Diagnosing and treating depression among elderly patients can pose challenges for internists, especially given the varying presentations and polypharmacy concerns associated with this demographic.
“What is unique about depression in the elderly is that many times the presenting concerns to the providers tend to be more of somatic and physical complaints and related to their multiple chronic conditions,” said Mukaila A. Raji, MD, FACP, distinguished professor of geriatrics at the University of Texas Medical Branch at Galveston, who noted that many times these patients are misdiagnosed. “The other unique aspect is depression in the older population can sometimes also be another symptom of previously undiagnosed dementia illness, such as Alzheimer's, or the beginning of previously undiagnosed bipolar disorder.”
Additionally, ACP Member Evelyn Granieri, MD, emerita professor of medicine at Columbia University in New York City, said that while most older people develop “situational or reactive depression,” which often happens following the loss of a life partner or other big changes, it's a mistake to think of these patients as homogeneous. “They are, in fact, the most heterogeneous of all of the cohorts of people for whom we care. And that heterogeneity really starts to take form once people hit around 70.”
Of importance, depression is not part of usual aging, said ACP Member Allison Moser Mays, MD, MAS, an assistant professor and geriatrician at Cedars-Sinai Medical Center in Los Angeles. “There can be a misconception among older adults themselves, their family members, and sometimes physicians and other clinicians that it's sort of normal to be a bit sad when you're older, and it's really not,” she said. “Depression is very treatable in older adults, and it's not consistent with normal aging.”
Identifying symptoms, red flags
Medicare guidelines advise clinicians to screen for depression annually, although this can be done in many ways.
Dr. Mays recommends using the Patient Health Questionnaire-2 (PHQ-2), a two-question survey designed to assess mood symptoms quickly and efficiently, as well as comparing outcomes over time and monitoring cognitive function. “Occasionally, we will see people who are diagnosed with some degree of cognitive impairment when really, if you were to treat and address their mood disorder, they would have much better focus, concentration, and effort, and they would do better in terms of cognitive testing and their daily function,” she said.
Likewise, Dr. Raji said clinicians should be on the lookout for changes to patients' day-to-day activities. “They may stop or reduce the connection and communication with their loved ones, they may not attend as much to the day-to-day needs such as hygiene and financial obligations, and they might stop going out to do what they loved to do before,” he said. “So as the depression becomes more and more severe and untreated, they also become more socially isolated and disconnected from their family and their community.”
One thing to be on the lookout for with elderly patients especially is the potential for a variety of medications to affect mental health. Specifically, Dr. Raji pointed to montelukast, varenicline, clonidine, corticosteroids, and opioids as agents that have been shown to be linked to depression.
Diminished senses might also contribute to increased risk of depression. “It is often that someone will start to withdraw because of hearing loss, and so addressing hearing loss is very important in terms of reengaging, keeping up those social connections, and decreasing social isolation,” said Dr. Mays. “Similarly with vision, people can feel more hesitant to leave their home if they're having more difficulty with their eyesight, and so in terms of a geriatric assessment, we're always making sure all your senses are as good as they can be.”
Combating social isolation, loneliness
A common cause of depression in older adults is social isolation, something that has skyrocketed due to the COVID-19 pandemic.
It's too early to say exactly how the pandemic affected rates of depression in the elderly, but Kimberly A. Van Orden, PhD, a clinical psychologist in the department of psychiatry at the University of Rochester Medical Center in New York, said it seems like “Older people are doing better than the younger people in terms of increases in depression and anxiety,” since people tend to get better at managing certain stressors with age. That said, she noted, certain subgroups of older people were much more vulnerable, including those who live in poverty who might not be able to use technology to allow them to foster social connections.
Over the past year, Dr. Granieri said, “We saw people feeling alone, isolated, and unstimulated, but what we did also see was [people] trying to find ways for family members and/or caregivers to interact with them.” (For more on one intervention to combat loneliness in those homebound during COVID-19, read the Success Story in this issue.)
“Now that everyone has had more personal experience with social isolation and loneliness, it's become clear that those were things that were really challenging for older adults before the pandemic,” Dr. Mays said. “Now everyone has more empathy and understanding for that.”
