Depresion

InnovAiT, Vol. 3, No. 4, pp. 199–208, 2010

doi:10.1093/innovait/inp231

Depression in the elderly

D

epression is the most common mental illness in the elderly, with an estimated 15% of the elderly population living in the community having clinically significant depressive symptoms. It is of medical and social importance as it is associated with increased morbidity and mortality, poorquality of life and increased social dependence. Recognition of depression in this age group has been found to be poor, with more patients presenting with somatic physical symptoms. Treatment can also be difficult compared with younger patients, with increased prevalence of side effects of medication, polypharmacy and poor compliance. Primary care practitioners are therefore crucial in thedetection and early instigation of appropriate treatment. This article looks at the risk factors, presentation and treatment options for depression in the elderly age group.
The GP curriculum and depression in the elderly disorders under the umbrella of ‘depression’ according to International Classification of Disease (ICD-10) criteria: mild, moderate or severe depressive disorder, dysthymic disorder,depression within bipolar disorder, organic depressive disorder and psychotic depression (Box 1). Furthermore, within the depressed elderly, an episode can be a first presentation or a recurrence of depression experienced at a younger age.

Curriculum Statement 9: Care of Older Adults requires O Knowledge of the holistic bio-psychosocial ‘whole’ that is the patient O Understanding of the physical,psychological and social changes that may occur with age and relating them to the adaptations that an older person makes and to the breakdown of these adaptations O Understanding of the special factors associated with drug treatment in the elderly Curriculum Statement 13: Care of People with Mental Health Problems requires O Effective screening and diagnosis of patients with mental healthproblems and awareness of patients at risk of developing disease using appropriate screening tools O Knowledge of management of mental health conditions, including medication and talking therapies O Knowledge of when to refer to specialist care O Knowledge of the principles of mental health promotion

Aetiology and pathophysiology
The aetiology of depression in later life is complex. There are variousneurological, biological, social and personality factors that contribute to the development of a depressive episode. Some of these risk factors are similar to those for depression at any age; however, there is some evidence that development of depression in later life should be looked at as a distinct clinical entity as there are aetiological factors that are specific to this age group. It isimportant that primary care practitioners are aware of these pathological processes and risk factors as they have implications for prevention and screening in highrisk groups of patients and a basic understanding will help when considering treatment options.

Definitions
The definition of ‘the elderly’ varies somewhat but is generally taken to be older than 65 years, although in some definitionsolder than 55 or 60 years, with the ‘old-old’ being over 75 or 80 years. There are also various mood

Neurobiological vulnerability
The neurobiological control of mood and emotion has been the subject of much research in recent years. It is thought that affective regulation is governed by several limbic and prefrontal structures and their interconnecting circuits, including the amygdala, thehippocampus and areas of the prefrontal cortex, anterior cingulate cortex, ventral striatum

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Box 1. ICD-10 symptoms and diagnostic criteria for depressive disorders Symptoms of depression O Lowering of mood O...