1. Depression in the Elderly M H Walker

2. Prevalence Controversial w.r.t. younger people Controversial w.r.t. younger people Instruments for younger people not appropriate Instruments for younger people not appropriate DSM IV depression has low prevalence DSM IV depression has low prevalence High prevalence of depressive symptoms High prevalence of depressive symptoms Perhaps 10-15% of >65s have significant depressive symptoms Perhaps 10-15% of >65s have significant depressive symptoms

3. Incidence Biphasic distribution Biphasic distribution Age 50 30

4. Diagnosis Instruments for younger people not appropriate – e.g. DSM, HAM-D, MADRAS – all these have physical elements, e.g. weight loss, which are likely to have a physical cause in the elderly Instruments for younger people not appropriate – e.g. DSM, HAM-D, MADRAS – all these have physical elements, e.g. weight loss, which are likely to have a physical cause in the elderly

5. Instruments for the Elderly Geriatric Depression Scale – 30,15 and 4 Geriatric Depression Scale – 30,15 and 4 BAS (and BASDEC) BAS (and BASDEC) Research: Research:  CARE (and SHORTCARE)  GMS-AGECAT  CAMDEX

6. Geriatric Depression Scale (15) Yesavage et al 1983 Are you basically satisfied with your life? Are you basically satisfied with your life? Have you dropped many of your activities and interests? Have you dropped many of your activities and interests? Do you feel that your life is empty? Do you feel that your life is empty? Do you often get bored? Do you often get bored? Are you in good spirits most of the time? Are you in good spirits most of the time? Are you afraid that something bad is going to happen to you? Are you afraid that something bad is going to happen to you? Do you feel happy most of the time? Do you feel happy most of the time? Do you often feel helpless? Do you often feel helpless? Do you prefer to stay at home rather than going out and doing new things? Do you prefer to stay at home rather than going out and doing new things? Do you feel you have more problems with memory than most? Do you feel you have more problems with memory than most? Do you think it is wonderful to be alive now? Do you think it is wonderful to be alive now? Do you feel pretty worthless the way you are now? Do you feel pretty worthless the way you are now? Do you feel full of energy? Do you feel full of energy? Do you feel that your situation is hopeless? Do you feel that your situation is hopeless? Do you think that most people are better off than you? Do you think that most people are better off than you?

7. Institutions Prevalence high in hospital Prevalence high in hospital Prevalence about 50% in residential homes using the BAS Prevalence about 50% in residential homes using the BAS Prevalence not higher than the community in sheltered accommodation (Walker et al 1998 – actually non-significantly lower) Prevalence not higher than the community in sheltered accommodation (Walker et al 1998 – actually non-significantly lower)

8. The Vascular Connection Depression known to be common after stroke Depression known to be common after stroke High proportion (up to 100% - Coffey et al 1989) of people with first ever depressive episode > 60 y.o. have hyperintensities on MRI scan High proportion (up to 100% - Coffey et al 1989) of people with first ever depressive episode > 60 y.o. have hyperintensities on MRI scan Concept of “vascular depression” Concept of “vascular depression”

9. Prognosis Traditionally poor Traditionally poor Unfortunately this appears to be true Unfortunately this appears to be true Vascular changes may underlie this Vascular changes may underlie this BUT many people respond to treatment and a recent meta-analysis suggests there is no worse response to modern antedepressants at older ages (Entsuah et al 2001) BUT many people respond to treatment and a recent meta-analysis suggests there is no worse response to modern antedepressants at older ages (Entsuah et al 2001) Higher rate of dementia – esp. if first episode >65 y.o. Higher rate of dementia – esp. if first episode >65 y.o. BUT many do not develop dementia BUT many do not develop dementia

10. Disease and Disability Physical illness and disability are the strongest associations with depression in the elderly Physical illness and disability are the strongest associations with depression in the elderly Illness and disability are also the strongest (-ve) prognostic factors (Murphy 1983) Illness and disability are also the strongest (-ve) prognostic factors (Murphy 1983) High prevalence of depression in the general hospital High prevalence of depression in the general hospital

11. Suicide and the elderly Suicide is more common in the elderly (esp. men) Suicide is more common in the elderly (esp. men) Parasuicide (suicide attempt) is less common in the elderly Parasuicide (suicide attempt) is less common in the elderly Elderly suicides often go unreported and/or unrecognised Elderly suicides often go unreported and/or unrecognised There has usually been evidence of depression There has usually been evidence of depression

12. Treatment - principles The elderly may have co-existing medical conditions The elderly may have co-existing medical conditions The elderly are likely to be taking other medication The elderly are likely to be taking other medication Prolonged untreated depression in the elderly may have adverse physical effects Prolonged untreated depression in the elderly may have adverse physical effects

13. Treatment - practice Tricyclic drugs have many adverse effects which are a particular problem for the elderly – e.g. confusion, postural hypotension, urinary retention, cardiac Tricyclic drugs have many adverse effects which are a particular problem for the elderly – e.g. confusion, postural hypotension, urinary retention, cardiac Minimize the potential for interaction Minimize the potential for interaction Beware of hyponatraemia Beware of hyponatraemia ECT can provide rapid relief, but generally another form of treatment will be required for maintenance ECT can provide rapid relief, but generally another form of treatment will be required for maintenance

14. Psychotherapy Traditionally not suitable for the elderly Traditionally not suitable for the elderly This is now being challenged This is now being challenged CBT well-established for the elderly CBT well-established for the elderly Outcome remains worse than in younger people (on average) – but prognosis is worse in general Outcome remains worse than in younger people (on average) – but prognosis is worse in general