Depression is the most common psychiatric disorder in the elderly population. Statistics on its prevalence are difficult to obtain, and therefore vary; but it is estimated that 5% to 65% of the elderly in both community and institutional settings display depressive symptomatology.1 Underscoring the problem of depression in this age group is the rate of suicide, which is higher than that of any other age group. The suicide rate for men increases with every decade of life.1
Despite being the most prevalent psychiatric disorder in the elderly, depression has been the most underdiagnosed and undertreated, for a number of reasons.2 First, the elderly tend to underutilize psychiatric services. This tendency may be due to having lived during a time when a stigma was attached to seeking professional help for emotional problems. Second, a negative societal attitude toward aging in our youth-oriented culture may influence healthcare professionals to undervalue problems of the elderly. We may be less sensitive to the signs and symptoms of depression or simply accept depression as an inevitable concomitant of normal aging. Last, and perhaps most important, late life depression may go unrecognized because it can be so difficult to detect. Diagnosing depression in an elderly individual is rarely a straightforward process. This disorder may be multicausal in origin and complex in presentation. It may masquerade as other disorders or be caused by them.
DSM III DIAGNOSTIC CRITERIA FOR MAJOR DEPRESSIVE DISORDER
As nurses, we are likely to encounter depressed elderly in a variety of settings. Early detection and referral can prevent the significant morbidity and mortality associated with late life depression. The purposes of this article are to provide a guide for detection and assessment of depression, and afford some insight into the complexity of this treatable disorder.
Definition and Classification
To avoid confusion in terminology, the American Psychiatric Association (APA) has developed a system of taxonomy included in the Diagnostic and Statistical Manual of Mental Disorders III3 (DSM III). Revised most recently in 1980, this manual contains the inclusion and exclusion criteria used for making various psychiatric diagnoses. Like nursing diagnosis, part of the manual's purpose is to allow for consistency in the usage of terminology. Table 1 provides the APA 's diagnostic criteria for major depressive disorder.
Late life depression is not listed in DSM III as a separate entity but fails under the general category of major affective disorders; that is, disorders of mood. The two major affective disorders are bipolar disorder, formerly called manic-depressive illness, and unipolar disorder, also called major depression. Though bipolar disorder is seen in the elderly, and may even occur as a first episode after the age of sixtyfive, for the purposes of this discussion we are concerned with the latter category, major depression, as this is the type that has a high-incidence in the elderly.
In addition to major depression, another type of depression that has a high rate of occurrence in the elderly is reactive depression. Previously referred to as situational depression, reactive depression differs from major depression in both presentation and etiology. While major depression is thought to be of organic origin, reactive depression is thought to occur in response to environmental stresses and, therefore, has an identifiable precipitant. Symptoms may be similar to those of reactive depression, but are generally thought to be less severe. Because of factors such as the multiplicity of loss, chronic illness, societal devaluation, and other "depressing" circumstances that accompany aging, the risk for reactive depression in the elderly is high.
Situational and reactive depression may even overlap. In the elderly, depression may be masked (ie, denied or somaticized). It may mimic dementia; or the symptoms may be confused with normal age changes, certain illnesses, or certain drug effects. Before learning how to solve this puzzle, it is useful to know some of the possible etiologies of late life depression.
Theories on the etiology of late life can be divided into two catephysiological and psychosocial. etiology of the individual's depression (for those cases in which cause can be determined) dictates the appropriate therapy. The more accurately the cure is matched to the cause, the better the likelihood of a successful outcome.
Physiological theories of late life depression stem from normal aging changes that occur in the neuroendocrine and central nervous system. While much of the evidence for these changes is derived from pharmacologic and animal studies, it is known that decreases in the concentration of certain adrenergic neurotransmitters in the brain, notably norepinephrine (NE), serotonin (5-HT), and dopamine (DA), occur as we grow older.4,5,6 It is thought that the effectiveness of the tricyclic antidepressants is due to their ability to block the re-uptake of these neurotransmitters, thereby increasing their availability in the brain.7,8
Changes in adrenergic neurotransmitters, or their precursors, may be only part of the picture. Evidence also exists for age-associated decreases in the cholinergic transmitter, acetylcholine.5 The affect of this deficiency on behavior is still largely speculative. In addition, over 20 active neuropeptides located in neurons and on neuron surfaces have been identified. These, along with substances such as endorphins and enkephalins, are currently being widely researched for their affect on mood and behavior.
