Tips to detect and treat depression in older patients
From the December ACP Observer, copyright © 2003 by the American College of Physicians.
By Alison McCook
Several years ago, Auguste H. Fortin VI, ACP Member, saw a new patient in his late 70s who complained of frequent urination. After finding that the patient had an enlarged, nodular prostate, Dr. Fortin referred him to a urologist, who told the patient he possibly had prostate cancer.
"The patient went home and shot himself that very day," said Dr. Fortin, who called the patient's house to see how the urology appointment had gone, only to have a sheriff answer the phone. "They had just found the body."
Looking back, Dr. Fortin, who is assistant clinical professor of medicine and the director of the psychosocial curriculum for the primary care internal medicine residency program at New Haven's Yale University, said he suspects the patient was depressed. "I guess hearing the possibility that he had cancer just tipped him over."
Many other internists can tell similarly stark tales of patients with untreated depression. The condition affects about 12% of men in the United States between the ages of 45 and 54—and slightly more women—at some point in their lives. However, depression is very easy to miss, and research shows that physicians don't diagnose or properly treat up to 60% of their depressed patients.
Recognizing depression and suicide risk can be particularly difficult in the elderly, who often present with multiple illnesses that occupy every minute of an office visit. Making matters worse, many of those complaints mimic the symptoms of depression.
The fatigue, weakness, weight loss and lack of appetite that may be signs of cancer or an infection, for instance, can also signal depression. Likewise, the confusion that may plague a depressed patient can lead family and friends to think that he or she has dementia.
James S. Powers, FACP, director of the geriatric medicine residency program at Vanderbilt Medical Center in Nashville, Tenn., recalled a patient in his early 80s who fit exactly that description. His family was considering placing him in a nursing home because he had become forgetful.
The patient was in good spirits overall, Dr. Powers said, but he was having trouble sleeping and eating. Before diagnosing dementia, Dr. Powers decided to prescribe an antidepressant to stimulate the patient's appetite.
"Within two weeks, this man was eating, he was much more alert and even his family agreed his memory was much better," Dr. Powers said. Perhaps most importantly, he added, the patient is still living at home.
While the above two examples show extremes of depression, they illustrate a point experts say physicians cannot ignore: Many elderly patients are depressed.
That's why depression "has got to be high on your radar screen for this population pretty much all the time," said Michael Harrington, ACP Member, an internist and geriatrician at the MetroHealth Medical Center in Cleveland who teaches internal medicine residents and geriatric fellows.
Here are some tips to help you identify depression among your elderly patients and prevent suicidal patients from acting on the depression that threatens to overwhelm them:
Be aware of generational differences in depression. Depression presents differently depending on a patient's age. Older patients, for instance, tend to have symptoms that include somatic concerns like back pain, headache or constipation, or a refusal to take medications. Older depressed patients also tend to have a short attention span, lose interest in food, exhibit sleeplessness and have trouble cooperating with recovery or rehabilitation efforts.
Dr. Fortin said that younger patients, on the other hand, are more likely to acknowledge depression than older patients. "Many older folks will be more able to talk about poor concentration than admit to a depressed mood," he said.
Consider life events. Your elderly patients are often coping with losses that can include the death of family and friends, the sudden loss of a job and daily activities that can accompany retirement, and increased dependence from illness and injury. All of these changes can trigger depression, which is why you need to keep abreast of what's going on in your older patients' lives.
While a period of mourning for these losses is natural, watch for patients who seem to be taking an especially long time to recover. Robert S. Crausman, FACP, a geriatrician, pulmonologist and former residency program director at Brown University in Providence, R.I., said he considers a diagnosis of depression if mourning lasts longer than three months and impacts patients' ability to go about their lives or enjoy their grandchildren.
"Anything that interferes with their functioning and daily activities should make you concerned that this is more than just sadness," he said.
