The Geriatric Syndrome of Late-Life Depression J. Kennedy,

Dr. Kennedy is associate professor and director of the division of geriatric psychiatry at Albert Einstein College of Medicine-Montefibre Medical Center, 111 East 210th Street, Bronx, New York 10467. This paper is part of a special section on syndromes in geriatric psychiatry.

of situations. The focus of treatment is extended beyond inducing nemission to preventing recurrence. And the assessment of treatment is expanded to include more socially meaningful outcomes in addition to the relief of symptoms. This bewildering array of recommendations would be challenging enough in treating younger adults, for whom a depressive disorder is likely to be the only source ofdisability. With olden adults, for whom comorbid physical and mental disordens are the norm rather than the exception, application of these pnincipies would be overwhelming if it were not for the concept of geriatric syndromes, to which late-life depression should be added. The concept of geriatric syndromes has evolved in medicine to characterize common late-life conditions for which the conventions of etiology and diagnostic nomenclature are inadequate (3). Miller and Kaiser (4) have defined geriatric syndromes as “disabling and potentially remediable problems commonly seen in geriatric patients.” Although new to psychiatry, the concept ofgeniatnic syndromes is an established component in materials used to prepare fellowship-trained primary cane physicians for certification in geriatric subspecialization (5). Cognitive impairment, incontinence, deficits in hearing or vision, osteopenia including osteoporosis and fractures, falls, immobility, pressure sores, malnutrition, and polypharmacy are the most frequently cited geriatric syndromes. The terminology is not just semantic convenience. Rather, it reflects the multiple etiologies that typify these problems and the multidimensional nature of treatment required to return the olden person to optimum functioning.

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Gary Existing course,

and

data on outcome

M.D. the

treatment, of depression

are not representative of the older depressed person who is most frequently encountered in clinical practice. if mental health services are to become mote effectively applied, late-life depression should be conceptualized not as a categorical disorder but as a geriatric syndrome with multipk etiologies requiring a combination of treatments. To support this argument, the author reviews the prevaknce of late-life depression across dinicaland community settings and in association with somatic and central nervous system conditions. He

recommends

a comprehensive

geri-

atric assessment and a tripartite treatment approach incorporating definitive, rehabilitative, and supportive interventions. The conclusions of the 1 99 1 National Institutes of Health Consensus Conference on Late Life Depnession (1), in combination with the American Psychiatric Association’s practice guideline for major depnessive disorder in adults (2), reflect a paradigm shift in the clinical approach to depression in old age. Treatment for depression is indicated at a lower threshold of severity of symptoms and in a broader range

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This paper reviews the prevalence of late-life depression in clinical and community settings and in conjunction with somatic and central nervous system conditions to support the view that late-life depression should be considered as a geriatric syndrome rather than as a categorical disorder. The paper then outlines the kind of functionally oriented compnehensive geriatric assessment needed to achieve optimum therapeutic benefits for the patient, and it describes a comprehensive treatment approach that includes definitive, rehabilitative, and supportive elements. Late-life

a geriatric

depression syndrome

as

Several lines ofevidence argue for the syndnomal approach to geriatric depression. First, it resolves the contradictions between clinical (6) and epidemiologic (7) studies of the prevalence of depressive symptoms in old age. Healthy, noninstitutionalized elders are remarkably free of major depression , but depressive symptoms are prevalent among physically ill or disabled elders. Most depressed older adults have symptoms that either are not congruent with diagnostic categories or coexist with physical illness. In a study that combined both symptom and diagnostic measures, Blazer and associates (8) found a subthreshold syndrome of mixed depression with anxiety in 1 .2 percent ofolder community residents. Secondary analyses identified an additional minor depressive disorder of late life characterized by impaired cognition and poor physical health. DSM-iii-R diagnoses neither captured nor displaced members of these groups (9). Current understanding of the ma-

43

Table 1 Sociodemographic

situations

and medi-

cal and

conditions

in which

psychiatric

the geriatric pression

syndrome approach be most beneficial

may

Sociodemographic

to de-

situations

Bereavement

and

Advanced

age (over

social

isolation

75 years)

Caregiving situation in which older person cares for a person with dementia Residence in a nursing Elder abuse and neglect

