- Unique features of depression in the elderly.
- Keys to picking up the diagnosis.
- Pharmacologic treatment.
- When to recommend referral.
Q: What is the best screening tool for assessing
depression in elderly patients?
A:The Geriatric Depression Scale is the most widely
validated screening tool. The questionnaire has been
reduced to a single question that is as sensitive and as specific
as the 15-item shortened form of the original 30-item
scale. The question is: "How often do you feel sad or depressed?"
This is certainly something that is easy to ask in
the course of a general physical examination or routine office
Q:Some patients don't admit to being sad or
depressed. Instead, they report feelings of
exhaustion or other somatic symptoms. What are the
tricks to reading between the lines and spotting
depression in such patients?
A:Asking patients if they feel "anxious" or if their
"nerves are bad" will often uncover depression, because
anxiety is a very common feature of depression in elderly
persons. Find out about diurnal variation in symptoms
by asking patients what time of day they feel the most exhausted
or tired or have symptoms such as pain. Patients
who are depressed often say that they feel worst in the
morning and better as the day progresses. In contrast, patients
who have chronic diseases tend to feel more exhausted
and fatigued as the day wears on.
Q:How do the symptoms of depression in elderly
persons differ from those in younger ones?
A:In many ways, the most prominent features of depression
in the elderly are unique to this age group
(Table 1). Once you determine the severity of these symptoms,
you can better establish therapeutic goals and select
the most appropriate treatment:
- Vegetative components. These include poor appetite and
poor sleep. Unlike younger patients with depression, who
sometimes increase their food intake, depressed older persons
tend to manifest anorexia and weight loss. The weight
loss is often attributed to other medical conditions instead
of serving as a prompt to ask about depression. Particularly
in patients who have been obese, rapid weight loss resulting
from depression may lead to unrecognized protein
malnutrition and related complications that present as physical
Sleep patterns vary in older persons with depression,
but early morning awakening is common. Some patients
also complain of nocturia, but they may in fact be getting up
to go to the bathroom because they are awake, rather than
awakening because of the urge to urinate.
- Multiple somatic complaints. Elderly depressed patients
may complain of pain everywhere in the body. Try to tease
out which pain is related to an underlying medical condition
and which might be related to depression. Pain is exacerbated
by depression and tends not to fit easily into a single
diagnostic picture. For example, a patient with angina who
is going to undergo coronary artery bypass surgery has
pain that is obviously related to a medical condition, but the
pain may be exacerbated if the patient is also depressed.
Painful conditions often improve with antidepressant
therapy, which suggests that the state of reduced neurotransmitter
levels associated with depression is also part of
the pathophysiology of pain. Antidepressants increase the
nerve transmitter levels that help suppress pain perception.
For example, patients with shingles often become depressed.
It may be difficult to determine whether the depression
is related to shingles or whether the pain of shingles
is exacerbated by depression.
- Psychological symptoms. These may involve obsessive
feelings of guilt and worry or rumination during the night.
Some patients review all of the things they've ever done
wrong and may feel that they're a burden to their families.Ask such patients whether they wish to die or have made
plans to take their life. A patient who has developed a specific
plan for suicide is in a critical situation. Urgent referral
to a psychiatrist is warranted for consideration of electroconvulsive
therapy or initiation of antidepressant medication
with careful follow-up to ensure that treatment is effective.
Some depressed patients also complain of memory
problems; this is because their ability to concentrate is
impaired by the depression. A high index of suspicion is
crucial when a patient complains of
memory problems but is obviously depressed--
for example, if he or she frequently
answers "I don't know" to
questions on cognitive screening tests.
In contrast, patients with underlying
dementia generally do not complain
of--and may deny--memory problems.
More often, it is their families
who raise the question of memory
impairment. During memory testing,
patients with dementia either give the
wrong answer or look to a family
member for the correct one.
- Psychomotor changes. Some depressed
older patients appear to have
"slowed down," which is a typical finding in depressed
younger persons. When asked, however, older patients
often complain about their "nerves" or report feeling anxious.
Many manifest signs of agitation. These psychomotor
changes may be mistaken for an anxiety disorder, and a
benzodiazepine or other sedative may be inappropriately
prescribed. Even though anxiety is a very common feature
of depression, it is the depression, not the anxiety, that requires
treatment. The anxiety will resolve with appropriate
- Diurnal variation in symptoms. The single most important
question to ask a patient with suspected depression is
how he feels in the morning. If a patient reports that morning
is the worst time and that it takes hours to get going,
you can be sure he is depressed. Unlike patients with arthritis,
whose stiffness dissipates during the first few hours, patients
with depression report that their overall sense of wellbeing
is worst in the morning. Occasionally, a patient reports
that he feels worse later in the day, and some feel
afraid to be alone at night.
Part of the challenge of diagnosing
depression in the elderly is to be
aware that depression presents a little
differently in this group and to be able
to differentiate which patient is reacting
normally to life events and which
patient is depressed. Although grief reactions
to the multiple losses of late life
may occur frequently, suspect depression
if a patient's symptoms result in
functional decline that persists longer
than 2 to 3 months after a significant
loss. With the features I've outlined
above, it is a fairly straightforward
process to diagnose depression and
prescribe the appropriate treatment.
