Older women and late life depression

Depression is one of the most common psychiatric conditions seen in older people, affecting between 15 and 20 per cent of the elderly population^1,2. The prevalence increases with age reaching its peak in the over 65 years population. It is also known to be more common in women with some studies estimating that it affects twice as many women as men³.

In elderly patients, depression not only interferes with the ability to function and enjoy once pleasurable activities, but it also affects the ability to remain independent in the community necessitating the assistance of primary care and community services.

This article discusses the assessment and management of depression in elderly women and the impact on gender specific co-morbidities.

Assessment and diagnosis of depression

The diagnosis of depression in elderly women is not an easy task. Older depressed women could experience atypical depressive symptoms whereas others may suffer from the biological symptoms of depression without showing low mood.

Depression is primarily a mood disturbance but in the elderly woman the biological signs of loss of sleep and appetite, change in weight, lack of personal hygiene, self harming thoughts and cognitive decline may precede any changes of mood.

There is also evidence that depression can exacerbate the course or initiate the onset of serious and disabling medical conditions. These factors all add to the under-recognition of late life depression. Therefore, the assessment of any complaint or medical condition in the elderly female population should include an assessment of mood, self harming thoughts and depressive symptomatology.

Table 1. Management of depression in women

1. Treatment of depression will improve disability
2. Treatment of depression should be a combination of pharmacotherapy and supportive psychotherapies
3. Pharmacotherapy should continue for at least six months after the symptoms have disappeared
4. Slow gradual decrease of the medication will help counteract any discontinuation symptoms

Common co-morbidities in the female population

Mild cognitive impairment in depression

Mild Cognitive Impairment (MCI) is associated with a number of depressive symptoms including mild memory impairment and learning deficits. It is an established complaint in elderly women who suffer from possible affective disorder. The patient may lack concentration and attention and may be too depressed to remember daily activities. Standardised assessment tools for depression and dementia would help to evaluate the symptoms and form a basis for follow up assessments.

Criteria for amnestic MCI are memory complaints from an informant, impaired memory functions, preserved cognitive functions and absence of dementia⁴. Although the clinical picture may come across as cognitive decline, low mood would respond to treatment and several of the symptoms would improve as the depression improves. Pseudo-dementia is a term commonly used for depressive symptoms that present as dementia. If cognitive decline is associated with depression, rigorous treatment will resolve the problem⁵.

Neuro-degenerative disorders

Depression is also a common neuro-psychiatric symptom among female patients with neurodegenerative disorders. Different forms of dementia including Alzheimer’s disease, multiinfarct and Lewy body dementia, cerebrovascular accidents (i.e. stroke and Parkinson’s disease) are all associated with increased rates of depression.

It is well established that including antidepressants in the management of the medical condition not only will improve mood but will also improve the medical condition and the performance of the patient. It will also decrease disability^6,7.

Endocrinological problems

Three per cent of women in England have diagnosed diabetes and the proportion increases with age to approximately 10 per cent over the age of 75 years⁸. All endocrinological problems, such hypo- or hyper- thyroidism, diabetes, B12 deficiency and others are associated with increased rates of depression. Low mood can be the first sign of these conditions^9,10.

Depression and coronary heart disease

It is estimated that 1.1 million women in the UK have Coronary Heart Disease (CHD)¹¹. The cooccurrence of CHD and depression in women is also common¹². There are complex interactions where depression may increase the risk of heart disease while patients with heart disease will have a higher risk of becoming depressed¹³.

Research findings show that both minor and major depression have significant effects on the pathogenesis and prognosis of heart disease¹⁴. The fact that patients with untreated depression are more likely to develop ischaemic heart disease and patients with heart disease are more likely to develop depression show the complex interaction between the two clinical diagnosis and the importance of recognising and treating them simultaneously.

In these patients, depression is also associated with biological conditions such as hypercholesterolaemia and atherosclerosis. At the same time depression may increase the risk of smoking, excessive alcohol intake and also lead to poor adherence to medical treatment, which in turn will increase the severity of the cardiological condition.

Depression and chronic obstructive pulmonary disease

Chronic Obstructive Pulmonary Disease (COPD) affects 13 per cent of women over 65 years of age¹⁵. Besides contributing to mortality, COPD increases morbidity, disability and the need for primary care input. There is an increased rate of major clinical depression in patients with a diagnosis of COPD with around 30 per cent of the population with COPD having a diagnosis of depression¹⁶.

Depression reduces adherence to medical and psychiatric treatment therefore the treatment of the depressed patient with COPD must be comprehensive and include assessment for mood disorder and antidepressant treatment when necessary.

Treatment of late age depression in women

Optimal treatment can be offered following a full assessment of women over 65 years, which should include information on medical conditions, social needs, support system and also the patient’s daily activities. Most of the cases of depression can be treated successfully with medication, psychotherapy or a combination of both. Patients with mild to moderate depression will benefit from supportive therapies, anxiety management techniques and from increased social support.

