Assessment

Until recently, rating scales to measure depression were not ideally suited to older adults. Perhaps the most widely used, the Hamilton Rating Scale for Depression (Hamilton, 1960), contains a number of somatic symptoms that may be hard to interpret in the older adult. The Montgomery Asberg Depression Rating Scale is perhaps more appropriate (Mottram et al., 2000). The Geriatric Depression Scale (GDS) is specifically designed for older people (Yesavage et al., 1983). This self- or assisted-rated tool is available in versions from 4 to 30 items and has been translated into a number of languages, most of which can be found on a free website (http://stanford.edu/~yesavage/GDS.html). The GDS works reasonably well in cases of mild to moderate dementia but loses sensitivity in patients with severe dementia (Baldwin, 2008). The GDS is reproduced in Table 20.2. It can be completed online. The Cornell Depression Rating Scale (Alexopoulos et al., 1988) has been developed to detect depression in those with dementia. It utilizes information from a caregiver as well as the patient.

Bearing in mind the earlier discussion about sexuality in later life, of the three scales mentioned, only the Hamilton rates libido and under the unsatisfactory item “genital symptoms,” which includes “menstrual disturbance.”

Screening for depression using rating scales is useful but is not a substitute for clinical skills. The history should include medical illness, medication (including over-the-counter drugs such as analgesics), alcohol intake and information about recent life events. Modifications to the clinical interview (shorter sessions, slower pace) may be required if there is sensory impairment, poor health or pain. A cognitive assessment should be included. This can be undertaken by using the Montreal Cognitive Assessment (MoCA; Nasredinne et al., 2005) or the briefer 6-item Orientation-Memory-Concentration (OMC; Brooke & Bullock, 1999). The MoCa can be downloaded from: www.mocatest.org/default.asp along with scoring instructions. Provided it is used for clinical purposes, copyright permission is not required. At the time of writing, the Mini-Mental State Examination (Folstein et al., 1975) is subject to copyright and therefore payment.

A physical examination should be conducted. As mentioned, ill‐health is often the trigger for severe depression (Table 20.1) and so is linked closely to prognosis. Laboratory investigation should include hemoglobin, full blood count, biochemical profile, B₁₂ and folate levels. Severe depression can rapidly lead to undernutrition. Elderly people have less physiological reserve than younger adults. In a frail 80-year-old woman it may lead to serious metabolic derangement in a short time.

Specialist referral should be considered for patients where dementia is suspected; when depression is severe, as evidenced by psychotic depression or suicidality; where risk is present through failure to eat or drink; or when patients have not responded to first-line treatment.

Treatment principles

The treatment of late-life depression should be multimodal and multidisciplinary. General principles are outlined in Table 20.3. Full remission (no symptoms) rather than improvement is the goal. There is evidence of efficacy for antidepressants (compared to placebo) (Nelson et al., 2008); psychological treatments, notably Cognitive Behavior Therapy (CBT; Laidlaw, 2010) and Inter-Personal Therapy (van Shaik et al., 2008); and psychosocial interventions.

Shedler (2010) compared effect sizes for different types of therapy and antidepressant medication from meta-analyses of recent outcome studies. Effect sizes for dynamic psychotherapy were as large as those reported for other treatments. Further, there is good evidence that older people have outcomes from different kinds of psychotherapy at least equal to those for younger patients (Woods & Roth, 1996).

Antidepressants

There is no difference between women and men in terms of antidepressant response (Quitkin et al., 2002); nor is it true that older patients respond less well to antidepressants although attaining remission may be harder (Kok et al., 2012) and it may take 2 to 4 weeks longer to recover (Nelson et al., 2008). Selective Serotonin Reuptake Inhibitors (SSRIs) are nowadays usually the first-line choice. They are as effective as tricylics antidepressants and somewhat better tolerated. However, there has been some concern about an increased risk of upper gastrointestinal bleeding in older patients prescribed SSRIs who are taking aspirin or non-steroidal anti-inflammatory drugs (de Abajo et al., 1999). There is a greater likelihood of the Syndrome of Inappropriate Anti-Diuretic Hormone (SIADH) with SSRIs than other antidepressants.

Altered pharmacodyamics and kinetics coupled with frailty mean that initial antidepressant dosages may be half those recommended for younger adults. The adage “start low, go slow” is appropriate. A recent warning of effects on prolonging the ECG QT interval, with an increased risk of arrhythmia, with citalopram and escitalopram has led to revisions of the upper dose recommendations, to 20 mg and 10 mg respectively. The use of these drugs with antipsychotic drugs (as in psychotic depression or augmentation treatment) is not recommended, as antipsychotics are themselves pro-arrhythmic.

