Generally, geriatric depression is considered to be a separate clinical entity. However, systematic research provides little or no evidence supporting this view [15
]. It has been reported that patients who manifest depression for the first time in late life, are less likely to have a positive family history for affective disorders compared to younger patients with depression [16
] and are more likely to manifest structural changes of the CNS [18
]. Various studies of MDD in elderly adults, reported that mood is more often irritable than depressive [21
]. Elderly patients with MDD appear to exhibit certain symptoms more than younger MDD patients. These symptoms include loss of weight, feelings of guilt, suicidal ideation, melancholic type MDD, hypochondriasis as well as a higher frequency of associated symptoms of psychosis [22
]. However, these findings vary across studies. The ratio of males to females with MDD remains stable across the age spectrum in various studies of depression [19
Many times, depression has an insidious course and neither the patient nor his/her relatives or therapists can recognise it easily. This is especially true in cases where other serious somatic problems are present [27
]. Clinicians should obtain a history from as many reliable sources as possible and critically evaluate this information while considering the entire clinical picture [28
]. Somatic symptoms are difficult to assess and, as a general rule, physicians should avoid assigning this symptomatology to an underlying mental disorder. It is highly likely the patient indeed suffers from a true 'somatic' disorder even in cases the physician is unable to diagnose it [29
]. On the other hand, it is clear that elderly depressives manifest more somatoform symptomatology, in comparison to younger depressives.
While, depression is common in older patients it still often goes unrecognised. A study of 141 family physicians and general internists found that two thirds of the physicians used no standard test to screen for depression. The two most common laboratory tests ordered were thyroid studies (41.1%) and chemistry panels (37.6%). Selective serotonin reuptake inhibitors were most commonly prescribed for depression (53.2%). It is important to note that 29% reported that they were frustrated when dealing with depressed elderly patients [30
-The concept of Masked Depression
] used to be popular in the past, but today it is not accepted by either DSM-IV or ICD-10. However, DSM-IV accepts that the onset of health concerns in old age is more likely to be either realistic or to reflect a mood disorder[29
], and thus indirectly leaves space for the concept of masked depression.
is one of the 'core' symptoms of depression at any age. However, this symptom may be absent in many elderly depressives. Additionally, the presence of a personality disorder may confuse the clinical picture. Usually, elderly depressed patients maintain their ability for emotional responses to positive external events and their mood fluctuates widely and more frequently than is the case in younger patients [32
]. In any case, the best way to clarify these issues is personal history, often from an informant.
-Anhedonia: Elderly depressives retain an emotional responsiveness to external positive events and profound anhedonia is rare.
-Psychomotor retardation is not usually present, and generally is linked with melancholic features or 'vascular' depression.
Anxiety symptomatology in the frame of geriatric depression is not well studied. Usually, definitions and criteria base upon the study of young patients are also applied to the elderly. This approach may not be appropriate. Anxiety in the elderly is rarely present alone and almost never fulfils criteria for a solitary anxiety disorder [33
]. A careful interview may reveal a pervasive tendency to manifestations of anxiety since early adulthood and many times a diagnosis of a personality disorder is given [22
]. Fear of death was considered to be a late-life characteristic, however empirical studies showed that it is most prominent during midlife, in contrast to Erikson's theories [35
]. In elderly patients, anxiety is often clinically present as tension, unrest, feelings of insecurity or fear, irritability and intense worry rather than as autonomical symptoms. The definitions and symptomatology of anxiety and depression largely overlap each other. About 38–58% [36
] of the elderly suffering from major depression also fulfil DSM criteria for an anxiety disorder. Many authors have suggested that the presence of anxiety in the elderly should be considered as a sign of depression, even in cases, which lack true depressive symptomatology [37
-Insomnia: In the elderly, sleep duration is often shorter and sleep is more fragmented, and this may mislead the physician to overlook this symptom.
-Loss of appetite: This symptom is also difficult to assess, especially in individuals living in circumstances whereby the quality of food may be low. On the other hand, true loss of appetite may mistakenly be attributed to low quality of food.
: This symptom is usually present, however it may be blamed on old age, and treated with vitamins and other 'antifatigue' drugs. The image of a health insurance booklet filled with this kind of prescription is extremely common worldwide. A recent study on suicide victims who had asked for professional help concerning their mental health problem before committing suicide, found that the vast majority of GPs who had examined these patients a few months prior to their completed suicide, had prescribed this type of medication for their treatment [38
-Thought content: Feelings of guilt and self-reproach are relatively rare and screening for these feelings may invoke hostility from the patient. Complaints concerning the level of care and the behaviour of staff and relatives are prominent. Feelings of helplessness and hopelessness are common.
Elderly depressed patients may have thoughts of dying including suicidal ideation. Many times this reveals itself indirectly, and therefore is not always easily recognizable. Generally, about 83–87% of elderly suiciders suffer from a mood disorder, with major depression accounting for 65% of cases [39
Suicide increases with increased age, and this constitutes an important health problem for the elderly. Elderly men are at a higher risk for completing suicide than elderly women. The co-existence of a serious somatic disease, like renal failure or cancer, represents a major risk factor for a well-planned suicide attempt [40
]. Other risk factors include loneliness and social isolation, usually as a consequence of bereavement. Some authors suggest that the failure to follow medical advice in serious general medical conditions should be considered a form of 'passive suicide'. 'Rational' suicide plans are not common even in severely ill patients. There is a possibility of acute-onset suicidal plans (after an acute incidence concerning general health e.g. stroke or heart attack) [32
and hypochondriacal symptomatology are more frequent in late-life depressives than in younger patients. As mentioned above, the assessment of this kind of symptomatology is extremely difficult, since many times such complaints are the result of actual health problems. Somatic and hypochondriacal complains with onset in old age may be indicative of an underlying depression [41
- The existence of psychotic symptomatology
during a depressive episode is considered to be a sign of poor prognosis and may respond better to electroconvulsive therapy [3
]. The usual content of delusions is depressive-aggressive (nihilistic, somatic, of poverty). Auditory hallucinations are less common. The presence of psychotic symptoms may be a prognostic sign of more frequent recurrences [42
] (only 10% of patients are symptom-free after one year) and of a need for repeated hospitalisations [43
] (about 2.5 times higher risk for readmission).