Q:Which features help distinguish a true
anxiety disorder from anxiety that is really a
manifestation of depression?
A:Anxiety disorders typically have their onset in early
adulthood. Although generalized anxiety disorder
may occur in up to 5% of community-dwelling older adults,
these persons usually have a history of anxiety that began in their 20s or 30s. Thus, an older person with anxiety of
recent onset and no history of previous anxiety is more
likely to be depressed. Consider a diagnosis of agoraphobia
in an older person with anxiety of recent onset who is
It is crucial to distinguish an anxiety disorder from depression-
associated anxiety. Serious complications, such as
cognitive dysfunction, fall-related injuries, and worsening of
depressive symptoms, can result if a benzodiazepine is mistakenly
prescribed for a depressed patient.
Q:Many of my elderly patients believe that
depression is a normal part
of the aging process. Does aging
itself cause depression, or are exogenous
factors, such as bereavement,
A:We infer that depression in older
persons is much more likely to
have a biological basis than in younger
ones, simply because antidepressant
pharmacotherapy is so effective in these patients. About 70%
of elderly patients respond to the first drug prescribed,
and about 90% respond to a second agent if the first wasn't
One hypothesis for a biological basis is that elderly persons
are at greater risk for depression because of age-related
neuronal dropout, which results in a loss of the brain's reserve
capacity to deal with stressful situations--precisely at
the time when the number of stressful situations increases because of bereavement and other traumas. Even so, depression--
like cognitive dysfunction--should never be considered
a "normal" part of the aging process. Depression is
always a medical diagnosis and is usually treatable.
I've observed that elderly persons who have experienced
extreme traumatic events early in their lifetime--such as war
or incarceration in a concentration camp--and who seem to
have been able to cope with them very well may in later years
have a diminished ability to cope with additional psychological
stresses, even though these may not be as severe.
Exogenous factors undoubtedly play a key role in depression
at any age, but as is the case with many bodily
systems, our reserve capacity to cope
with stress is diminished with age.
Q:Other than age, what are
the major risk factors for
depression in the elderly?
A:Chronic diseases, especially
chronic pain syndromes, are
often associated with depression
(Table 2). Acute illnesses or disorders that have a sudden
onset and that result in significant disability may also lead
to depression. Surgery (even if uncomplicated) can be
stressful enough to precipitate a depression; this is a common
phenomenon in older patients who have undergone a
coronary artery bypass procedure.
Undiagnosed depression--which may underlie other
medical conditions--is the most common cause of hospital
readmission in elderly patients.
Q:Which pharmacotherapeutic agents are most
effective in elderly persons? What are the
specific pitfalls associated with these agents?
A:The selective serotonin reuptake inhibitors (SSRIs)
are first-line therapy for depression in the elderly;
these agents also relieve depression-related anxiety. They
are considered first-choice agents because they have a better
safety profile than the tricyclics--for example, they are
associated with fewer cardiac side effects. Nevertheless,
SSRIs are not associated with a reduced incidence of falls
compared with the older agents. The SSRIs have a somewhat
quicker onset of action than the tricyclics; however, it
still takes 2 to 3 weeks to begin to see improvement.
Tricyclic antidepressants, such as nortriptyline, may be
helpful in a very anxious depressed patient, particularly one
with insomnia. Even though SSRIs
have become the therapy of choice, recent
studies have shown that nortriptyline
can be as effective for depression
in older persons.1-3
Fluoxetine is best prescribed with
caution in elderly patients, primarily
because of its very long half-life. This
can be problematic if delirium or another
acute illness develops. Moreover,
the risk of extrapyramidal side effects
may be increased with a rapiddose
titration of fluoxetine.
The "start low and go slow" recommendation
absolutely applies to the
SSRIs. I recommend initiating therapy
at half of the usual starting dose. The dose should not be
titrated up from this level more often than every couple of
weeks; thereafter, it can be titrated monthly until a therapeutic
dose is achieved.
Q:Which SSRI adverse effects are most troublesome
in the elderly?
A:Extrapyramidal side effects--including akathisia and
Parkinsonian-type symptoms--are sometimes not
recognized as side effects of SSRIs and may be confused
with persistent symptoms of depression; this can lead to inappropriate
dosage escalation. Some patients experience GI
side effects, including constipation, diarrhea, or stomach
upset. These can be avoided by starting therapy at low
doses. Vivid dreams may be a dose-limiting side effect. The
potential for drug interactions exists, but this does not generally
occur at the lower doses recommended.
Generally, the SSRIs are very easy to use. Ironically,
this is why it can be difficult to judge how well a patient is doing. Sometimes we assume that as long as a patient is not
having side effects, his depression is being effectively treated--
but this isn't always true. That's why I recommend
using the 5 features outlined above (see Table 1) to determine
if the patient is making progress and to ascertain that
his symptoms have been fully treated.
Q:If a patient is having difficulty tolerating a
particular antidepressant, should I encourage
him to try it for a bit longer, or is a switch to a new
drug a better option?
