The possibility of depression is always present in the clinical encounter. The rate at which primary health care providers recognize clinical depression varies widely: from 19% to 94%. Cognitive impairment and other medical comorbidities often hinder the ability to arrive at an accurate diagnosis. Yet elderly patients overwhelmingly prefer the care of their primary physician to that of a mental health professional. With the advent of managed care plans, this trend is expected to increase. There is little to no adequate screening tool. Patients are more likely to respond to screening when questions about sleep and appetite lead this portion of the interview.

The physical examination should be comprehensive in order to assess comorbid states. Station and gait and the risk of falls should be evaluated, because a shorter step length and a slower gait velocity are common in depressed patients. canadian pharmacy viagra

A Mini-Mental Status Examination (MMSE) should be included with the general and mental status examination. Specific questions addressing sleep changes, appetite changes, and weight loss need to be pursued. The MMSE does not diagnose executive dysfunction, which is important to identify. Executive dysfunction involves a failure in areas of leadership, decision-making, and the processes of inference and deduction. A depression screen is a valuable tool for diagnosis and tracking. Depression, as described by the Diagnostic and Statistical Manual of Mental Disorders, fourth revised edition (DSMIV), includes the features listed in Table 1.

Although this definition of depression is reliable for younger populations, its use in the elderly can be challenging. Five or more of the nine symptoms must be present most of the day during a two-week period, according to self-report or a report by others, and at least one of these symptoms must be anhedonia or depressed mood.

Whereas the Geriatric Scale-30 may be the more precise predictor of severity of depression than 9-point scores, it is somewhat more time-consuming to perform and score. The Geriatric Depression Scale-15 is both reliable and reproducible across cultures and languages.  Simple to administer, sensitive, and specific, it should be used as a screening tool when needed. Score cut-offs of 5 to 6 demonstrate a specificity of 64.5% and a sensitivity of 90.9% when compared with DSM-IV criteria. Higher scores are associated with an increasing severity of depression. There must be a change from previous functions with a score of 10 with the Geriatric Depression Scale-15 (Table 2) or with a similar assessment tool.

Trained staff members can easily, reliably, and cost-effectively screen and derive a score, and the doc­tor can complete a further evaluation. Treatment may then be initiated, if appropriate, for the individual. Some objective level of scoring may help make physicians feel more comfortable in prescribing therapy to these patients in need.

Basic laboratory evaluations should be conducted to look for otherwise easily missed diagnoses, including a comprehensive metabolic profile, a complete blood count, and an assessment of thyroid-stimulating hormone CTSH). An imaging study of the brain may also be indicated if neurological findings are abnormal.

Differential Diagnosis

Numerous misconceptions abound and can lead to the underdiagnosis, misdiagnosis, and underreporting of depression. Normal aging does not include excessive fatigue, appetite changes, or increasing irritability that leads to isolation. Depression can be a prodrome of dementia, it can coexist with dementia, or it can be a risk factor for dementia. However, excessive psychomotor retardation, dysphoria, decreased concentration, and cognitive decline may be related to a reversible depression (pseudo-dementia) rather than a progressive dementia; this needs to be investigated as a reversible cause of dementia.

Table 2.

Are you basically satisfied with your life? Yes No (1)
Have you dropped many of your activities and interests? Yes No
Do you feel that your life is empty? Yes No
Do you often get bored? Yes No
Are you in good spirits most of the time? Yes No (1)
Are you afraid that something bad is going to happen to you? Yes No
Do you feel happy most of the time? Yes No (1)
Do you feel helpless? Yes No
Do you prefer to stay at home rather than going out to do new things? Yes No
Do you feel that you have more problems with your memory than most? Yes No
Do you think it is wonderful to be alive? Yes No (1)
Do you feel pretty worthless the way you are now? Yes No
Do you feel full of energy? Yes No (1)
Do you feel that your situation is hopeless? Yes No
Do you think that most people are better off than you are? Yes No
Adapted from Almeida OP,Almeida SA: Int J Geriatr Psychiatry 1999;14:858-865.50

The differential diagnosis is broad and varied and must include alcoholism, adverse effects of medications, early dementias, infections, metabolic disorders, bipolar disorders, and malignancy. Elder abuse may be particularly difficult to identify. The extensive differential diagnosis makes it necessary to seek key clues.

The onset of depression after a new medication, atypical injuries, and steady weight loss suggests other processes. Severe cognitive impairment without moderate-to-severe social withdrawal suggests dementia more than depression.