I searched MEDLINE and Ageline abstracts to 1980 with the keywords “depression”, “depressive disorder”, “bereavement”, “geriatric aging”, “late-life”. I focused, however, on empirical studies, meta-analyses, and authoritative reviews published after 1990, since most progress in understanding late-life depression took place after this date. Among them, I selected work published in English on the diagnosis, recognition, pathophysiology, prevention, and management of late-life depression.
SeminarDepression in the elderly
Section snippets
Diagnosis
For a diagnosis of major depression to be made, DSM-IV and ICD-10 state that either depressed mood or loss of interest or pleasure must be present (panel 1). Although not part of the diagnostic criteria, late-life major depression is often associated with peripheral body changes and cognitive impairment. Changes to the body include hypercortisolaemia, increased abdominal fat, decreased bone density, and increased risk for type 2 diabetes and hypertension.4 Non-demented elderly people with major
Epidemiology
1–4% of the general elderly population has major depression,2 equivalent to an incidence of 0·15% per year. Twice as many women as men are affected. Both the prevalence73 and the incidence74 of major depression double after age 70–85 years. Similarly, the number of elderly people with bipolar disorder is increasing, because the absolute number of old people is rising and, possibly, because the proportion of elderly individuals with this illness is increasing.75
Minor depression (panel 1), has a
Pathophysiology
Dorsal neocortical structures are hypometabolic and ventral limbic structures are hypermetabolic during depressed states.78, 79 Similar changes arise in experimentally induced sadness,79 but are quickly reversed when stimuli are removed. The persistence of the changes in depressed patients suggests that additional biological factors predispose to depression and sustain depressive symptoms (figure).
Frontostriatal pathways in the brain mediate positive affect-guided anticipation, and
Heredity
In addition to changes in brain structures, hereditary factors could predispose to late-life depressive syndromes (figure). In community-residing elderly twins, heredity accounted for 18% of the variation in depressive symptoms.104 Elderly people who are depressed are, however, less likely to have a depressed relative than younger patients who are depressed.105 Personal or family history of a depressive disorder affects the incidence of depression after stroke as much, if not more, than the
Prevention
There is a hypothesis that positive mental health can be enhanced if people believe they have the ability to act in a way that will result in achievement of their goals.2, 112 As such, elderly individuals with chronic medical illnesses at risk for depression who receive instruction on body-mind relations, relaxation techniques, cognitive restructuring, problem solving, communication, and behavioural management of insomnia, nutrition, and exercise, have increased self-efficacy and reduced
Management
The aims of treatment are to reduce the symptoms of depression, to prevent suicidal ideation, relapse, or recurrence of symptoms, to improve cognitive and functional status, and to help patients develop the skills needed to cope with their disability or psychosocial adversity if appropriate.117 Behavioural rehabilitation should be combined with antidepressant treatment to improve function as depressive syndromes subside.
Treatment planning should start with an assessment that focuses on
Care delivery
Most elderly individuals who are depressed are treated in primary-care settings.3, 32 However, primary-care doctors rarely diagnose depression and, when they do, often provide inappropriate treatment.3, 33, 131 Barriers to adequate diagnosis and treatment include doctors' reluctance to discuss emotional problems, time constraints, and medical comorbidity, complicating diagnosis and competing for clinical attention.132, 133 Perceived stigma134 contributes to patients' reluctance to initiate
Outlook
Late-life depressive disorders often arise in the context of psychosocial adversity, chronic medical diseases, and disability, and besides suffering and family disruption worsen medical outcomes. Although ageing and disease-related brain abnormalities that predispose to late-life depression have been identified, a direct lesion-depression association is unlikely. Behavioural abnormalities are subserved by high-level interactive and redundant neural systems. When damaged, these systems can cause
Search strategy and selection criteria
References (144)
- et al.
Association of depression with medical illness: does cortisol play a role?
Biol Psychiatry
(2004) - et al.
Persistence of cognitive impairment in geriatric patients following antidepressant treatment: a randomized, double-blind clinical trial with nortriptyline and paroxetine
J Psychiatr Res
(2003) - et al.
The psychological and physical health of family members caring for an elderly person with dementia
J Clin Epidemiol
(1992) - et al.
The predictors of persistence of depression in primary care
J Affect Disord
(1994) - et al.
New onset and remission of suicidal ideation among a depressed adult sample
J Affect Disord
(1999) - et al.
Age of onset in geriatric depression: relationship to clinical variables
J Affect Disord
(1988) - et al.
Risk factors for suicide in later life
Biol Psychiatry
(2002) - et al.
Comorbidity of late-life depression: an opportunity for research in mechanisms and treatment
Biol Psychiatry
(2002) Depression in late life: review and commentary
J Gerontol Med Sci
(2003)- et al.
Depression and Bipolar Support Alliance consensus statement on the unmet needs in diagnosis and treatment of mood disorders in late life
Arch Gen Psychiatry
(2003)