Antidepressants are effective in patients with comorbidity such as stroke, heart disease and chronic obstructive pulmonary disease (COPD) and are tolerated satisfactorily by patients in nursing homes, although no adequate trials of efficacy have been conducted. Unfortunately evidence shows that they are often ineffective in treating depression complicating Alzheimer’s disease (Banerjee et al., 2011).

Average starting and therapeutic dosages for elderly patients, along with side effect profiles, are shown in Table 20.4.

Psychological and psychotherapeutic interventions

Psychological treatments are as effective as antidepressants for mild and moderate depressive disorder (Baldwin et al., 2003) and may be preferred by older patients over medication (Unűtzer et al., 2002). However, they are seldom readily available and a belief that medicine alone will eradicate depression may increase feelings of helplessness and dependence with poor long-term effects (Heifner, 1996). In fact there is increasing evidence that psychotherapy may produce neurobiological change in the patient (Shore, 1997). For example, there is a significant effect on serotonin metabolism (Viinamaki et al., 1998) and serotonin receptors (Karlsson, 2011). There is also evidence that attachment styles have physical and neural effects (Ciechanowski et al., 2001; Buchheim et al., 2011). In this sense, Freud the neurologist was correct in anticipating reconciliation between neurology and psychology.

There are few studies examining the psychotherapies with older people and the results are rarely distinguished by gender. The most common theme is loss. Losses accumulate with age although each one is particular and specific (Knight & Satre, 1999). Pollack (1982) writes of the psychodynamic work in mourning leading to liberation and the possibilities of future freedoms. However, it may be impossible to recover from some losses, for example the loss of a child.

Other analysts too have eschewed Freud’s (1905) dictum that people over 50 are no longer educable and have drawn on the work of Erikson (1959) and King (1974, 1980). In the UK, Hildebrand (1982) pioneered workshops aimed at helping younger therapists see patients who were struggling with the developmental tasks and difficulties of later life. Good supervision helps the therapist deal with powerful countertransferential feelings evoked by working with older, possibly disabled patients (Garner, 2004). The biological and social realities of the patients’ lives need to be acknowledged. Physical pain and disability will not be alleviated by psychotherapy but the effects on the patient’s life and relationships may be understood and changed. There are a number of accounts of group psychotherapy with older patients (Evans, 2004). This modality can diminish a sense of isolation, failure and shame (Garland, 2007). In a group, denial of age becomes less possible, helping patients to accept approaching death and the process of dying (Canete et al., 2000; Evans, 2004).

The lack of social interaction in nursing and residential homes is a potential focus for psychosocial interventions. Although the task may feel overwhelming, something can be done about the level of social engagement. Jones (2003) writes of the success of a nurse-led group, using a modified reminiscence technique, on the level of depression in elderly women in long-term care. Reminiscence therapy, as well as being a treatment in its own right, also increases the engagement and contact between staff and residents. Perhaps more attention needs to be given to admitting friends together (Dayson et al., 1998), as well as to increase the emotional engagement and understanding of the staff (Garner, 1998).

In a large-scale meta-analysis of psychosocial and psychotherapeutic interventions with older adults, Pinquart and Sorensen (2001) found CBT improved depression and subjective well-being, an effect that was greater if the therapist had had specialized training in work with older adults. CBT is now a mainstream treatment for depression and anxiety in later life (Laidlaw, 2008; Wilson et al., 2008), with evidence for its efficacy in primary care (Serfaty et al., 2009) and among the oldest old (Gallagher-Thompson & Thompson, 2010). Patients often attribute to aging – to being old – the signs and symptoms of depression. The attitude to aging needs to be a focus in all types of psychological treatments with older women (Laidlaw, 2010; Garner & Evans, 2010).

Life review is involved in many psychotherapeutic models and particularly in modifications that may be made for older adults. Creatively reminiscing, the patient may constructively reevaluate failures, achievements and relationships. Reminiscence can of itself be adaptive, helping to maintain a sense of permanence and continuity of the self. In a comparison of a life-review group and a cognitive therapy group, both treatments were equally effective, as measured by the Beck Depression Inventory and Life Satisfaction in the Elderly Scale; this also held true for the old-old group (Weiss, 1994).

Miller et al. (1994) used Interpersonal Psychotherapy (IPT) to spousal bereavement-related-depression in late life with some success, and IPT may hold promise in the treatment of dysthymia.