Common

cardiac

tions Myocardial

an

home

and vascular

condi-

infarction

Stroke Common neurologic Parkinson’s disease Dementias Other physically of recent onset

conditions

disabling

conditions

Hip fracture Trauma Psychiatric disorders

Conditions benefiting from the syndrome approach

Dysthymia Minor depression

Major depression, especially recurrent Mixed anxiety and depression Bipolar

when

illness

Depression

psychosis disorder with mood

with

Adjustment or anxious Disabling

somatic

characteristic

depressed

complaints ofsomatic

unillness,

such as somatoform disorders real or potential

Self-harm,

Suicidal

ideas

Self-neglect Self-injurious

behaviors

jor neurotransmitten systems and biological treatments also supports the concept oflate-life depression as a geriatric syndrome. First, serotonergic aberrations are implicated in the etiologies of both affective and anxiety disorders as well as psychotic and nonpsychotic illness (10). Second, antidepressants are effective in the treatment of both depressive and anxiety disorders but are not adequate alone for the treatment of psychotic depression. Studies of primary cane patients reinforce the value of viewing latelife depression as a geriatric syndrome. The amounts of ambulatory care services used by older adults (11), as well as their entrance and permanence of stay in nursing facilities (12), are related to depressive

44

symptoms independent of associated disability and the weight of medical conditions. In the Medical Outcomes Study, depressed primary care outpatients were consistently more physically and socially dysfunctional than their peers with chronic physical conditions (1 3). Only candiovascular disease carried a greater disability. The disability of depression amplified rather than displaced the disability associated with chronic conditions. Moreover, one-quarter of patients whose depressive symptoms did not reach criteria for dysthymia or major depression developed a major depressive disorder within 24 months offollow-up (14). Thus the physical morbidity associated with depression may be avoidable (1 5).

Table 1 presents sociodemognaphic situations and various physical, neurological, and psychiatric conditions in which the geriatric syndrome approach to treatment may be most helpful. As many as 30 percent of elderly medical inpatients and outpatients show significant levels of depressive symptoms (16), and close to half that amount meet DSM-iii criteria for a depressive disorder (17). Major depression occurs in the majonity of patients within six months after stroke (18) and impedes rehabilitation (19). Twenty percent of persons with Parkinson’s disease experience a major depressive episode, and another 20 percent suffer dysthymia(20). Depressive disorders are no less frequent in dementia (21)and are common among caregivens of persons with dementia living in the community (22). The most prevalent mental illness in nursing homes is dementia, followed by depression and by dementia complicated by depression (23). Low income, life events, and difficulties with companionship heighten the risk of depression (24,2 5). Older adults may also be more likely than younger adults to develop a major depressive episode after bereavement (26). However, poor health and disability play the predominant role in explaining the prevalence and dynamics of depressive symptoms in

Psychiatric Services

older community residents, ovenshadowing the contribution of sociodemographic, life event, and interpensonal factors (27). And among elders receiving routine care, psychotropic treatment tends to be symptomatic, with hypnotics and antianxiety agents, rather than definitive, with antidepressants. Not surprisingly, depressive symptoms are relatively persistent in the context of routine care (27). Current opinion about recovery among older adults hospitalized for a depressive episode is also pessimistic (28). Although two-thirds of olden patients recover, from a quarter to a third remain either relatively symptomatic on significantly disabled. The rates of relapse and recurrence increase with advanced age. In some studies, psychosocial factors are associated with poor patient outcome, but cognitive impairment and physical illness are more consistent pnedictors (29). Comprehensive assessment Because late-life depression is so intimately tied to functional disability, a more functionally oriented comprehensive geriatric assessment, as described by Blazer (30) and Winognad (3 1), among others, is often required to achieve optimum therapeutic benefits. Table 2 presents the components of an evaluation that should identify therapeutic avenues, obstacles to intervention, and reasonable goals. The product ofa comprehensive geriatric assessment is a rehabilitative path to the most independent level of function attainable given the person’s abilities and environment. The assessment need not be exhausting to be comprehensive. Most older adults are brought to the attention ofa psychiatrist by a third panty such as a family member, a primary care provider, or a social service agency. Therefore, an interview with a collateral informant is usually acceptable to the patient and may be essential both for assessment and for maintenance of a therapeutic regimen. Time spent with a collateral informant makes the interview of the patient more efficient for the psychiatrist and less burdensome for the patient.