Reasons for suspecting a neuroendocrine basis for endogenous depression are twofold. First, the clinical syndrome is typically associated with symptoms suggestive of hypothalamic dysfunction (eg, disturbances in mood, sex drive, appetite, autonomic activity, sleep) as well as the diurnal variation frequently seen in the depressive symptoms. Second, norepinephrine (NE) and serotonin (5-HT) regulate the secretion of the hypotfialamic neuroendocrine cells and, indirectly, pituitary function. Deficiencies in the functional activity of these neurotransmitters would be expected to be reflected in the hormonal responses that they modulate. It has long been known that a significant number of depressed patients hypersecrete Cortisol due to conditions such as Cushing's syndrome or the intake of steroids.
Age-related changes in the endocrine system are numerous due to a general decline in overall functioning of hormones and receptors. Another area of investigation is circadian rhythms. Because of the cyclic nature of depressive disorders, it is thought that depression could be related to a desynchronization of the individual's circadian pattern.
The psychiatric literature is replete with discussions about the possible psychologic etiologies for depression. Such theories are difficult to substantiate and impossible to prove, yet serve as the basis for therapy. Interestingly, of the more than 150 recognized psychotherapies in use today, only Beck's cognitive-behavioral model was developed specifically to treat depression.9 This fact serves to illustrate that only in recent years has geriatric psychotherapy begun to come into its own.
Though research in geriatric psychology is young, many report successful outcomes in psychotherapy, whatever form the treatment may take.2,10 Not surprisingly, combination therapies, such as drug and psychotherapy, report the greatest success statistically. Though much of the therapy practiced does not have a sound research base, the success of therapy in general demonstrates the amenability of the elderly to treatment.
The answer to the question of the psychological etiology of late life depression is being sought in two major areas: intrapsychic and environmental. Intrapsychic etiologies include the psychological theories that center around the idea of a continuity of mental status throughout the lifespan. For example, unresolved conflicts or maladaptive patterns in the early years may result in depression in later years, or depression may simply be chronic in nature.
Environmental etiologies, on the other hand, include the events in an individual's life or social situation that may result in a reactive depression. Contributing factors such as poverty, poor physical health, loneliness, or any number of losses that can accompany the aging process may result in depression; particularly in those whose coping resources may be limited. Again, it is important to try to match treatment to causative factors.
A final consideration for causative factors for late life depression exists in the possibility of a secondary or iatrogenic depression; that is, certain illnesses, as well as many of the drugs used to treat those illnesses, may cause depression. Since the elderly have the greatest percentage of illnesses and also use more of both over-the-counter and prescription medications than other age groups, their risk for secondary depression is significantly increased.
How then, do we as nurses assess depression? Nursing assessment for depression includes behavioral manifestations as described in the DSM III, nursing history, and physical and mental status examinations. Careful analysis of these components in relation to the onset and duration of the problem is essential for recognizing depression.
Nursing assessment considers behavioral manifestations as they relate to the person's ability to function effectively within a particular environmental sphere. As the inclusion and exclusion criteria for major depression contained in DSM III prove useful for patient assessment, these items will be discussed in terms of their relevance to late life depression, (see Table 1)
Dysphoric mood - This symptom tends not to be reported by the elderly, probably because of a syndrome that GoIdfarb termed "masked depression."" In the elderly, for reasons that are uncertain, somatic complaints tend to replace those of mood disturbance. The elderly may complain of a variety of physical symptoms (eg, gastrointestinal upsets, sleeplessness) but deny feelings of sadness, worry, or irritability. People associate old age with the onset of physical illness, so somatic discomfort is expected and accepted by society. Somatic complaints need to be taken seriously and investigated carefully before making a diagnosis of depression. The elderly may, at times, complain of not caring anymore, or express feelings of hopelessness or helplessness; expressions associated with a high suicide risk.1 Expressions of these feelings require further discussion to elicit the presence of suicidal ideas and concerns.
Poor appetite, or weight loss or gain - These are not especially reliable symptoms in this age group as some decrease in appetite and weight is seen in normal aging and is also seen with many disease conditions. Inquiry as to the rapidity of weight loss or gain would be helpful as it may correlate with other physical symptoms and indicate physical illness. Weight loss or gain may also be of relatively recent onset and coincide with the onset of other depressive symptoms or with situational crises.
Sleep disturbance - Changes in sleep patterns are known to occur with normal aging, notably an increase in the number of awakenings and a decrease in the amount of Stage 4 or "deep" sleep. However, sleep changes may also accompany physical illness. Although sleep disturbance is a difficult symptom to interpret, it is an important one as it may precede others. Improvement in sleep is frequently the first sign of recovery. Again, associating this symptom, through the client history, with the onset of other depressive manifestations helps to identify the depressive syndrome.
Loss of energy - This may be incorrectly interpreted as normal aging. Although activity levels do decline somewhat over the years, in the absence of disease the older individual should not be aware of a marked decrease in amount of energy. A reference point needs to be established for the change in the energy level. Was the change something noticed in the past few weeks or months, or is the person referring to a change as compared to five or ten years previously?