are reported in the international literature to be a usual finding in depressed patients. In elderly individuals there is an increased possibility of the co-existence of depression and dementia, or some other type of 'organic' decline of cognitive disorder. The syndrome of 'pseudodementia' has also been described [44
]. This term refers to the manifestation of dementia symptomatology, which in fact is due to depression and disappears after antidepressant therapy. A common finding of everyday clinical practice is the discrepancy between the cognitive complaints of the patient and their neuropsychological evaluation, which may indicate that there is no apparent cognitive disorder [45
]. The careful assessment of cognitive function may well lead to correct diagnosis and differentiation between dementia and depression. Thus the term 'pseudodementia' may be misleading [47
]. Indeed, the evidence increasingly suggests that cognitive deficits are a noted concomitant of late-life depression. Of the patients suffering from late life depression, 20% to 50% are estimated to have cognitive impairment greater than that observed in age and education-matched controls [50
]. The cognitive domains implicated in late life depression include executive function, psychomotor speed, attention and inhibition, working and verbal memory, and visuospatial ability [53
]. In particular, observed deficits in attention and response inhibition and executive function in this population has led investigators to propose the "executive dysfunction" hypothesis of depression, whereby deficits in this cognitive domain is strongly associated with late-life depression and vegetative symptoms [55
]. These deficits are proposed to be subserved by deficits in frontal lobe function. Several investigators have suggested that the cognitive deficits in depressed older adults are of clinical significance given that such deficits have been associated with increased rates of relapse, disability and poorer antidepressant response [56
Hierarchically, dementia should be ruled out before making a diagnosis of depression. Recent reports consider 'pseudodementia' the result of the interaction of depression with other biochemical disturbances of the brain and point to the possibility that the patient may develop dementia in the future [59
(agitation) is defined as verbally aggressive, physically aggressive or physically non-aggressive behavior that is socially unacceptable, according to the definition proposed by Cohen-Mansfield and Billig [60
]. Of these three aspects of agitated behavior, verbal aggressiveness is considered to relate to depressed affect in non-demented individuals, or in individuals suffering from a mild form of dementia [62
]. Verbally aggressive behavior includes continuous complaining, the demand for the attention of relatives and the staff, negativistic behavior, continuous asking and shouting. It is possible that the patient may have objective reasons that make him/her manifest agitation. Patients who confound physicians and nursing staff, both diagnostically and therapeutically, may respond well to antidepressant medication [63
Many of these patients manifest a type of behavior that can be characterized as 'passive-aggressive' or 'self-aggressive'. They refuse to get up from bed, eat, wash themselves, or talk. Also, they often hide important information concerning severe somatic disease and in this way they let it go untreated.
-Insight may vary and may be totally absent in cases of agitated or regressed behavior.
It is not yet clear whether the clinical manifestations of depression vary across cultures and different socio-economic backgrounds. Two opposing theories have been proposed. The first suggests that there is a transculturally stable core of symptomatology [64
], while on the contrary, the second argues that depression may manifest itself in a different way in patients who do not share a common cultural environment [65
]. Many authors believe that there is an increased prevalence of depressive symptomatology (not necessarily clinical depression) in black Americans compared to whites, because socio-economic factors are not usually taken into account [66
Studies from Japan and Taiwan [67
] report lower frequency of depressive symptomatology in the elderly population compared with studies from Western Europe and the US. The authors attributed these discrepancies to differences in the structure of the family (larger families with stronger bonds in Japan) and to the increased activity of the Japanese elderly.
As far as the quality of symptomatology and the relative frequency of appearance of individual symptoms in young patients are concerned, studies suggest that Caucasians manifest more affective symptoms (depressed affect), patients from China manifest more somatic complaints (e.g. sleep disorder) and that the Japanese manifest more interpersonal functioning problems (e.g. feelings of rejection by others) [68
]. However, a particularly well designed study of Krause and Liang [72
] suggested that the above conclusions are not valid for elderly patients.
Recent studies suggest that ethnicity may impact the prevalence of suicide. African-Americans manifest the peak of suicide in the age of 25–29 years, and this peak seems to relate to stressful life events. The same is true for Indian-Americans and Alaskan natives. White males appear to manifest two separate peaks in the histogram of suicide, one during mid-life (mid-life crisis) and one after the age of 80 [73
]. In addition to ethnicity, social environment may also impact the prevalence of suicide.
It is highly possible that the marked differences in mental health between ethnic groups reported by some authors might reflect socio-economic and health differentials acting concomitantly and adversely. Inequalities in housing, social support, income and physical health status may account for variation in mood observed between immigrants and locals, and may partly explain differences in life satisfaction. Better social support and housing among 'minority ethnic' elders who live alone might be expected to alleviate social stress and improve mental health and psychological well-being [74
Although not well studied, religion is another factor that may be associated with depression. A study from the US reported that almost 25% of patients use religion to cope with depression [75
], and also religious patients had more stable, supportive and higher social environment and higher intellectual functioning [76