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Physical examination and diagnostic laboratory procedures are often carried out before the patient is referred for psychiatric evaluation. A

begins with a tripartite approach composed of definitive, rehabilitative, and supportive elements. Because the relationship between de-

review

pression and disability

of medications,

both

pre-

is reciprocal,

scnibed and otherwise, will reveal unfavorable interactions and negimens that the patient may have difficulty following. Reduction in polypharmacy and a switch to medications less likely to affect the older person’s mental status and quality of life (32) are obvious goals. Nutnitional assessment may also be mdicated when the patient is frail, when dentition is in disrepair, and when weight loss is a problem. Functional assessment of activities ofdaily living includes a review of the person’s capacity to attend to personal hygiene, ambulation, shopping, and management of finances and the extent to which assistance is required in any of these areas. During the functional assessment, the physician searches for disabilities that might be remediated with physical on occupational therapy as well as former responsibilities that the patient has unnecessarily relinquished as a result of apathy or despain. A review ofsleep habits will assist in differentiating sleep disturbance of depression from inefficient sleep habits related to inactivity, scheduling irregularities, noctunia, or arthralgia. An assessment of social rhythms (33), the day-to-day flow ofboth formal and informal socially supportive activities, will indicate the extent to which the patient is isolated on has abandoned social reinforcers of selfesteem and engagement. It will also specify socially meaningful points of intervention as well as measures of recovery. Finally, a series of elective procedures are indicated when the patient fails to respond to interventions on when a latent dementia or other central nervous system disorder is suspected. They include challenging the hypothalamic-pituitary-

interventions must be relevant to both etiology and treatment of each to be fully effective (34). The approach begun in the first weeks or “acute phase’ of treatment extends into the first months, the “continuation phase,” and beyond into the first year or “maintenance phase.” In the acute phase, alleviation of symptoms is termed “remission,” with the term “recovery” reserved for a more extended asymptomatic period. The reappearance of symptoms in the continuation phase is termed ‘nelapse” and implies that the patient never fully recovered from the index episode. In the maintenance phase, the reemergence of depression is termed a “necurnence” (35). Major depressive disorders more often have a lifelong course so that the prevention of recurrence beyond induction of a remission becomes the longrange goal (36). Physical disorders that are accompanied by depression should be treated definitively. For example, thyroid disease should be treated with thyroid replacement. However, the treatment of associated depression need not be withheld while waiting for the somatic disorder to remit. Adding antidepressant treatment should be based on the extent to which the person’s function is impaired as well as the depth and duration of dysphonia. This approach should be applied to depression in the context of bereavement as well. The cause of the depression may be obvious (“natural”), but when recovery is not spontaneous or the condition is too painful, interventions are justified. When depression arises de novt in late life, without comonbid conditions, definitive treatment is antidepressant medication or psychother-

adrenal axis, neuropsychological evaluation, brain imaging, electroencephalogram, and examination of spinal fluid. Comprehensive treatment As shown in Table 3, the treatment of depression as a geriatric syndrome

apy on both. However, even combined antidepressants and psychotherapy may not be adequate. More often, lessening disability and improving social function, as well as reducing sadness, apathy, irritability, sleep disturbance, and loneliness, will require interventions in the en-

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‘

Table 2 Comprehensive depression1

geriatric

assessment

of

History Physical examination Mental status examination, including cognitive screening instrument Interview ofcollateral informant Patient personality assessment Survey ofprescnibed and over-thecounter medications Nutrition

survey

Functional assessment daily living Functional assessment Assessment ofsocial support

ofactivities ofsleep

of habits

rhythms

(social

activities)

Routine diagnostic Electrocardiogram

procedures

‘

No.1

Complete blood count Urinalysis T3, T4, thyroid-stimulating B12 level Folate level Glucose, electrolytes, BUN, nine chemistries

Liver function VDRL test (IfVDRL

chest

ment

is positive,

X-ray

skin

test

for tuberculosis virus

procedures

resistance

creati-

tests

test for HIV cated) Elective

hormone

may

to clarify

and

and

mdi-

be

treat-

or prognosis

Dexamethasone

suppression

test

Electroencephalogram

Computed Magnetic

transaxial resonance

Neuropsychological

Polysomnogram Examination I

Adapted

from

tomography imaging tests

(sleep study) ofcerebrospinal Blazer

fluid

(30) and Winograd

(31)

vinonment and with the caregivers. Social isolation may need to be countered by referral to, or return to, a senior citizen or religious center, by hiring a home health aide or companion, on by helping the family schedule a more reliable pattern of visitation. Physical therapy in the home or a physiatry clinic may assist the older person to regain or improve ambulation, stamina, and independence. Occupational therapy focused on the upper extremities and the manual skills so important in caring for one’s hygiene and nutrition may be critical to the restoration of self-esteem, pride in appearance, and optimism. Physical and occupational then-

