Depression not a "normal" part of aging

Scenario

A 78-year-old man, a retired engineer who is still active and working in the family business, is brought to your office by his son. The man complains of worsening memory loss over the last three to four months. He has experienced increasing difficulty remembering conversations and the content of meetings, and keeping appointments. Recently, his son found unopened statements on the kitchen table and realized his father had not paid his bills.

The father has a history of hypertension and benign prostatic hyperplasia, both well-controlled with medications that have not been changed for several years. A review of symptoms was negative, except for more frequent "aches and pains of old age." The man lives alone -- his wife died close to a year ago. He eats dinner at his daughter's home once or twice a week. She has not noticed a decrease in his food intake. The rest of the week he does his own grocery shopping and eats mostly "TV dinners." He is not a smoker and denies alcohol or other substance abuse.

A physical exam showed a man who looks his stated age. He is in no distress, alert and oriented; pleasant but somewhat disheveled. His vitals, head and neck, cardiovascular, lung and abdominal exam were normal, as was his neurological exam. His Mini Mental State Examination result was 27/30, losing two points in recall and one point in calculation. He scored seven positive answers out of 15 in the Geriatric Depression Scale. The normal range is zero to five.

Discussion

Symptoms of depression may be responsible for this patient's change in behavior. Something is different about him, and it emerged rapidly. Otherwise, he has been good at managing his tasks and responsibilities.

For patients in similar circumstances, depression should not be overlooked as part of the differential diagnosis, especially in cases where older men are left alone. It can mimic other conditions and symptoms -- signs of dementia, weight loss, and even aches and pains. These complaints should not be viewed as a regular part of getting older. And, although temporary blue moods are normal, especially in regard to the physical, emotional and financial hardships that can accompany aging, persistent depression that interferes with the ability to function is not, according to the National Institute of Mental Health.

The incidence of depression in the geriatric patient population is fairly common. Most studies have found prevalence to be between 5% and 15%. National Institutes of Health statistics indicate about 2 million of the 35 million Americans 65 and older experience full-blown depression. Another 5 million confront less severe forms. The risk increases when the patient has co-morbidities and when his or her ability to function becomes limited. In such situations, untreated depression can delay recovery or worsen the outcome of other illnesses. Still, the condition remains widely underrecognized and undertreated.

A combination of reasons explains why. Geriatric patients generally present with multiple medical problems and overlapping symptoms. Thus, it is challenging and time-intensive for physicians -- requiring more than the usual 15 minutes allotted for an office visit -- to investigate the physical and emotional factors involved for a patient like the one described here.

Often, the associated complaints are thought of as old age. Even health professionals may think persistent depression is an acceptable response to other aging-related serious illnesses -- an attitude patients sometimes share. And, stigma can be an issue. Patients frequently don't report psychological symptoms and reject the possibility they may be depressed. They also may resist the notion of a "happy pill."

But physicians can take tangible diagnostic steps. Initially, the doctor needs to rule out the possibility the depressive symptoms are caused by medication side effects (e.g. steroids, cardiac medications, benzodiazepines) or another medical condition -- untreated pain, vitamin B-12 deficiency, sleep deprivation or thyroid disorder -- by doing a complete history, physical exam and lab tests.

The doctor then can proceed with a treatment plan. Referrals to a mental health professional can be a positive step. Also, antidepressant medications can help. Older patients benefit from the same psychopharmacologic agents as younger patients.

But a word of caution. Proceeding with SSRIs or other antidepressant drugs for older patients can be tricky. These patients are often taking many medications, with increased risk of drug-drug interactions. Age and multiple chronic medical conditions influence the pharmacokinetics of medications and increase the sensitivity to side effects. Therefore, adjusting medications for older patients is more difficult than it is for younger ones.

Some tips include always checking for interactions, and monitoring levels of other medications if needed. Close follow up of the patient is necessary, especially when he or she begins the treatment. And, as always, it is important to start low and go slow.

Depression is a widespread condition that can take a serious toll on geriatric patients' quality of life and functionality. Being aware of the trouble signs is critical for physicians treating this population. After all, even in its most severe forms, statistics show the condition is highly treatable for older patients. Moreover, treatment often improves the outcomes of co-existing medical conditions. And this advice applies to a range of depressive symptoms. A patient can fall short of actual DSM-IV diagnosis of major depression but still very much need attention.