Resistant depression

Resistant depression should be approached in the same way as for younger patients (see Chapter 19), although in older adults white matter disease of the brain may be an additional factor in poor treatment response (Baldwin & O’Brien, 2002). The steps to consider are: optimize the dose; switch to an antidepressant from another class; combine two antidepressants from different classes; augment with a non-antidepressant. Lithium augmentation has a reasonable (albeit incomplete) evidence base (Baldwin, 2003), but is often not well tolerated by older people. Combining an antidepressant with an atypical antipsychotic drug is increasingly popular and has an evidence base (Nelson et al., 2009), but there is a real risk of precipitating the metabolic syndrome over time. For that reason, unless the combination is specifically to treat psychotic depression, the atypical agent should be reviewed at 4–6 months with a view to gradual discontinuation. Lipids, glucose, weight and waist circumference should be monitored. Age should not be a barrier to Electroconvulsive Therapy (ECT) in the right cases (generally to save life or prevent serious deterioration). It is generally well tolerated (Tew et al., 1999) but relapse rates are high. Combining medication with a psychological intervention gives the best results (Reynolds et al., 1999).

As yet, there is no definitive evidence that Hormone Replacement Therapy either protects against depression in older women or can be successfully used to treat it (Whooley et al., 2000; Cutter et al., 2003). Looking to the future, novel agents such as ketamine can induce short-term remission in resistant depression and is attracting research interest (see Chapter 19).

As with all clinical work, using psychological mindedness in interactions will be to the benefit of older patients with chronic resistant low mood and to their caregivers and staff endeavoring to look after them (Garner, 2008). Negative reactions among staff and caregivers toward patients with resistant symptoms are common and difficult to discuss but need to be addressed.

Anxiolytic drugs

Used in the lowest possible dose for the shortest period of time benzodiazepines are highly effective in the short-term treatment of moderate-to-severe symptoms of anxiety. Treatment beyond 2 to 4 weeks risks dependency. As with antidepressants, starting dosages and therapeutic dosages are roughly half that of the younger adult (Table 20.5). Falls, sedation and ataxia may occur in older adults and some may even develop a reversible dementia. Benzodiazepines are contraindicated in patients with respiratory depression, sleep apnea and severe hepatic impairment.

Buspirone is thought to act on 5HT_1A receptors and has a low risk of dependence but may take a number of days before it is effective. It does not counteract benzodiazepine withdrawal. Beta-blockers reduce somatic symptoms of anxiety but can be problematic in older patients because there is a risk of aggravating underlying physical problems such as bronchospasm, hypotension, heart failure and diabetes. Water-soluble beta-blockers such as atenolol are less likely to cross the blood-brain barrier and may be associated with fewer central nervous system side effects such as sleep disturbance and nightmares. Atenolol is also more cardioselective. The use of low-dose phenothiazines in the treatment of anxiety in older women is not recommended because of the risk of tardive dyskinesia. Pregabalin, an antiepileptic drug, is licensed for the treatment of anxiety and has an evidence base for later life (Montgomery et al., 2008).

Nonpharmacological interventions

In a large US survey of prescriptions, 7.5% of older people were prescribed anxiolytic drugs (Aparasu et al., 2003) while in Europe 15% were taking benzodiazepines even though they had no diagnosed mental disorder (Kirby et al., 1999). Higher prescription rates have been reported among widows and those who are socially isolated (Hartikainen et al., 2003) and older women are significantly more likely to be prescribed antianxiety drugs than are men (Aparasu et al., 2003). Older women taking such medication are 1.5 times more likely to have falls than nonusers, with no evidence that shorter-acting anxiolytics are safer in this regard (Ensrud et al., 2002).

There is, therefore, growing interest in nonpharmacological approaches to the treatment of anxiety disorders in older women. Evidence is best for CBT, which is skills-enhancing and problem-focused for patients fearful of being overwhelmed by fearful thoughts. Barrowclough et al. (2001) demonstrated sustained benefit for CBT over counseling for anxiety in older adults living at home. Single-session CBT was effective in reducing symptoms of anxiety and depression in older patients with chronic obstructive pulmonary disease (Kunik et al., 2001). Using CBT, patients with panic disorder achieve a decrease in symptoms and in physiological arousal (Swales et al., 1996). A randomized controlled trial (Stanley et al., 2009) showed good outcomes with CBT for late-life anxiety in primary care. Last, a psychoeducational program was effective in reducing both anxiety and depressive symptoms in older women (Schimmel-Spreeuw et al., 2000). The course included relaxation training.