Ask about symptoms. In the elderly, depression can manifest as fatigue, insomnia, feeling blue, loss of interest in favorite activities, weight loss and lack of energy. Experts say that regularly asking older patients about these and other symptoms is the best approach. "Just asking is the best screen," said Dr. Crausman.
Some useful questions include: How are you sleeping and eating? Do you find yourself tired all the time, and do you feel better after sleeping? Have you lost interest in the things you used to enjoy or experienced any major life changes recently? Do you feel hopeless and worry about becoming a burden?
You can sometimes elicit a more telling response by asking patients if they are happy, rather than sad, said Cleveland's Dr. Harrington. Depression carries a social stigma, he pointed out, and many patients who deny feeling sad may be willing to admit they don't feel blissfully fulfilled.
When discussing elderly patients' sense of well-being, it is particularly important to ask how they feel in the morning. Depressed patients tend to feel worse upon waking and then improve as the day progresses—the opposite pattern from what you often see in other illnesses. That's an important clue that patients' symptoms may have more to do with their mind, not their body.
Pay attention to behavior. If your patients' words don't convince you that they are not depressed, scrutinize their behavior. When Dr. Fortin first met the patient who went on to commit suicide, for instance, the man came off as suspicious, slightly paranoid and disagreeable. Looking back, Dr. Fortin said he realizes that those behaviors might have been subtle signs of depression.
Other behavioral changes that can signify depression include weight loss, lack of eye contact, a demanding or hostile tone, and frequent office visits. Likewise, listening to how patients answer questions can provide additional hints about their state of mind, Dr. Harrington said.
"If they're giving 'yes' and 'no' answers or saying 'I don't know' or 'I don't care,' that should be your next trigger," he explained. "You should start asking them why they don't care."
Another red flag: the outwardly happy patient who has difficulty recovering from hip fracture, stroke, heart attack or some other medical event. "They might appear cheerful and eat and sleep OK, but they're just not getting better," said Dr. Powers. "Think depression."
Rule out dementia. One challenge residents face when diagnosing depression in the elderly is that many symptoms match those of dementia.
"Depression itself can cause a 'pseudo dementia,' which can mimic worsening cognitive decline," said Dr. Fortin. When a patient presents with some sort of cognitive decline or dementia, he continued, "that's another time when our antennae have to be up to the possibility that this is a pseudo dementia caused by depression."
Some clues to help distinguish dementia from depression can come from listening to how patients answer questions, pointed out Dr. Harrington. For instance, patients who are depressed may try to avoid questions about their mood, saying they are tired or don't want to answer. They may also simply refuse to respond.
Patients suffering from dementia, on the other hand, may "go on and on about something that may not make any sense," Dr. Harrington said, "but they're generally going to answer your questions."
Recruit family members. When speaking with family members, ask whether patients have experienced any recent shifts in mood or comportment. Have they become more withdrawn, paranoid, or disconnected from friends and routines? Family members can also clue you in on whether patients are going through a tough time.
Use simple screening tools. If you are having trouble diagnosing depression in an older patient, use a screening tool such as the geriatric depression scale (see "Screening resources."). "Screening is well worth the effort," said Charles F. Reynolds III, MD, professor of psychiatry at the University of Pittsburgh Medical Center. "It doesn't take long and it may be life-saving."
If you're afraid that screening will steal too much time from the visit, recruit support staff to help out or schedule a follow-up appointment to administer the screening tool.
Prescribe an antidepressant. If you suspect depression in your elderly patients and think they can tolerate medication, ask them to try an antidepressant for a few weeks to see what happens.
Make sure that you offer the right dose, said Dr. Reynolds. "Undertreatment or underdosing is fairly common in primary care settings and usually doesn't do the patient much good," he said. "If you have an elevated index of clinical suspicion, prescribe what is likely to be an effective dose of an antidepressant."
Ask about suicide. Finally, if you think elderly patients are depressed, ask if they have considered taking their own lives. Don't let them leave the office until you are convinced they won't.
