Beyond Sad Mood: Alternate Presentations of Major Depression in Late Life
Major depression and subsyndromal depression are common in older persons. Unrecognized depression results in increased morbidity and mortality. Recognition of depression is challenging due to patient- and clinician-related factors. Diagnosis in the older person is confounded by medical comorbidities as well as normal changes. Depression in older adults manifests differently: somatic complaints, nonspecific symptoms, and cognitive difficulties are common, as are behavioural changes, including apathy and irritability. Anhedonia better reflects depression, since depressed mood is often denied by the older person. Depression is likely to be missed if only typical symptoms are sought. Appropriate recognition can lead to improved treatment and outcomes.
Key words: depression, older adult, diagnosis, recognition, management.
Introduction
Of the big three “D’s” that characterize psychiatric problems in older patients (i.e., delirium, dementia, and depression), depression is the most common disorder in individuals 65 and older.1 It often results in reduced executive functioning as well as a lowered quality of life.2 It has also been associated with increased morbidity and mortality.3 In addition, depression is cited as a leading cause of suicide in this age group.1 Clearly, with the demographic trend towards an ever-burgeoning older population, management of depression in this population will play a more prominent role for primary care physicians and geriatric psychiatrists alike. It therefore becomes imperative to recognize, appropriately diagnose, and effectively treat depression among older adults. The recognition of depression in the aged is often not straightforward due to a number of challenges, which may be described as attributable to the patient (i.e., patient-related factors) or to the physician (i.e., clinician-related factors).
Several patient-related factors can impede the recognition of depression in older patients. Numerous physical and physiologic changes occur in the aging person that can mimic symptoms of depression. For instance, decreases in sleep, changes in energy levels, or slowing of cognitive speed, all of which are part of the normal aging process, may misleadingly be attributed to a mood disorder and lead to an overdiagnosis of major depression. Moreover, older adults are vulnerable to illnesses whose symptoms overlap with symptoms of major depression. Getting older also means appearance of unanticipated stressors that, in turn, can have a significant impact on a person’s well-being. Examples of such stressors include spousal death, development of health problems in loved ones, increasing disability or impairments in independent activities of daily living, work retirement, “empty nest” syndrome, and downsizing. Finally, irrational patient-related factors, such as denial by the patient or by the family of depression due to fears of stigma, act as further barriers in the recognition of the problem.
In addition to the patient-related factors noted above, clinicians may also fail to recognize depression. Variations in the presentations of mood disorders can confound many clinicians. Major depression in older patients is often characterized by heterogeneous symptoms. Constituent symptoms of depression are often subtle or may not even appear to exist. While the diagnosis of major depression remains the same for all age groups according to the Diagnostic and Statistical Manual (DSM-IV-TR),4 the older population has some unique features that can confound the diagnosis.1,5 This review examines some of these atypical features that constitute depression in older adults. In addition, the review examines mimics of depression in the aging, since these features can confound even the more experienced clinicians. We conclude with