Elsevier

Maturitas

Volume 79, Issue 2, October 2014, Pages 153-159
Maturitas

Review
Depression and the older medical patient—When and how to intervene

https://doi.org/10.1016/j.maturitas.2014.05.010Get rights and content

Abstract

Depression in the elderly, particularly those with chronic physical health problems, is a common, but complex problem. In this paper we review the research literature on both the epidemiology and management of depression in the older medical patient. After a general overview of depression in the elderly, we discuss some of the particular issues relevant to depression and co-morbid physical illness amongst elderly patients. Depression can be difficult to diagnose in medically unwell older adults, particularly when there is substantial overlap in symptomatology. The epidemiology and evidence base for the treatment of depression in a number of chronic health problems common in an older adults population are then discussed, specifically cardiac disease, cerebrovascular disease, cancer, chronic kidney disease, chronic obstructive pulmonary disease, and Parkinson's disease. For many of these conditions there is emerging evidence that treatments can be effective in reducing depressive symptoms. However, these potential benefits need to be balanced against the often-increased risk of adverse events or interactions with medical treatments. Although co-morbid depression is consistently associated with poorer medical outcomes, there is limited evidence that standard anti-depressive therapy has additional benefits in terms of physical health outcomes. Collaborative care models appear particularly well suited to medically unwell older adult patients, and may provide more generalised benefits across both mental and physical health measures.

Section snippets

Introduction and methods

There has been a growing recognition of the prevalence and impact of depression in older patients, particularly those with physical illness. This paper reviews the recent literature on depression in the medically ill older patient, focusing on both epidemiological and management studies. After a general overview of depression in the elderly (and specifically in the physically ill), we focus on a number of conditions for which comorbid depression is prevalent in this age group. Where possible,

Epidemiology

Large scale epidemiological surveys report that depression affects about 5% of those 65 and older [1]. There has, however, been recent concern regarding clinicians’ ability to correctly identify which older adults are depressed, with validation studies using structured interviews only confirming major depressive episodes in about 18% of older adults whom clinicians felt may be depressed [2]. This is much poorer than similar studies of younger adults, presumably because of the difficulty

Epidemiology

Developing physical illness in old age has long been recognised as a major risk for depression [8], [9]. For example, Pfaff et al. [10] demonstrated that depression was 3–4 times more likely to occur amongst older adults with the highest number of medical comorbidities and the greatest level of functional impairments.

General issues

First, a number of approaches for the management of depression in the older medical patient have been explored. While the majority of studies have focused on antidepressants in

Cardiac disease

There is a complex inter-relationship between depression and coronary heart disease (CHD), with evidence for both an increase in CHD in those with depression, and increased morbidity and mortality in CHD patients who become depressed. With regard the former, the large prospective US Nurses’ Health Study [17] reported on outcomes of depression in over 63,000 women without a prior history of CHD or stroke. This study found that depressive symptoms were associated a greater likelihood of the later

Epidemiology

Depression is common in patients with stroke, with a prevalence of almost 20% in inpatients and 23% in outpatients [39]. A population-based study of subjects aged 85 years and older in Scandinavia [40] found that 43% of those with a history of stroke were depressed. A history of both stroke and ongoing depression was associated with greater 5-year mortality compared with stroke alone. It was previously believed that the location of a stroke was important in the aetiology of post-stroke

Epidemiology

Depression is commonly associated with cancer [46]. A recent major meta-analysis [47] found rates of major depression of 16% in oncology and haematology inpatient and outpatient settings. Some aspects of cancer may increase the risk of depression; for example older patients with metastases were 2.2 times more likely to be depressed, while those with cognitive impairment were 3.6 times more likely [48].

Treatment

A recent systematic review and meta-analysis identified nine RCTs of antidepressants in the

Epidemiology

A recent meta-analysis estimated that the prevalence of interview-defined depression for those with chronic kidney disease (CKD) was 20%, with those on dialysis having a higher prevalence of 23% [53]. As with many chronic diseases, the reasons for this high level of co-morbidity are likely to be mixed, but factors such as shared social and biological risk factors and the dramatic impact of renal failure and dialysis on independence and quality of life are likely to be of major importance [54].

Epidemiology

Fan et al. found that 41% of COPD subjects had at least mild to moderate depressive symptoms, with the most severely depressed being at increased risk of respiratory hospitalisation [63], [64]. Those with the highest depression symptom scores had a significantly increased 3-year mortality rate (odds ratio [OR] 2.7) and were more likely to experience dyspnoea and have a low body mass index. Few patients had received treatment for depression.