Still, “The loneliness brought on by the COVID pandemic has worsened previous mental health conditions in this country, and it also underscores the suboptimal resources for caring for people with mental health conditions,” added Dr. Raji.
Simply asking questions and raising the issue of mental health are key, said Dr. Van Orden. She advised clinicians to ask patients how often they talk to other people, if they're getting the help they need to complete their daily activities, and if they are feeling isolated. She also recommended using the UCLA Loneliness Scale, which has just three items including companionship, feeling left out, and feeling isolated, to assess patients.
Remedying depressive symptoms in some older adults should start with rectifying what might be causing loneliness and isolation in the first place. A systematic review and network meta-analysis published March 24, 2021, by The BMJ found that nondrug therapies can outperform pharmacologics for depressive symptoms, at least for those specifically with dementia.
“The idea is not a one-size-fits-all,” said Dr. Van Orden. “We wouldn't just take an older person who's lonely and just say, ‘OK, well, you should have a peer companion or friendly calling program,’ because that may not address why they are feeling lonely or isolated. We try to think about matching the program to the person.”
She recommended asking older patients what might help them, as they often know what they need but will only volunteer that information if prompted. Dr. Van Orden also recommended using local Area Agencies on Aging, which can provide help for transportation, meals, and social services for older adults. A locator is online. “I think they get underutilized by primary care physicians and everyone in general,” she said. She also recommended AARP's Connect2Affect webpage as a potential resource.
Dr. Granieri said she likes to give her patients “social homework,” such as leaving the house every day for 10 minutes (making sure to take COVID-19 precautions by wearing a mask and social distancing) or calling a relative three times a week. “Sometimes that gets them invested in their plan of care,” she said. “And then when they come back, you put a note in the EMR to check homework and you make them a part of that therapeutic intervention. People like to do that. They want to feel a part of things.”
Start low, go slow with pharmaceuticals
If talk therapy, social programs, or other nondrug treatments don't seem to be working, medications may be an option for elderly patients with depression.
“As in all of geriatrics, start low and go slow,” Dr. Mays advised. “There are certain antidepressants that are more anticholinergic than others and so they have an increased likelihood of having side effects for older people, whether it's dry mouth or increasing risk of falls.” She usually turns to selective serotonin reuptake inhibitors (SSRIs) like sertraline and escitalopram first.
Dr. Raji agreed with this strategy, adding that he likes to be able to use one agent that can treat many symptoms, especially given the potential for dangerous drug-drug interactions. “Polypharmacy is a big concern in the elderly and tends to arise when prescribers prescribe one drug for each symptom,” he said. “It's very easy for prescribers to put patients on interventions that may paradoxically reduce their ability to walk safely, can increase their risk of falls, can mess up their thinking, can even make them more depressed and may not be consistent with what their life goals and health care priorities are.”
Once a patient is started on an antidepressant, “You have to follow them up within a month,” advised Dr. Granieri. “And then it depends upon their response. There are some labs you have to check, like certainly sodium and renal function, while you're titrating the medications. And then if you don't see a response within a few months, then you take them off of it. … These are not drugs that you add to the growing list of medications.”
Beyond that, she advised referring the patient to a geriatric psychiatrist, acknowledging that this can be difficult to do based on availability. In lieu of that, consult with a geriatrician “just for a one-time consult to see if there's anything else that can be done.”
Dr. Mays added that it would be worthwhile to work with a geriatric pharmacist to help titrate drugs and review other medications to help pare down polypharmacy, although she noted that prescribing antidepressants should really be done at the discretion of the clinician. “Some internists really have their medications they're comfortable with and then after that, if those aren't working, send them on. Other internists have a lot more comfort with adjusting medications. I would say if you have had patients who have tried maybe one or one plus a booster, then they'd benefit from working with a psychiatrist.”
Dr. Raji stressed that it's also important to embrace the premise that mental health is as critical as physical health. “If we don't take care of the mind—the thinking and the feeling—we cannot get the patient optimally tuned with respect to congestive heart failure, COPD, and other chronic conditions,” he said.