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Diagnosing Depressive Disorders
DEPRESSION IN THE ELDERLY
elderly patient Major depression is extremely common in the older patient:
• 25% of all depressed patients are over the age of 60
• 20% of patients over the age of 65 have significant signs of depressive illness
• 10 to 20% of older depressed patients commit suicide.

Symptoms of depression in the elderly:
• vague back and neck pain
• no energy
• no appetite
• difficulty sleeping.

Mood equivalents of depression in older patients may be key too: if patients are irritable, demanding or importuning, they may be showing signs of depressive illness as well and further probing is likely warranted.

Distinguishing between depression and dementia may be necessary as well; not uncommonly, both disorders co-exist.

Identification of depression in the elderly is also complicated by attitudes towards mental illness and the elderly. Not only are older patients reticent to talk about their emotions, the stigma that still accompanies mental illness is particularly real for older patients, for whom depression is often a sign of weakness.

There may also be a tendency for society to assume that major depression is a normal consequence of aging or at least a consequence of physical deterioration and illness, both of which are more likely in advancing age. The elderly also face many losses - spouses, friends, work and health - and normal bereavement is often difficult to distinguish from a major depressive episode. (Grief that does not begin to resolve within several months of the event may be a harbinger of a major depressive episode and deserves closer investigation).

 

Depression Checklist for the Elderly

A simple checklist has been specially developed to detect depression in the elderly. The patient is asked to choose the answer that best describes how they have felt over the past week. Answers indicating depression are in the bolder type. Each answer counts as one. A score between 5 and 9 indicates a strong possibility of depression, while a score of 10 is almost always a sign of depression.
1. Are you basically satisfied with your life? Yes No
2. Have you dropped many of your activities and interests? Yes No
3. Do you feel that your life is empty? Yes No
4. Do you often get bored? Yes No
5. Are you in good spirits most of the time? Yes No
6. Are you afraid that something bad is going to happen to you? Yes No
7. Do you feel happy most of the time? Yes No
8. Do you often feel helpless? Yes No
9. Do you prefer to stay at home rather than going out and doing new things? Yes No
10. Do you feel you have more problems with memory than others? Yes No
11. Do you feel it is wonderful to be alive now? Yes No
12. Do you feel pretty worthless the way you are now? Yes No
13. Do you feel full of energy? Yes No
14. Do you feel that your situation is hopeless? Yes No
15. Do you think most people are better off than you are? Yes No
From Yesavage JA. Depression in the elderly: How to recognize masked symptoms and choose appropriate therapy. Postgrad Med 1992; 91(1):256.

Depression & Chronic Illness in the Elderly
Complicating identification of major depression in the elderly is the often concomitant presence of a medical condition that may predispose the individual to depressive symptoms:

• dementia
• stroke
• cancer
• Parkinson's disease
• Alzheimer's disease
• metabolic and endocrine disorders - hypo- or hyperthyroidism; anemia; diabetes; renal failure; abnormal calcium levels
• subarachnoid hemorrhage
• alcohol abuse.

 

Patients may be fearful or demoralized about a chronic illness, but major depression is not a normal response to illness. If symptoms suggestive of depression are present, the illness should be diagnosed and treated accordingly.

Clinical Presentation in the Elderly: SIG E CAPS
The clinical picture of elderly patients has been summarized by the mnemonic SIG E CAPS: Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor, and Suicide.

The SIG E CAPS criteria parallel the DSM-IV criteria for major depression:
Sleep - typically early morning awakening, occasionally exhibited by hypersomnia
Interest - loss of interest in previously enjoyed activities (social and job activities, hobbies, sex)
Guilt - unwarranted feelings of self-reproach
Energy - perpetual fatigue
Concentration - confusion or slowed thinking, inability to concentrate
Appetite - poor appetite and loss of weight; occasionally, overeating
Psychomotor - psychomotor retardation; occasionally, agitation
Suicide - recurrent thoughts of death or suicide.

 

Depression or Dementia?
It is important to distinguish patients whose memories are impaired due to a depressive illness from those who are suffering from dementia. Key differentiating features include:

Depression or Dementia?

Depression Dementia
Onset: relatively rapid insidious, indeterminate
Symptom duration: usually short usually long
Mood: consistently depressed variable
Cognitive impairment: inconsistent fairly consistent
Disabilities: highlighted by patient concealed by patient
Typical Answers: "I don't know" "Near miss", confabulation

Blazer DG, Friedman SW. American Family Physician 1979;20(5).

Please see:

Section IV: "Depression in Special Populations"
CANMAT – Guidelines for the Diagnosis and Pharmacological Treatment of Depression
(1st Edition Rev., 1999)
P. 46

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Over one million Canadians suffer from some form of depressive illness.