Chapter 4 Carolyn Chew-Graham1 and Cornelius Katona2 1 Research Institute, Primary Care and Health Sciences and National School for Primary Care Research, Keele University, Keele, UK 2 Department of Psychiatry, University College London, London, UK This chapter considers the presentation and management of anxiety and depression in older people, and explores the challenges clinicians face in responding to the needs of older people with these common mental health problems. Depression severe enough to warrant intervention is one of the commonest mental health problems facing older people, affecting more than 1 in 10 older people in the community. There are a number of risk factors for depression, which the GP needs to be aware of (Box 4.1), and some of these are also risk factors for anxiety, particularly chronic physical conditions and loneliness. Depression is associated with disability, increased mortality, including from suicide, poorer outcomes from physical illness, and increased use of primary and secondary and social care resources. Major depression is a recurring disorder and older people are more at risk of recurrence than the younger population. Anxiety disorders are also common in older people. ‘Anxiety’ covers the terms generalised anxiety disorder (GAD), panic and phobic disorders. GAD is a common disorder, of which the central feature is excessive worry about a number of different events associated with heightened tension. Anxiety and depression often coexist (or overlap) in older people and may also be comorbid with physical conditions (leading to poorer outcomes in those conditions). Patients with anxiety disorders may complain of worry, irritability, tension, tiredness or ‘nerves’, but older people may present with somatic symptoms that may cause diagnostic difficulty for the GP and (if not identified) may result in unnecessary investigations for the patient – with the resultant worries aggravating the depression and anxiety symptoms. The GP needs to be aware of the link with alcohol misuse and should always explore alcohol consumption in older people who present with symptoms of depression or anxiety. Older people consult their primary care practitioner more frequently than younger people, and those who are depressed consult twice as often as those who are not. Despite this, depression is diagnosed less often in older people. Older people who are depressed can present with nonspecific symptoms rather than disclosing depressive symptoms. Standard diagnostic criteria (ICD 10, DSM – for anxiety and depression) have been developed to reflect symptoms observed in younger people. They have inherent limitations for diagnosis of depression in older people, whose presentation may differ because of ageing, physical illness or both. Other clinical features often found in older people include: somatic preoccupation, hypochondriasis and the morbid fear of illness, which are more common presentations than the complaint of low mood or sadness. In addition, physical symptoms, in particular seemingly disproportionate pain, are common and the primary care clinician may feel they represent organic disease. This can cause problems for the GP, as a depressed patient’s hypochondriacal complaints can be quite different from the bodily symptoms one might expect from knowledge of the patient’s medical history. Subjective memory disturbance may be a prominent symptom and lead to a differential diagnosis of dementia, but true cognitive disturbance is also common in late-life depression. The GP should assess memory using the GPCOG (see ‘Resources’ below) or the Abbreviated Mental Test Score (see Appendix 4). Depression in older people (particularly when there is no history of depression earlier in the patient’s life) is associated with increased risk of subsequently developing a ‘true’ dementia. Lastly, a persistent complaint of loneliness in an older person (even when that person is known to live with others) should prompt enquiry into mood, feelings, views on the future, and a more systematic enquiry about biological symptoms of depression, along with a formal assessment, including a risk assessment. Older adults may have beliefs that prevent them from seeking help for mental health problems, such as a fear of stigmatisation or concern that antidepressant medication is addictive. They may not consider themselves candidates for care because of previous experience of help-seeking. In addition, older people may be reluctant to recognise and name ‘depression’ as a specific condition that legitimises attending their GP, or they may misattribute symptoms of major depression for ‘old age’, ill health or grief and use normalising attributional styles that see their depression as a normal consequence of ill health, of difficult personal circumstances or even of old age itself. GPs may lack the necessary consultation skills and confidence to correctly diagnose depression in older people, and anxiety is particularly under-diagnosed. They may also be wary of opening a ‘Pandora’s box’ in time-limited consultations and instead collude with the patient in what has been called ‘therapeutic nihilism’. Additionally, a lack of congruence between patients’ and professionals’ conceptual language about mental health problems, along with deficits in communication skills on the part of both patients and professionals, can lead to uncertainty about the nature of the problem and reduce opportunities to talk about appropriate management strategies. The use of case-finding questions (Box 4.2) should be part of usual practice for GPs in consultations with older people who have risk factors for depression and anxiety (Box 4.1) or where the GP has a clinical suspicion that depression may be present. The questions should be used as prompts by the GP, rather than formal ‘screening’ questions whose wording has to be adhered to rigidly.
Anxiety and Depression in Older People
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