Depression "Disconnect" in the Elderly

August 15, 2007
Caroline Helwick

Internal Medicine World Report, August 2007, Volume 0, Issue 0

Use Objective Test Results as Your Guide

By Caroline Helwick

NEW ORLEANS—Recognizing depression in the elderly, especially in those with cognitive impairment, can be tricky, according to several experts who reported their findings at the American Association of Geriatric Psychiatry meeting.

Although sad mood is a hallmark of depression, anhedonia more strongly correlated with major depression in a study of 163 older adults with mild cognitive impairment or dementia. Every depressive symptom examined was independently associated with the clinical diagnosis, but patients who self-reported a "loss of interest" were almost 3 times more likely to be depressed than those who did not report it, said Mohit P. Chopra, MD, of the Department of Psychiatry, Geriatrics, and Biostatistics, University of Arkansas for Medical Sciences, Little Rock.

The study also found that informants (usually family members) were not particularly likely to notice loss of interest and were less likely than physicians to identify the depression.

"There was a significant amount of disagreement between patients and informants as to symptoms of depression. In only 15% of cases did patients and informants agree that ?Dad' was depressed. In 49%, the relative reported depression, but ?Dad' denied it," said Dr Chopra.

He continued, "We think persons with dementia may no longer be able to formulate and express feelings of sadness, but somehow are better able to identify loss of interest. Unfortunately, this is the same symptom that was associated with much disagreement between patients and informants in the study."

In contrast, better agreement was found among the 2 parties on negative thoughts. Although patients with dementia generally do not express negative thoughts, when they do, families listen, Dr Chopra noted.

Different Study, Similar Findings

The Clinical Antipsychotic Trials in Intervention Effectiveness—Alzheimer's Disease trial of 257 patients with dementia and their caregivers also reported the prevalence of depression in older patients and the caregivers' lack of recognition of it.

Lea C. Watson, MD, MPH, of the University of North Carolina School of Medicine, Chapel Hill, identified depression in 37% of the patients with dementia, based on the Cornell Scale for Depression in Dementia. In the majority of cases, patients did not recognize their own depression; when they did report being depressed, the clinical assessment usually corroborated it.

"There were many false negatives, but few false positives. When they said they were depressed, they were usually correct by objective measures," Dr Watson said.

Caregivers identified depression in their loved one in just 60% of cases. Their accuracy improved when the patient's Mini-Mental State Examination score was >18. "The point is that clinicians cannot count on the caregiver to recognize depression in a person with dementia. Objective testing needs to be done in these patients," she concluded. "We should also ask caregivers about their own depression."

In addition to a trial of antidepressants, Dr Watson recommends evaluating other factors for areas that could be modified. "Sometimes we are not respecting the person's autonomy, and this leaves the patient angry and depressed. I have found that when you yield to some of the patients' preferences and structure their day in ways that are more agreeable to their individual needs, you often see an improvement in the depression."

Telephone Counseling Can Help

Another alternative is to incorporate depression counseling into existing chronic disease management programs, said Carolyn L. Turvey, PhD, of the Department of Psychiatry, University of Iowa, Iowa City.

Disease management and home monitoring are already being used by health maintenance organizations and VA healthcare systems. Dr Turvey integrated depression screening into a standard heart failure (HF) management program.

Patients used a daily automated home monitoring device, the Pharos Tel-Assurance system, to report symptoms of depression as measured by the Patient Health Questionnaire (PHQ-9), along with symptoms of HF and their weight. The PHQ-9 was used to screen for depression, because it was developed specifically for use in primary care populations and was validated for telephone use. Nurse care managers followed up with phone calls.

"We do basic illness management but also talk to patients by telephone a half an hour per week," Dr Turvey said. The focus is on coping with functional impairment. Key topics include:

  • Grief, loss, and acceptance
  • Changing interpersonal roles
  • Learning to ask for help
  • Initiating new recreational activities
  • Developing new expectations.

"Many psychotherapy interventions could be effective in the primary care setting. The reason some patients improve and others do not may be the fact that we do not address both physical and mental health together," Dr Turvey said. "In our comorbid illness management program, we set behavioral and emotional goals, in addition to physical goals, and provide supportive counseling."