The percentage of elderly people continues to grow in America, with the “oldest old” now recognized as the fastest-growing segment. Nearly 7 million of the 35 million Americans (15%-25%) 65 years of age or older have depression, and 1 million of the 7 million have major depression; the overall prevalence is 1% (1.4% in women, 0.4% in men). By 2020, these figures will swell by another 60%.
The annual direct and indirect costs of depression ($43 billion) are equal to those for coronary heart disease. The prevalence rate approaches 12% to 30% in long-term-care facilities and 60% to 70% in subacute rehabilitation centers after treatment in a hospital. Depression has been identified in 17% to 37% of patients treated in primary care settings, with 30% of these patients having major depression, whereas the rate drops to 3% for healthy elderly people living in the community.
Three-fourths of these patients are initially seen in the primary care setting. Although recurrence may be as high as 40%, the figures are lower than that reported in the younger population, partly because of the tendency to focus on somatic symptoms in the elderly and partly because of cognitive impairment that interferes with the accurate reporting of symptoms.
Subsyndromal depression is a clinically significant depressive disorder that does not fulfill the duration criteria or the number of symptoms necessary to make the diagnosis of dys-thymia or major depression. Minor depression in the elderly is more prevalent than major depression. Minor depression may be the residual phase of a major depressive episode, but it simply lacks the criterion of duration, a brief episode of an underlying recurrent major depressive disorder or, more likely, a reaction to the routine stressors prevalent in older populations. Fifteen percent to 25% of minor depressions evolve into a major depressive episode within a two-year period, and these are associated with significant disability as well as suicidal ideation.
The rate of minor depression ranges from 2.5% to 9.4%, but it increases significantly (by 47% to 53%) as individuals move into clinical settings. The rate among nursing-home residents averages about 30%. The ratio of females to males is 1.3 to 1—less than for major depression, which is a ratio of 1.4 to 0.4.
Untreated, the natural course of depression is one to two years, but 53% of patients have an increased likelihood of becoming disabled one year later, and 51% have more disability days than persons with major depression. Patients with minor depression are also more likely to have a concomitant anxiety disorder. The increased use of health services and costs (1.5 to two times), including physician visits (an increase of 38% to 61%), medications, and an increased length of stay in acute hospital and rehabilitation settings are common.
Engel noted that the rising number of do-not-resuscitate (DNR) orders might be a manifestation of the patient’s inability to fight on—a response to illness described as the “giving-in, given-up” complex.
The National Institute of Mental Health states that geriatric depression is one of the most common conditions associated with completed suicide in older Americans. Older Americans make up 15% of the population, but they account for 18% of suicide deaths—almost twice that of the general population. Elderly white men are at the highest risk, whereas elderly women are less likely than younger women to complete a suicidal act. These alarming statistics may reflect the much higher suicide completion rates of older men living alone. Importantly, studies show that the majority (75%) of elderly people who have committed suicide had visited a primary care physician within the preceding month, but their symptoms were unrecognized and untreated.
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Depression is the most common diagnosis in older individuals who commit suicide; it is more common than substance abuse or psychosis occurring alone or in combination with mood disorders in the young. Major depression adds to the risk of mortality regardless of health status.
Associated Risk Factors for Depression
Risk factors for depression in the elderly include:
Up to 15% of widowed individuals experience potentially serious for as long as one year after the loss of their spouse.
The hallmark of depressive illness in elderly patients is associated with a concurrent medical comorbidity, a factor that represents a major difference from depression in younger populations. Major depression is more likely to be found in medically ill patients who are older than 70 years of age, hospitalized (11%), or institutionalized (12%).
Depression often results in higher morbidity and mortality rates through a vicious circle and represents a risk factor for death that can last for many years beyond widowhood, isolation, or financial deprivation. Severe or chronic diseases are associated with a higher prevalence and persistence of depression, including:
Failure to treat underlying depression in these patients may lead to suboptimal decisions and care.
Medications may also produce depression in the elderly. The need for older patients to take multiple medications to treat several medical problems makes polypharmacy a common phenomenon that is often difficult to identify. Dosage reductions and the outright elimination of or a change of agents may be necessary in an attempt to identify the agent responsible for depression and other adverse drug reactions.
Drugs that have frequently been reported to cause depression include steroids; histamine H1 blockers; centrally active alpha blockers; stimulants; antibiotics; sedatives; benzodi-azepines; and anti-inflammatory, cardiovascular, chemothera-peutic, antipsychotic, antiparkinsonian, and anticonvulsant agents. Dosage reduction, when possible, is always a good place to start. A follow-up evaluation in two to three weeks should show some response, depending on the agents to be tapered and stopped.