A:If a patient whose depression appears to have responded
to an antidepressant is clearly having unacceptable
side effects, the first step is to reduce the dose. I
don't like to discontinue an agent that seems effective if the
problem is simply too high a dose. On
the other hand, if a patient is not deriving
any benefit from a medication, a
switch to a different SSRI is in order.
You can usually tell after about an 8-
week trial of a drug--if you've titrated
it properly--whether the patient is improving.
This is a subjective evaluation.
It is helpful to document the patient's
presenting symptoms under
each of the 5 categories listed above
and to use that as a guide for follow-up
Q:What is your next step when
a patient's depression does
not seem to be responding to a particular SSRI, even if
there are no adverse effects?
A:I first try another SSRI. Enough of these agents are
now available that there are often several from which
to choose based on the patient's symptom profile.
It's a good idea to prescribe a limited number of SSRIs
initially so that you become very familiar with the effectiveness
and potential side effects of each one. This familiarity
will be useful when a significant dose escalation is required.
Newer drugs can be used as second-line agents to facilitate
familiarity with them as they become available.
Q:Which SSRIs might you recommend in specific
A:Fluvoxamine, which is available in generic form, is
particularly effective in elderly patients who need energy
during the daytime but who aren't sleeping at night.
Drug interactions with this agent have not been an issue at doses up to 100 mg. However, if drug interactions are a
concern, venlafaxine is a good alternative. I have achieved
good therapeutic effect with many of the other SSRIs,
which I use according to the labeling and data reported in
Q:What is the optimal follow-up time for a patient
whose depression has responded to medication?
A:It's a good idea to see such patients every 6 months.
Always encourage patients to make an appointment
sooner if they have any questions or problems. Particularly
if they have any concerns about side effects and are considering
discontinuing their medication, encourage them
to call you first. If their condition has been stable with a
particular dose of an antidepressant, chances are the "side
effect" is related to a different medication or to an intercurrent
illness. When patients become ill, they may consider
their antidepressant to be the most expendable medication.
Be sure to reinforce the idea that the antidepressant
is effective only if taken exactly as prescribed.
Q:If a patient has had a good response to a
medication at a maintenance dosage, how long
should I wait to taper the dosage?
A:With a depression of recent onset and with a firsttime
diagnosis of depression, older patients should
generally be treated for 1 to 2 years (depending on the
severity of the depression and the response to treatment),
because of the increased risk of recurrence. For a trial of
drug withdrawal, a gradual taper is recommended. If the
depression recurs during the taper, the patient will probably
need to take the medication at the established therapeutic
dose for life.
Q:For which patients should I consider psychiatric
A:Depending on the perceived urgency of treatment
and on your own comfort level with higher doses, referral
to a geropsychiatrist may be considered, especially if
the depression has not responded to a second SSRI. One of
the most common reasons for lack of therapeutic effectiveness
is insufficiently high doses.
Also consider consultation if your patient has had only
a partial response to therapy; that is, if his symptoms persist,
but to a lesser degree, or if he has frequent episodes of
recurrent symptoms. Certainly, urgent referral is warranted
in any patient with suicidal ideation.
It is inappropriate to continue with a drug if its effect is
suboptimal--especially since there are so many pharma-cotherapeutic options. It is much more complicated in the
long run to manage patients who have been undertreated
or partially treated.
Q:Some of my patients are uncomfortable with
the idea of taking an antidepressant.
Is psychotherapy an effective option in this setting?
A:I often refer such patients to a licensed clinical social
worker or other professional who can provide psychotherapy.
Many patients do benefit, even those who have
mild cognitive impairment. Often, the decision to undergo
psychotherapy is based on cost and convenience considerations.
Patients can also seek counseling from a member of
the clergy or become involved in group programs or other
informal activities. Some patients' families
give them all the support they
need, and this can be a key factor in
overcoming a depressive illness.
Some older patients may resist
taking antidepressants because they
grew up in a time when psychiatric illness
was a major stigma. Some patients
may be more receptive to psychotherapy
or may have mild depression
that responds very well to this
type of therapy. The decision whether
to use antidepressants, psychotherapy,
or a combination of the two depends
on the severity of the depression, the patient's response to
a single modality, and practical considerations.
Q:Would you comment on the use of
St John's wort?
A:The results of clinical trials of St John's wort have
been ambiguous. Although this herb may be useful
for mild to moderate depression, recent trials (including one
conducted by the NIH) suggest that St John's wort is ineffective
in treating a major depression of moderate severity.4
Side effects of St John's wort include dry mouth, dizziness,
GI symptoms, increased sensitivity to sunlight, and fatigue.
This agent may also have adverse interactions with other
drugs or reduce their effectiveness.
Because complementary medicines are not held
to the same FDA standards as prescription or overthe-
counter agents, the contents may not correspond exactly
to statements on the label. There may also be significant
batch-to-batch discrepancies in chemical composition
and quality, even in a single product from the same
Be sure to encourage patients to inform you of any alternative
or complementary products they may be taking so
that the potential for side effects and drug interactions can