Psychomotor agitation or retardation - These symptoms may be confused with dementia or, in the case of retardation, be considered a part of normal aging. Perceptual and motor changes that accompany aging may cause some slowing, but severe, recent onset of slowing is indicative of depression.1 Psychomotor agitation and irritability are manifestations of depression with a high-anxiety component. Investigation of areas of concern and worry that the person may have about his or her health, future, or environment may yield information about possible factors contributing to depression.
Anhedonia or decreased libido - A diminished sex drive may be mistakenly thought by both the elderly and clinicians to be normal, but this is not the usual situation. It is relevant to ask about a change in sex drive as many elderly persons remain sexually active. Other data would include a change in sexual pleasure. Nurses and physicians frequently neglect to take a sexual history, especially from the elderly.
Guilt - This is a somewhat controversial symptom. Some feel that guilt is seen much less commonly in old versus young depressed persons and may be substituted with loss of self-esteem,1 while others feel that there is no difference in prevalence among differing age groups. Determination of the elderly's thoughts about themselves, their feelings of self-worth and of their value to the family and community may reveal problems that are associated with depression.
Disturbance in cognition - This sign may be confused with dementia. Interestingly, a "clouding of consciousness" can be the first symptom of late life depression. After the confusion disappears, the depressive symptomatology may become more apparent. An elderly person who complains of memory loss is more likely to be depressed than demented, since demented persons rarely present with a complaint of memory loss as a distressing problem. Demented persons in the early stages often try to cover up cognitive problems with socially acceptable adaptation techniques, such as the statement, "That (name, place, event) escapes me at the moment." Assessment needs to include whether the person views memory loss as a problem and, if so, the time period over which the loss has been manifested.
Recurring thoughts of death - This may be thought of as normal in persons who are near the end of their natural lifespan, but it is not. Elderly persons may give thought to Ulis event, but it is not normal to dwell on it. In assessing this manifestation, one needs to inquire about the person's views and expectations for the future, and evaluate this in relation to physical health.
While DSM III criteria have been shown to be reliable for detecting depression in an elderly population,12 the differential diagnosis is difficult to make. Many of these signs and symptoms may seem normal in the older person and therefore be accepted by both self and others, when in actuality they are not normal. Other symptoms, such as disrupted sleep, may simply represent normal aging changes. It is important to note onset and duration of symptoms. A recent, sudden onset would be more indicative of a depressive episode than of a normal aging change.
Client History - The usual method employed for history taking with the older adult would be appropriate to use for the depressed elderly with special attention to the somatic complaints. These complaints, in order of frequency of accompaniment with depression, are: gastrointestinal disturbance, especially constipation, flatulence, and abdominal pain; sleep disturbance; headache; chest complaints, especially shortness of breath, tightness, and pain; and neuralgia or joint pain.1,13 Onset and duration of complaints are characteristics that provide clues for deciding if a particular manifestation might indicate the presence of depression. Family members, friends, or caretakers may be able to supply this information for a withdrawn or forgetful person. A medication history is also important as many medications and combinations of medications can produce depression. Some of the more commonly implicated medications are alcohol, benzodiazepines, barbiturates, corticosteroids, reserpine, propranolol, methyldopa, and haloperidol.
Physical Examination - Elderly persons suspected of being depressed need a thorough physical examination as depression can often be a "rule-out" diagnosis. Special attention should be paid to the possibility of endocrine disorders, malignancy, hypo- or hyperthyroidism, infection, cardiac function, and neurological deficits; all of which can produce a secondary depression. Some diseases, such as cancer of the pancreas (which occurs most frequently between ages 50 to 70), hypercalcemia, and hypo- or hyperthyroidism, are notable for presenting with depression as the first symptom.14 Other disorders that may be associated with depression manifestations include gastrointestinal, respiratory, musculoskeletal, and renal problems. Laboratory tests need to be done to rule out the possibility of depression secondary to pernicious anemia or electrolyte imbalance. The particular tests that are helpful in ruling out problems other than primary depression are complete blood count, urinalysis, thyroid function, electroencephalogram, and computerized axial tomography (CAT scan) of the brain.
CHARACTERISTICS THAT DISTINGUISH DEMENTIA FROM DEPRESSION
Mental Status Examination - The mental status examination is an important part of the data collection base for depression. This may be conducted in a variety of ways including interview, self- administered questionnaires, observer-related tests, and formal psychological and neuropsychological testing. In addition to performing a general assessment of orientation, memory, mood, and suicidal ideation, one may screen for depression and related cognitive deficits through use of a tool designed for that purpose.
