The Big Three: Depression, Delirium, and Dementia
•What are the most common characteristics of people with depression? How is depression diagnosed? What causes depression? What is the relation between suicide and age? How is depression treated?
•What is delirium? How is it assessed and treated?
•What is dementia? What are the major symptoms of Alzheimer’s disease? How is it diagnosed? What causes it? What intervention options are there?
What are some other major forms of dementia? What do family members caring for patients with dementia experience?
ing has lived in the same neighborhood in New York for all of her 74 years. Her son, who visits her every week, has started noticing that Ling’s memory problems have gotten much worse, her freezer is empty, and her refrigerator has lots of moldy food. When he investigated further, he found that her bank accounts were in disarray. Ling’s son wonders what could be wrong with her.
Ling’s behaviors certainly do not appear to be typical of older adults. Unfortunately, Ling is not alone in experiencing difficulties; many older adults have similar problems. In this section, we consider three of the most common difficulties: depression, delirium, and dementia. As we will see, both depression and delirium are treatable; the most common form of dementia, Alzheimer’s disease, is not. The three conditions are connected by overlapping symptoms and the possibility that they may coexist. Let’s consider each in detail.
Most people feel down or sad from time to time, perhaps in reaction to a problem at work or in one’s relationships. But does this mean that most people are depressed? How is depression diagnosed? Are there age-related differences in the symptoms examined in diagnosis? How is depression treated?
First of all, let’s dispense with a myth. Contrary to the popular belief that most older adults are depressed, the rate of severe depression declines from young adulthood to old age for healthy people (Gatz, 2000; NIMH, 2008), a fact that also holds cross-culturally (Chou & Chi, 2005). Rates for depression tend to be higher in Latino older adults than for other groups of older adults (Centers for Disease Control and Prevention and National Association of Chronic Disease Directors, 2008). In the United States, less than 5% of older adults living in the community show signs of depression, but
the percentage rises to over 13% among those who require home health care (NIMH, 2008). Young adults are at the most risk. If we consider people’s reports of symptoms of depression, a different picture emerges. In this case, the highest rates occur in younger adults and people over age 75, with middle – aged adults having a lower rate (Rothermund & Brandtstater, 2003). Importantly, there is also evidence of a cohort effect, with more recent-born cohorts showing higher rates of depression.
Finally, depression commonly accompanies other chronic conditions. For example, research indicates that 33% of people with diabetes also show symptoms of depression, as do 42% of people with cancer and 45% of people who have had a recent heart attack (National Academy on an Aging Society, 2000b). For those people who do experience depression, let’s examine its diagnosis and treatment.
General Symptoms and Characteristics of People with Depression. The most prominent feature of clinical depression is dysphoria, that is, feeling down or blue. There are important developmental differences in how this feature is expressed (Gatz, 2000). Older adults may not label their down feelings as depression but rather as pessimism or helplessness (Zarit & Zarit, 2006). Indeed, a large community study of more than 6,500 adults revealed that older adults were much less likely to endorse statements relating to dysphoria (Gallo et al., 1994). In addition, older adults are more likely to show signs of apathy, subdued self-deprecation, expressionlessness, and changes in arousal than are younger people (Zarit & Zarit, 2006). It is common for depressed older adults to withdraw, not speak to anyone, confine themselves to bed, and not take care of bodily functions. Younger adults may engage in some of these behaviors but do so to a much lesser extent. Thoughts about suicide are common, and may reflect a shutdown of a person’s basic survival instinct.
The second major component of clinical depression is the accompanying physical symptoms. These include insomnia, changes in appetite, diffuse pain, troubled breathing, headaches, fatigue, and sensory loss (Zarit & Zarit, 2006). The presence of these physical symptoms in older adults must be
368 CHAPTER 10
evaluated carefully. As noted in Chapter 3, some sleep disturbances may reflect normative changes that are unrelated to depression; however, certain types of sleep disturbance, such as regular early morning awakening, are related to depression, even in older adults (Krahn, 2005). Alternatively, the physical symptoms may reflect an underlying physical disease that is manifested as depression. Indeed, many older adults admitted to the hospital with depressive symptoms turn out to have previously undiagnosed medical problems that are uncovered only after thorough examinations and evaluations (Mulley, 2008). A list of some of the most common diseases that are often accompanied by depression can be seen in Table 10.2.
Physical Illnesses That Cause Depression
in Older Adults
Coronary artery disease
Hypertension, myocardial infarction, coronary artery bypass surgery, congestive heart failure
Cerebrovascular accidents, Alzheimer’s disease, Parkinson’s disease, amyotrophic lateral sclerosis, multiple sclerosis, Binswanger’s disease
Diabetes mellitus, hypothyroidism or hyperthyroidism, hypercortisolism, hyperparathyroidism, Addison’s disease, autoimmune thyroiditis
Pancreatic, breast, lung, colonic, and ovarian carcinoma; lymphoma; and undetected cerebral metastasis
Chronic obstructive pulmonary disease, rheumatoid arthritis, deafness, chronic pain, sexual dysfunction, renal dialysis, chronic constipation
Source: Sunderland, T., Lawlor, B. A., Molchan, S. E., & Martinez, R. A. (1988). Depressive syndromes in the elderly: Special concerns.