Management

There have been few trials of treatments for depression

Epidemiology

Major depression is commonly associated with Parkinson's disease with a prevalence of 8–17% (depending upon the population studied [69]). Differentiation between depression and Parkinson's disease can be difficult as patients with Parkinson's disease without depression may also manifest with similar symptoms of psychomotor retardation and reduced facial expression. Depression has been reported to be more prevalent in those with more advanced Parkinson's disease and in those with associated

Conclusions

Depression amongst older adults with physical illness is a common, but complex problem. It can be difficult for clinicians to identify which patients are depressed, with many common features of depression easily confused with non-specific symptoms of old age or co-morbid physical illness. However, correctly diagnosing depression in this patient group is vital as it can have a dramatic impact on quality of life and is consistently shown to be associated with poorer physical health outcomes. As

Contributors

Philip B. Mitchell and Samuel B. Harvey drafted the manuscript.

Competing interests

The authors declare no conflict of interest.

Funding

The authors have received no funding for this article. The research activities of Philip Mitchell are funded by an Australian National Health and Medical Research Council Program Grant (1037196).

Provenance and peer review

Commissioned and externally peer reviewed.

References (71)

  • C.M. O’Connor et al.

    Safety and efficacy of sertraline for depression in patients with heart failure: results of the SADHART-CHF (Sertraline Against Depression and Heart Disease in Chronic Heart Failure) trial

    J Am Coll Cardiol

    (2010)
  • R. Fraguas et al.

    A double-blind, placebo-controlled treatment trial of citalopram for major depressive disorder in older patients with heart failure: the relevance of the placebo effect and psychological symptoms

    Contemp Clin Trials

    (2009)
  • K.T. Veien et al.

    High mortality among heart failure patients treated with antidepressants

    Int J Cardiol

    (2011)
  • R.G. Robinson

    Poststroke depression: prevalence, diagnosis, treatment, and disease progression

    Biol Psychiatry

    (2003)
  • A.J. Carson et al.

    Depression after stroke and lesion location: a systematic review

    Lancet

    (2000)
  • A.J. Mitchell et al.

    Prevalence of depression, anxiety, and adjustment disorder in oncological, haematological, and palliative-care settings: a meta-analysis of 94 interview-based studies

    Lancet Oncol

    (2011)
  • S. Palmer et al.

    Prevalence of depression in chronic kidney disease: systematic review and meta-analysis of observational studies

    Kidney Int

    (2013)
  • P.L. Kimmel et al.

    Multiple measurements of depression predict mortality in a longitudinal study of chronic hemodialysis outpatients

    Kidney Int

    (2000)
  • J.R. Koo et al.

    Treatment of depression and effect of antidepression treatment on nutritional status in chronic hemodialysis patients

    Am J Med Sci

    (2005)
  • S.C. Palmer et al.

    Association between depression and death in people with CKD: a meta-analysis of cohort studies

    Am J Kidney Dis

    (2013)
  • S.S. Hedayati et al.

    Epidemiology, diagnosis, and management of depression in patients with CKD

    Am J Kidney Dis

    (2009)
  • L.M. Cohen et al.

    Update on psychotropic medication use in renal disease

    Psychosomatics

    (2004)
  • Y. Yuan et al.

    Selective serotonin reuptake inhibitors and risk of upper GI bleeding: confusion or confounding?

    Am J Med

    (2006)
  • A. Fritzsche et al.

    Effects of medical and psychological treatment of depression in patients with COPD – a review

    Respir Med

    (2011)
  • P. Barone et al.

    Pramipexole for the treatment of depressive symptoms in patients with Parkinson's disease: a randomised, double-blind, placebo-controlled trial

    Lancet Neurol

    (2010)
  • A.L. Byers et al.

    High occurrence of mood and anxiety disorders among older adults: The National Comorbidity Survey Replication

    Arch Gen Psychiatry

    (2010)
  • R. Mojtabai

    Diagnosing depression in older adults in primary care

    N Engl J Med

    (2014)
  • O.P. Almeida et al.

    Depression, antidepressant use and mortality in later life: the health in men study

    PLoS ONE

    (2010)
  • A.J. Mitchell et al.

    Prognosis of depression in old age compared to middle age: a systematic review of comparative studies

    Am J Psychiatry

    (2005)
  • C. Coupland et al.

    Antidepressant use and risk of adverse outcomes in older people: population based cohort study

    BMJ

    (2011)
  • G.M. van der Weele et al.

    Effects of a stepped-care intervention programme among older subjects who screened positive for depressive symptoms in general practice: the PROMODE randomised controlled trial

    Age Ageing

    (2012)
  • D.M. Clarke

    Growing old and getting sick: maintaining a positive spirit at the end of life

    Aust J Rural Health

    (2007)
  • J.J. Pfaff et al.

    Medical morbidity and severity of depression in a large primary care sample of older Australians: the DEPS-GP project

    Med J Aust

    (2009)
  • D. Taylor et al.

    Pharmacological interventions for people with depression and chronic physical health problems: systematic review and meta-analyses of safety and efficacy

    Br J Psychiatry

    (2011)
  • G.E. Caughey et al.

    Comorbidity of chronic disease and potential treatment conflicts in older people dispensed antidepressants

    Age Ageing

    (2010)
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