While a number of instruments have been developed to test cognitive and affective functioning, they vary greatly in design and purpose. Although it is not feasible to review all such tools in the context of this article, a few deserve mention as nurses are often involved in the use of these measurements.
Test reliability is of particular importance for use with the elderly population. Affective functioning, for example, may be assessed by using such tests as the Beck Depression Inventory or the Hopkins Symptoms Checklist, both of which appear to be useful with this age group.15,16 Other tests, the Zung SelfRating Depression Scale for example, though helpful in younger populations, do not provide accurate information in the older age group.17,18
Part of the difficulty in evaluating the older individual for depression is that depressed elderly may appear to be demented. What has been called "pseudodementia" (the term is controversial) actually refers to cognitive deficits of psychogenic origin. Depressed elderly may develop significant memory and other intellectual impairments, become very withdrawn or agitated, and appear, superficially, to be demented. The distinction between depression and dementia may not be possible without careful, systematic assessment. Table 2 lists some differentiating characteristics between dementia and depression.
Certain cognitive tests, such as the Short Portable Mental Status Questionnaire (SPMSQ) and the Mini-Mental State (MMS) have been extensively tested for reliability and validity with older adults.19,20 These cognitive tests assess general mental status and do not discriminate between depression and dementia.
Late life depression is a complex phenomenon that may be multicausal in origin and require multitargeted intervention. Nurses working with the elderly in community, long-term care, or acute settings may be the first to observe the signs and symptoms of depression. Assessment of depression is only the first step in the nursing process; however, early detection and referral can make the difference between a simple or complicated course of depression for the older adult.
- 1. Blazer D: Depression in Late Life. St Louis, The CV Mosby Co. 1982.
- 2. Butler RN, Lewis MI: Aging and Mental Health: Positive Psychosocial and Biomedical Approaches, ed 3. St Louis, The CV Mosby Co, 1982.
- 3. Diagnostic and Statistical Manual of Mental Disorders III. American Psychiatric Association, 1980.
- 4. DeLeon-Jones F: Biochemical aspects of affective disorders, in Affective Disorders: Psychopathology and Treatment. Chicago, Year Book Medical Publishers, Inc. 1982.
- 5. Samorajski T: Central neurotransmitter substances and aging: A review. J Am Geriatr Soc 1977; 258):337-348.
- 6. Schatzberg A, Orlsulak P, Rosenbaum A, et al: Toward a biochemical classification depressive disorders, v: heterogeneity of unipolar depressions. Am J Psvchiatrv 1982; 139(4):471-475.
- 7. Ban TA: Psychopharmacology of Depression: A Guide for Drug Treatment. New York. S. Karger, 1981.
- 8. Veith RJ: Depression in the elderly: Pharmacologic considerations in treatment. J Am Geriatr Soc 1982; 30(9):581-586.
- 9. Beck AT: Cognitive Therapy of Depression. New York, The Guilford Press. 1979.
- 10. Comfort A : Practice cf Geriatric Psychiatry. New York, Elsevier-North Holland Pub Co, 1980.
- 11. Goldfarb AI: Masked depression in the old. Am J Psychother 1967; 21(4):791-796.
- 12. Blazer D: The diagnosis of depression in the elderly. JAm Geriatr Soc 1980; 28(2):52-58.
- 13. Finlayson R, Martin L: Recognition and management of depression in the elderly. Mayo Clinic Proceedings 1982; 57:115-120.
- 14. Ouslander JG: Physical illness and depression in the elderly. J Am Geriatr Soc 1977; 25(8):337-348.
- 15. Beck AT, Ward CH, Mendelson M, et al: An inventory for measuring depression. Arch Gen Psychiatry 1961; 4:53-63.
- 16. Monroe RT, Whiskin FE, Bonacich P, et a!: The Cornell medical index questionnaire as a measure of health in older people. J Gerontol 1965;20:18-22.
- 17. Zung WWK: A self-rating depression scale. Arch Gen Psychiatry 1965; 12:63-70.
- 18. Kane RA , Kane RL: Assessing the Elderly: A Practical Guide to Measurement. The Rand Corporation, 1981.
- 19. Burton RM, Damon WW, Dellinger DC: A conceptual model for resource allocation. The OARS model, in Multidimensional Functional Assessment: The OARS Methodology. Durham. North Carolina, Duke University Center for the Study of Aging and Human Development. 1978.
- 20. Folstein MF, Folstein S, McHugh PR: Minimental state: A practical method for grading the cognitive state of patients for the clinician. J PsychiatrRes 1975; 12:189-198.
DSM III DIAGNOSTIC CRITERIA FOR MAJOR DEPRESSIVE DISORDER
CHARACTERISTICS THAT DISTINGUISH DEMENTIA FROM DEPRESSION