45

Table

3

Treatment

of late-life

depression

as a geriatric

syndrome

When depression is associated with somatic illness, disability, or dementia Definitive, restorative (such as thyroid replacement) Rehabilitative (such as physical or occupational therapy) Supportive (such as family or caregiver counseling, psychoeducation) When depression arises de novo or the above approaches seem inadequate

Psychotherapy Individual Marital,

(interpersonal family, group

Pharmacotherapy Nortriptyline

Sertraline, Venlafaxine Trazodone Tranylcypromine

Bupropion

or cognitive-behavioral)

of unipolar (therapeutic paroxetine

(not

(no sedation (sedating,

disorders levels available,

hypotensive (hypotensive

(not sedating

mild

anticholinergic

effect)

sedative, no cardiovascular or cognitive risks) or cognitive impairment, may elevate blood pressure) but

but not anticholinergic) neither anticholinergic

but associated

with

seizures

nor sedating)

and weight

loss)

Buspirone

(for anxiety with depression) Pharmacotherapy of bipolar disorders or augmentation of unipolar regimen Lithium (therapeutic levels available, extended release preparations available) Carbamazepine, valproic acid (therapeutic levels available) Triiodothyronine (for augmentation only) When depression occurs with psychosis or fails to respond to combinations ofthe above Haloperidol (extrapyramidal side effects but little cardiovascular risk) Thionidazine (no extrapyramidal effects but hypotensive, sedative) When depression is life threatening or fails to respond to combinations of the above

Electroconvulsive

therapy,

twice

weekly,

apy may be particularly important when apraxia complicates the panesis ofstnoke or the memory impairment of dementia. A speech pathologist may be essential ifaphasia confounds the rehabilitation ofmood and interpersonal skills following a stroke. When the identified patient is unlikely to benefit or incapable of benefiring from the restorative approach, the focus of concern turns to the caregiver in an effort to support the maintenance of what independence and well-being remains. Psychotherapy and psychoeducation. Medication noncompliance, comorbidity, and social isolation are not the only problems requiring nonmedication approaches (37). As a personality trait, depression may predispose the vulnerable individual to recurrent major depression, contribute to poor treatment response, or impede rehabilitation (38). “Double depression,” the appearance of a major depressive episode with a background of prior dysthymia or chronic depression, is seen in as many as one-third of clinic patients with a mood disorder (39). Cognitive-behavioral psychotherapy and interpersonal psychotherapy were developed specifically for depression and operationalized with

46

over three

to five weeks

specific instructions for research purposes. The cognitive-behavioral approach is based on altering the depressive triad ofdistorted beliefs that the individual is inadequate, the situation is immutable, and the futune is negative. Studies that have found benefits of cognitive-behavional therapy for depressed older adults have more often focused on physically healthy, cognitively intact community residents. The indications for cognitive-behavioral thenapy as opposed to interpersonal thenapy and the efficacy ofthe two interventions among disabled elders requine study (40). However, it is genemIly accepted that combined pharmacotherapy and psychotherapy minimize both attrition from treatment and recurrence (41). Depression may provoke a cycle of deterioration within marriage and family relations (42). Issues of communication, intimacy, and individuation that commonly arise in marital therapy with younger couples are present with older couples but may be difficult to approach without attention to the individual’s need for concrete social services or psychotropic medication (43). The problem of recurrence of depression despite good compliance with the treatment

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program highlights the need for a family psychoeducational approach as a multigenerational treatment modality for depression (44). Antidepressant therapy. Anticholinengic, sedative, and cardiovascular effects and drug interactions limit the utility of even the safest agents. Therefore, the choice of agents is dictated by a drug’s side effect profile , patient characteristics, and availability of therapeutic levels rather than by differences in efficacy. Because the latency of antidepressant effect may be prolonged in the elderly (45), considerable psychotherapeutic skill is required to mainrain the patient’s and family’s collabonation. However, associated anxiety, agitation, and sleep disturbance may be ameliorated earlier. Maintaining treatment at levels used during the acute phase of illness will achieve a 36-month recurrence-free interval in close to 80 percent of patients (46). Reducing the acutephase antidepressant dose for maintenance increases the recurrence rate and may contribute to incomplete remission, leading to a persistent depressive condition (47). Nontniptyline is my first choice for depression in older patients. It has known upper and lower plasma levels (the therapeutic window) in which response to the drug and toxicity are more likely to occur. Nortniptyline also has mild anticholinengic action and may be effective at a low dose (48). A soluble-fiber laxative should be instituted with the first prescription to prevent constipation. Ifanticholinergic and pnoarrhythmic effects must be avoided entirely, the reversible monoamine oxidase inhibitor tranylcypromine may be useful (49). Dietary and medication precautions must be followed, and hypotension can be a problem. When sleep disturbance or agitation are the most troublesome featunes, trazodone may be effective without impairing cognition or promoting arnhythmi#{225}s. It is potentially hypotensive. For patients who are lethargic or demented, frail, and hypotensive, the other senotonergic agents-sentraline and paroxetineon the mixed senotonergic-noradrenergic venlaflixine may be chosen. BuJanuary