Elderly patients are much more likely than younger patients who are suicidal to be successful when trying to take their own lives. In 2000, for example, 15 Americans over the age of 65 committed suicide every day. One report in the May 2003 American Journal of Psychiatry found that 45% of suicide victims had contacted a primary care provider within the past month, and older people who had taken their lives were more likely to have contacted their doctors than younger victims.
Instead of bluntly asking if patients ever consider killing themselves, Dr. Reynolds suggested introducing the topic "gently," by perhaps asking if patients worry about becoming a burden to their families. When patients admit to suicidal thoughts, ask if they have planned how they might end their lives.
And when you bring up suicide, always ask if a patient has access to a handgun. Statistics show that almost six out of every 10 suicides are committed with a handgun, and a report in the July/August 2002 issue of the American Journal of Geriatric Psychiatry found that older adults who have a handgun in the home are more likely to commit suicide than others.
"Asking if there's a firearm in the home is tantamount," said Arinn Dixon Widmayer, executive director of Doctors Against Handgun Injury, a program of the New York Academy of Medicine and a coalition of 12 national clinical societies, including ACP. "That's not crossing any boundaries, that is merely safety and prevention."
If you think an older patient is suicidal, take the same steps you would with younger patients. Don't leave patients alone if they appear to be at immediate risk. Ask them to accept help and if they won't, physically place them out of harm's way by calling an ambulance to transport them to an emergency department or psychiatric facility.
"In my practice, patients have to convince me that they won't do it," said Dr. Fortin. "Otherwise I'm going to get them into some protective situation."
Alison McCook is a freelance writer in Brooklyn, N.Y., who specializes in health care.
Information on Doctors Against Handgun Injury, as well as order forms for brochures, is online.
While physicians suffer from depression at the same rate as the general public, the consequences can be much more tragic.
A review article in the June 18, 2003, issue of the Journal of the American Medical Association (JAMA) found that doctors are more likely to commit suicide than members of the public. And while men in the general population are four times as likely to kill themselves as women, women physicians are just as likely to take their own lives as male physicians.
"Suicide among physicians has been a frightening occurrence for as long as I have been a doctor," said geriatrician and pulmonologist Robert S. Crausman, FACP, a former residency program director at Brown University in Providence, R.I. "I can't think of a physician who doesn't know of or have a friend who committed suicide."
The JAMA report—and an accompanying consensus statement—grew out of a two-day workshop held in October 2002 by the American Foundation for Suicide Prevention. Experts at the meeting drafted recommendations to encourage physicians to seek help for mental illness, and a consensus statement described how the medical system needs to change its treatment of doctors suffering from mental illness. (An abstract of the report is online.)
The stresses associated with medical training and careers may explain why female physicians are just as likely to commit suicide as their male colleagues, said psychiatrist Charles F. Reynolds III, MD, of the University of Pittsburgh Medical Center, a co-author of the statement. As professionals, women may feel more competing demands from balancing family and other personal obligations than men, Dr. Reynolds explained. That added stress could make coping with undiagnosed or poorly treated depression or substance abuse even harder, driving them to suicide, he added.
And few doctors who feel stress or suffer from mental illness appear to seek help, according to the JAMA report. "Many physicians don't have adequate medical care for themselves," Dr. Reynolds said. "In addition, they may be reluctant to seek help for depression out of fear that they will lose their licenses or otherwise be penalized."
Many medical students also hesitate to get the professional support they need to deal with mental illness. Research indicates that only 22% of depressed students use mental health services—and that only 42% of those who say they are depressed and considering suicide seek treatment.
When asked why they don't seek professional help, most students say they do not have enough time. Many also say they fear the stigma or worry that treatment would be noted on their academic records.
These concerns are not unfounded, the report noted: Physicians with psychiatric disorders "often encounter overt or covert discrimination in medical licensing, hospital privileges, health insurance, and/or malpractice insurance."
The geriatric depression scale is a 30-item scale that takes several minutes to complete. A copy is available online.
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