β-blockers, cimetidine, clonidine, hydralazine, estrogens, progesterone, tamoxifen, vinblastine, vincristine, and dextropropoxyphene have been associated with late life depression.

Psychosocial Factors

Psychological and social variables are often intertwined. They may be just as important as physical factors in understanding the elements leading to late-life depression.

Personality attributes

Neuroticism is an enduring tendency to experience negative emotional states. Those who score high on neuroticism scales are more likely to respond poorly to stress and to interpret situations as threatening or hopelessly difficult. Neuroticism has been associated with late-life depression consistently across many studies. Other personality attributes that may contribute to late-life depression include the presence of a personality disorder, attachment style, and obsessional traits. The frequency of strictly diagnosable personality disorders shows only a small decline with aging. Patients with a personality disorder are almost 4 times more likely to experience maintenance or re- emergence of significant depressive symptoms than those without a personality disorder. Insecure attachment is another risk factor for developing new depression. In elders and older adults, both patients with early and late onset depression showed greater insecure attachment and poorer social adaption compared with never-depressed controls. Obsessional traits seem to affect suicide risk, possibly because they may undermine an elder's ability to cope with the challenges of aging, which often call for substantial adaptations.

Behavioural Factors

Learned helplessness is the idea that the cause of depression is the belief that it is futile to attempt remedial actions in a continuously stressful environment. A reformulation of the model attributes depression to the belief that highly desired outcomes are improbable or highly aversive outcomes are probable and that the individual expects that no response in their repertoire will change that likelihood. These beliefs about oneself and one's environment lead to helplessness and depression. Unfortunately, elders frequently face circumstances that can produce thought patterns that may lead to learned helplessness. As the result of aging, they may feel helpless against the onslaught of recurrent and uncontrollable physical illness and its effects on them and to changes in their social position. Poor functional status secondary to physical illness is among the most important of the causes of depressive symptoms in older adults. Disability is a chronic and stressful condition that may provoke reactions, such as feelings of worthlessness or hopelessness that ultimately contribute to depression. Long-standing situations, such as on-going financial/family difficulties; falls and injuries; functional decline; and lack of social contacts all make elderly vulnerable to depression.

Social support

Social isolation and impaired social support have been associated with moderate and severe depressive symptoms in the elderly. The most consistent predictor of late life depression is perceived support, also called emotional support. The perceived support depends on factors such as social network size, network composition (especially close family and friends), social contact frequency, satisfaction of social support, instrumental/emotional support, and helping others. And satisfaction with support was a more important predictor of depression. Consequences of impaired social relationships can be significant because the absence, estrangement/ moving out or death of a spouse, relative or friend, can contribute to depression and suicidal behaviour in elders. An all too common scenario is the ‘empty nest syndrome’. Empty nest refers to the years a couple spend together between the launching of their last child and the death of one of the spouses. The transition to the empty nest begins when the first child is launched from the home and ends when the last child departs. Such factors include an unstable or unsatisfactory marriage, a sense of self based primarily on identity as a parent, or difficulty accepting change in general makes empty nest a major stressor. Full-time parents (stay-at-home mothers or fathers) may be especially vulnerable to empty nest syndrome. Adults who are also dealing with other stressful life events such as the death of a spouse, moving away or retirement are also more likely to experience the syndrome. The risk of depression caused by a lack of contact with friends/ relative has been estimated to be 2.5 times, and the risk of depression caused by loneliness has been calculated to be 3.6 times.

Life stressors

Life stressors may predispose elderly to depression. These stressors include adverse life events and on-going difficulties; death of a spouse or other loved one; medical illness, especially diseases of the cardiovascular system, and injuries; and disability and functional decline. The presence of disabilities, with a low Activities of Daily Living Score increased the risk of depression by 3.7 over 1 year. As noted previously, the loss of a loved one is one of the most significant risk factors for late-life depression. How one copes with the loss, how traumatic or unexpected the death is, and the degree to which the death results in social isolation might be some of the linking features between loss and depression.

Treatment and prognosis

The existence of multiple physical diseases in elderly, use of multiple medicines, occurrence of pharmacokinetic and pharmacodynamics changes necessitate many factors to be taken into account while using medicines in this age group. The changes alter the pharmacokinetic properties of the medicines and increase the frequency and intensity of side effects. Therefore the rule is to ‘start low and go slow’. Therefore low doses of antidepressants should be recommended for elderly at the beginning, and then the dose should be increased gradually. Therapeutic effects should be closely monitored and simple dose schemes should be used. Drug interactions especially with medications for co-morbid illnesses should be of prime vigilance. Meta-analysis shows that 50% patients respond to a single antidepressant and half of those who did not give response to treatment give response to additional treatment or replacement of medicines. It is reported that major depressive disorder recurrence rates are higher in elderly than young people. So maintenance of pharmacotherapy is a common scenario, in such cases monitor effects and adverse effects closely.

Psychosocial interventions applied together with the biological treatments both increase the compliance to treatment and are supportive to the individual in finding suitable solutions. Supportive psychotherapy, cognitive behavioural therapy, group therapy, and family therapy are useful. The main principles that should to be taken into account in psychotherapy approaches are: to provide patients to control their emotions, to support individual’s ego and hope, to support the patients’ relationship with supportive people and relatives, to talk the existent problems of the patients and to provide handling of these problems rationally and in a way to encourage to solve, and to help patients in adopting changing conditions. Especially subjects such as retirement, physical diseases, cognitive dysfunctions, separation, divorcement, loneliness and death can be dealt with during therapy process.

Prevention

Preventive efforts may aim to prevent a first onset, a recurrence in late life, or a relapse following treatment. Since over half of older adults with depression have the first onset in late life, it is as appropriate to design prevention efforts targeting first onsets in this age group as at earlier ages.

Preventive efforts are often targeted at those who are at increased risk of disorder. The most promising preventive approach may be treating older adults with subsyndromal depressive symptoms in order to prevent full-blown disorder. The treatment of comorbid insomnia or other sleep disturbance may represent a particularly valuable opportunity to prevent future depressive episodes in older adults. Fortunately, cognitive behavioral treatments for insomnia in this age group are highly effective, even among individuals with secondary insomnia and those who are dependent on sleep medications.

Other prevention interventions target older adults at risk of depression due to physical illness and disability, bereavement and caregiver status. Interventions that have the most empirical support include individual therapy for at-risk bereaved older adults, educational interventions for subjects with chronic illness, and cognitive-behavioral interventions to reduce negative thinking. Stroke patients who preventively receive antidepressant medication are less likely to become depressed than those who received placebo.

Prevention strategies may also be used to reduce the risk of adverse outcomes of depression in older adults. Screening for suicide risk among older adults with depression, followed by effective depression treatment, reduces suicidal thoughts and may, therefore, reduce risk of suicidal behaviours.

Approaches not targeted according to identified risk factors may also be helpful; including programs that educate professional and lay audiences regarding recognition of depression in older adults, stressing particularly that depression is not a normal part of aging. Encouraging th elderly to care for their physical health, especially by controlling their diet and having regular exercise. They should be encouraged to identify and seek treatment for medical illnesses. They also should be encouraged to participate in meaningful family and social interactions to improve their emotional well-being.

Conclusion

Depression in the elderly is a complex disorder. In many ways, it is the quintessential biopsychosocial disorder. The risk factors, presentation, medical co-morbidities, psychosocial stressors particular to elderly, physiologic and pharmacokinetic, vulnerabilities and drug interactions pose unique challenges. But as with any other illness early identification and evidence based interventions can help them to effectively overcome depression, there by adding not just years to their lives but life to those years.

Suggested References

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Late Life Depression