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propion may be particularly effective for depression ofParkinson’s disease. Sentrali ne , paroxeti ne , venlafaxine, and bupropion are stimulatory rather than sedative, and have no cardiac or cognitive toxicity (2). I consider them preferable to the psychostimulant methylphenidate. However, despite a favorable side-effect profile, the selective serotonergic reuptake inhibitons may prove to be too selective for some yet-to-be-defined subpopulation that requires the more noradrenergic effects of nontniptyline, tranylcypromine, or the recently introduced venlafaxine. Medicationsfor bipolar disorder and augmentation strategies. The use oflithium to treat late-life bipolan disorder or to augment the therapeutic response ofantidepressants in the elderly is not well studied. Elderly persons may experience lithium toxicity even when therapeutic levels are normal (50). The anticonvulsants carbamazepine and valproic acid are not first-choice agents to augment antidepressants or to treat mania. However, they have therapeutic 1evels and may be preferred for dementia patients and others whose cerebrovasculan or renal function is sufficiently compromised to make lithium unsafe. Finally, low doses of tniodothyronine (T3) may be added when complete remission is not attamed despite adequate therapeutic levels and adequate duration of antidepressant treatment. When psychosis is apparent or is suspected of contributing to incomplete remission, low-dose halopenidol can be added to nortniptyline, trazodone, or tranylcypromine. Thioridazine is less likely than haloperidol to provoke extrapynamidal side effects, but due to its sedative and hypotension propensities, it should be added only when sertnaline, paroxetine, venlafaxi ne, or bupropion is already in place. There is no rationale for monotherapy in the treatment of psychotic depression. Electroconvulsive therapy. Agerelated characteristics increase the usefulness of electroconvulsive therapy (ECT) as a treatment for geriatric major depression (51). They include medication intolerance or inefficacy and the need to rapidly turn around suicidal risk or morbid nutritional

Psychiatric

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1995

status. Advanced age, concurrent use ofantidepressants, and compromised cardiovascular status increase the risk ofadverse reactions, with cardiovascular complications being the most frequent events. The cognitive impairment associated with ECT includes universal but temporary postictal confusion, less common transient anterograde or retrograde amnesia, and the rare but permanent amnestic syndrome in which memory of events surrounding the treatment is lost (52). Treatments should be limited to twice weekly and may be administered unilaterally to the nondominant hemisphere to minimize confusion. Unfortunately, bilateral treatmerits may be more effective (53). Maintenance treatment with ECT has gained recent support (54) and may offer higher rates of recovery. Conclusions Existing data on treatment, course, and outcome of depression are based on studies of categorical disorders that are too restrictive for the most frequently encountered older patients with depression (55). Similarly, the outcome of late-life treatmerit has been more often judged on the basis ofsymptomatic relief rather than reduction in disability or improved quality of life. Without a more global approach to both treatment and outcome, the benefits of mental health services for the more heterogeneous group of seniors found to be depressed will remain unproven (56). These problems require a new vantage point that conceptualizes old-age depression as a syndrome rather than a categorical disorder. However, the existing studies of depression in physically healthy elders as well as those with comorbid conditions are already sufficient to call for an expanded state of the art in clinical practice. Research on matching treatments of late-life depression with various patient settings, with comorbid conditions, with the differential skills of the various clinical disciplines, and with the use of specialists versus generalists is critical to establish efficacy and justify health care expenditures. Given the complexities of etiology and treatment in

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old age, clinical clinical science. to support the depression as a tainment will merely academic.

art may well outpace Without the science concept of geriatric syndrome, cost-conmake the argument

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