Hello, I am Amin Fungunton. Welcome to this video that aims to help you better understand diagnosis and some general aspects of treatment of depression in the elderly population so that you can understand the challenge of screening in this population. Depression is among the most frequently occurring disorder worldwide. Approximately, 10% of the world population is over 65 years of age and about 10% of them have depression. In other words, about 1% of the world population is both old and depressed. 1% is late-life depression. As you can see, this frequency is increased in general practice, hospitals, and nursing home settings. Depression usually starts at a young age and many elderly patients with depression have had depression in the past. Some elderly develop their first depressive episode after 65 years of age. They have a late onset form of depression. Depression is a syndrome defined by the presence of a number of subjective and objective clinical features having lasted for at least two weeks. Feeling depressed, having anhedonia, which is the loss of pleasurable feelings, having lost interest in things and asthenia meaning lack of energy are core features of depression. Other additional features include reduced self-esteem, feelings of guilt, ideas about death or suicide, attentional deficits, psychomotor slowing or on the contrary agitation, a variety of sleep disorders and disorders of appetite and eating. A major depressive episode is diagnosed if at least two core and two additional features have been present for at least two weeks. A major depressive episode may be light or of increasingly severe intensity as the number of features increases. As you can see in the table, depression is similar but not entirely identical in the elderly as compared to younger people. In the elderly, feeling depressed is often less pronounced. Patients have physical or memory complaints. They lack motivation. Agitation, alcohol, or drug abuse including new onset abuse can be features of old-age depression. Suicide is more frequent relative to younger people. Depression is often post asymptomatic. This means that it may not encompass all features of depression as found in younger people. Telling post asymptomatic depression from some depressive symptomatology may be difficult in the elderly. Besides, severity, duration and the impact of a patient's life may help make the distinction. Indeed, some functional impairment often accompanies old-age depression. Importantly, even minor depression may significantly impair daily functioning in the elderly. There is hardly any decrease of functional impairment or anhedonia and no temporal persistence of depressive symptoms in cases that are not characteristic for depression. The depressed are often apathetic. Yet apathy often exists without depressed feelings in the elderly and suggests a number of other pathologies such as Subcortical Vascular Encephalopathy or Parkinson's disease. Of course, these patients can also be depressed. The causes of depression are numerous, but hardly ever straightforward. A linear causal model of the etiology of depression is inadequate. It is the type and intensity of a stressor, along with a person's individual level of vulnerability that determines whether or not depression develops. There is hardly any stressor that is by itself the single cause of depression. Stresses and vulnerability factors may be biological, psychological or social in nature. Biological factors are for instance a somatic disease such as Parkinson's disease, vascular disease with or without reduced dependency, drugs or alcohol abuse. Psychological and social factors may be loss of a family member or of one's social status, a personal conflict, specific personality traits, and many others. Depression is a brain disorder and major hyper metabolic changes can be observed in depression. In lasting and untreated depression, the number of days of untreated depression correlates positively with hippocampal atrophy. There may be a bidirectional relationship between this type of brain changes and depression. As for the younger population, major depression is more of a syndrome than a disease. Depending on specific clinical or temporal features, different types of depression may be distinguished. Of course, bipolar disorder is among the more important ones also in the elderly. If an elderly person presents with first episode depression, an underlying vascular brain disease may indicate vascular depression. Early stage dementia of different etiologies ought to be considered in the case of late onset depression. Depression can be prodromal, meaning an initial presentation of dementia, and is a frequent feature of mild cognitive impairment that may evolve to its dementia. Depressive and cognitive features often co-exist. This should prompt an investigation to determine if the patient has dementia with effective features. Depression with cognitive impairment as depression can be neurotoxic or both dementia and depression. These distinctions are critical as depression can be efficiently treated once the correct diagnosis is made. The high prevalence, the suffering and the high potential for effective treatment should prompt the clinician to screen for depression in all of their elderly patients. This is an example of a tool to screen for depression. Asking a patient whether they often feel discouraged or sad has a 70% sensitivity and a 90% specificity that a positive answer is motivated by the presence of a depressive episode. Unfortunately, depression in the elderly is often not diagnosed. However, overdiagnosis and inappropriate treatment has also become an issue. If screening for depression is positive, further investigations including thorough history taking psychiatric and somatic status, a complete laboratory parameters as well as an ECG are required to establish a diagnosis of depression, depression type, psychiatric and physical co-morbidities as well as a baseline to initiate treatment. The aims of the treatment is to complete remission of depression and to prevent suicide. Treatment is global and considers physical, functional and social needs the patient may have. The initial phase is characterized by a close temporal follow up. Prescribing an antidepressant and asking the patient to come back in three weeks is not appropriate. Indeed, the risk of suicide may be high in this initial phase of treatment. Generally speaking, the risk to commit suicide and to die of it is much higher in the elderly as compared to the younger population. Depression and old age besides alcohol dependency and male sex are among the more important risk factors for suicide. Psycho-social support may be necessary. Psychological and biological treatments are available for depression. Psychological treatments include psycho-education and various forms of psychotherapy such as cognitive behavior therapy, interpersonal psychotherapy or psychodynamic psychotherapy. Biological treatments include antidepressants mainly serotonin, re-uptake inhibitors, and others. Electroconvulsive therapy, repeated Transcranial Magnetic Stimulation, and others. Many of these treatments have a high evidence-base for effectiveness. Treating depression requires psycho-education, prescribing of medication, and having psychotherapeutic competence that may need to be combined depending on the type of depression and the patient's needs. For instance, severe non-psychotic depression may require a combined drug and psychotherapeutic approach, while severe psychotic depression may require an antidepressant and an anti-psychotic or Electroconvulsive treatment. Patients with severe depression or with bipolar disorder are usually referred to a geriatric psychiatrist or a general psychiatrist used to treating elderly patients. Referral to a psychiatrist does not only depend on the patient and their disease, but also on the referring physician's competencies. Some of the frequently observed mistakes in screening and treatment of depression include not enough of an initial follow up, absence of a global approach, inadequate drug dozing, or prolonged treatment in the absence of efficacy and the absence of psycho-social support. Thus, treatment of depression in the elderly may be complex and must take into account the particularities of the type of depression at the multi-morbidity of the patients. It often requires multidisciplinary competence. However, addressing deepening treatment issues is not part of this lecture. Transferring a patient to a geriatric psychologist may be appropriate in the case of diagnostic difficulties or doubts. Severe depression, particularly when there are psychotic features, when there is a major risk to physical health for instance refusal to eat or risk of suicide exists. It is also indicated in the presence of co-morbidities that are difficult to treat or after treatment failure. Many thanks for your attention.