However, women with severe depression will need pharmacotherapy in the form of antidepressants such as selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors and at times tricyclic antidepressants.

Frequent assessment of the condition and six weekly follow up will give a good understanding of the necessary augmentation strategies that may also be needed such as lithium, valproate, carbamazepine, sleeping tablets, anxiolytics, betablockers and sometimes low doses of antipsychotic medication. In addition, treatment of depression will help in resolving the disability that led to inpatient treatment in many instances¹⁷.

Elderly women are sensitive to higher doses of medication and may show frequent side effects. It is important therefore to alert carers and family to any possible side effects to avoid dizziness, falls or any other problems that may lead to non-adherence with the treatment. Depression is a relapsing condition and women show more frequent relapses than men. It is important to continue with the treatment for at least six months after the symptoms have been treated.

It is also important to decrease the medication gradually to eliminate any possible discontinuation symptoms. Sudden decrease and cessation of the medication may lead to symptoms of irritability, dizziness, palpitation, tremor, lack of sleep and gastrointestinal problems, which do not allow the patient to terminate the treatment.

It is important to gradually decrease and stop the antidepressant after at least three months.

Prognosis

The prognosis of depression in elderly females depends on early and appropriate treatment, adherence with treatment, absence of any physical illness, and the presence of a well established support system. Continuing stressors and life events, history of or present substance abuse, untreated medical conditions, a progressive dementing condition will also all contribute to a relapsing depressive disorder.

Conclusion

Depression is a treatable disorder, which increases in frequency and even severity with older age. It is well established that it is strongly associated with medical conditions that tend to mask the signs and symptoms of depression leaving the patient to suffer unnecessarily. It is very important to recognise the signs of depression and treat the patient appropriately.

Medical conditions respond to treatment more favourably when treatment for depression is established appropriately. Training in recognition of mood disorders may enhance the well being of the medically ill.

---

Professor Dora Kohen, Professor of Women’s Mental Health, Lancashire Postgraduate School of Medicine and Health

In memory of Professor Dora Kohen

---

References

1. Beekman AT, Copeland JR, Prince MJ. Review of community prevalence of depression in later life. British Journal of Psychiatry Journal of Psychiatry 1999;174: 307-11
2. Baldwin R, Wild R. Management of depression in later life. Advances in Psychiatric Treatment Psychiatric Treatment 2004; 601: 2004; 601: 10 131-39
3. Weissman MM, Klerman GL. Sex differences in the epidemiology of depression. Archives of General Psychiatry Psychiatry 1977;34: 98-111
4. Presten RC, Doody R, Katz A, et al. Current concept of mild cognitive impairment. Archives of Neurology 2002; 58(12): 1985-92
5. Yaffe K, Blackwell T, Gore R, et al. Depressive symptoms and cognitive decline in non-demented elderly women: A prospective study. Archives of General Psychiatry; 56(5): 425-30
6. Rozanski A, Blumenthal JA, Kaplan J. Impact of psychological factors on the pathogenesis of cardiovascular disease and implications for therapy. Circulation 1977; 99(16): 2192-2217
7. Taylor D, Barber KR, McIntosh M, Khan M. The impact of post acute myocardial infarction (AMI) depression on patient compliance and risk factor modification. Psychology, Health and Medicine 1998; 3(4): 439-42
8. http://www.heartstats.org/datapage. asp?id=1106 (date last accessed: 03/02/06)
9. Fava GA, Sonino N, Murphy MA. Major depression associate with endocrine disease. Psychiatric Developments 1987; 4; 321-48
10. Engum A, Bjoro T, Mykletun A, Dahl AA. Thyroid autoimmunity, depression and anxiety; are there any connections; An epidemiological study of large population. Journal of Psychosomatic Research 2005; 59(5): 263-8
11. British Heart Foundation. www. heartstats.org/datapage.asp?id=1584 (date last accessed: 11/11/05)
12. Swap DF, Bao AM, Lucassen PJ. The stress system in the human brain in depression and neuro-degeneration. Ageing Research and Review 2005; 4(2): 141-94
13. Koening HG. Depression in hospitalized older patients with congestive heart failure. General Hospital Psychiatry Hospital Psychiatry 1998;20(1) 29-43
14. Hemingway H, Marmot M. Evidence based cardiology; psychosocial factors in the aetiology and prognosis of coronary heart disease. Systematic Review of prospective cohort studies. British Medical Journal British Medical Journal 1999; 318(7196): 1460€“67
15. Verbrugge LM, Patrick DL. Seven chronic conditions: Their impact on US adults’ activity levels and use of medical services. American Journal of Public Health 1995; 85(2): 173-82
16. Verbrugge LM, Patrick DL. Seven chronic conditions: their impact on US adults’ activity levels and use of medical services. American Journal of Public Health 1995; 85(2): 173-82
17. Oslin DW, Strein J, Katz IR, et al. Change in disability following inpatient treatment for late life depression. Journal of American Geriatrics Society Geriatrics Society 2000;48(4) 357-62