Psychopharmacology Bulletin, 24, 567-576.
The third primary characteristic is that the symptoms must last at least 2 weeks. This criterion is used to rule out the transient symptoms that are common to all adults, especially after a negative experience such as receiving a rejection letter from a potential employer or getting a speeding ticket.
Fourth, other causes for the observed symptoms must be ruled out (Mulley, 2008). For example, other health problems, neurological disorders, medications, metabolic conditions, alcoholism, or other forms of psychopathology can cause depressive symptoms. These causes influence appropriate treatment decisions.
Finally, the clinician must determine how the person’s symptoms are affecting his or her daily life. Is the ability to interact with other people impaired? Can he or she carry out domestic responsibilities? What about effects on work or school? Is the person taking any medication? Clinical depression involves significant impairment in daily living.
Although the primary risk factors for depression do not change with age, some important personal characteristics do. Being female, unmarried, widowed, or recently bereaved; experiencing stressful life events; and lacking an adequate social support network are more common among older adults with depression than younger adults (Zarit & Zarit, 2006). Subgroups of older adults who are at greater risk include those with chronic illnesses (of whom up to half may have major depression), nursing home residents, and family caregivers (who commonly report feeling depressed; DeFries & Andresen, 2009).
Rates of clinical depression vary across ethnic groups, although correct diagnosis is frequently a problem with minorities due to inadequate access to care (Alegria et al., 2008). Older people of ethnic minorities who are not highly acculturated in the United States tend to show higher rates of depression; this is especially true for Chinese Americans and Mexican Americans (Lam et al., 1997). Immigrants who live alone are also at higher risk for depression (Wilmoth & Chen, 2003). Latinos have a higher rate of depression overall, with some estimates indicating that up to one fourth of older Latinos have depression or related disorder, possibly caused by poor health in general. Latinos who speak primarily Spanish or
are foreign-born are especially likely to show depression (Mercado-Crespo et al., 2008). Older African Americans have lower rates of depression than European Americans (Moulton, 1997). Clearly, the pattern of ethnic differences indicates that the reasons for them are complex and not well understood.
Gender and Depressive Symptoms. Women tend to be diagnosed as being depressed more often than are men (Barry et al., 2008). A longitudinal study over 6 years showed that this is due in part to women being more susceptible than men to depression (Barry et al., 2008). Additionally, the symptoms of dysphoria and feelings of guilt or self-blame are present in classic clinical depression but appear to be absent in a version of depression experienced by
Contrary to myth, the rate of depression actually declines with age.
older women called the depletion syndrome of the elderly (Kasl-Godley et al., 1999).
Gender differences in mortality related to depression have been reported. In men but not in women, minor depression is associated with significantly higher mortality; major depression is associated with higher mortality in both genders (Anstey & Luszcz, 2002; Penninx et al., 1999). Some evidence also indicates that men who were taking antidepressants were also more likely to die (Ryan et al.,
2008) . Why these consistent gender differences are observed are unknown.
Assessment Scales. Numerous scales are used to assess depression, but because most were developed on younger and middle-aged adults, they are most appropriate for these age groups. The most important difficulty in using these scales with older adults is that they all include several items assessing physical symptoms. For example, the Beck Depression Inventory (Beck, 1967) contains items that focus on feelings and physical symptoms. Although the presence of such symptoms usually is indicative of depression in younger adults, as we noted earlier such symptoms may not be related to depression at all in older adults. Scales such as the Geriatric Depression Scale (Yesavage et al., 1983) aimed specifically at older adults have also been developed. Physical symptoms are omitted, and the response format is easier for older adults to follow. This approach reduces the age-related symptom bias and scale response problems with other self-report scales measuring depressive symptoms. A third screening inventory, the Center for Epidemiologic Studies-Depression Scale (CES-D; Radloff, 1977) is frequently used in research.
An important point to keep in mind about these scales is that the diagnosis of depression should never be made on the basis of a test score alone. As we have seen, the symptoms observed in clinical depression could be indicative of other problems, and symptom patterns are very complex. Moreover, there is some evidence of gender bias; in one study, both the Geriatric Depression Scale and the Beck Depression Inventory were more accurate in diagnosing depression in older women than in older men (Allen-Burge et al., 1994). Only by assessing many
370 CHAPTER 10 aspects of physical and psychological functioning can a clinician make an accurate assessment.
Causes of Depression. Several biological and psychosocial theories about the causes of depression have been proposed (Langlieb & DePaulo, 2008). Both theories are related to two types of situations: sudden severe loss and long-term, high-level stress.
Biological theories focus most on genetic predisposition and changes in neurotransmitters. The genetic evidence is based on several studies that show higher rates of depression in relatives of depressed people than would be expected given base rates in the population. This genetic link is stronger in early – onset depression than it is in depression that has its onset in late life (Kasl-Godley et al., 1999).
There is substantial research evidence that severe depression is linked to imbalance in neurotransmitters such as low levels of serotonin. Low levels of serotonin are a likely result from high levels of stress experienced over a long period. The usual signs of low serotonin levels include waking up in the early morning (often around 4:00 a. m.), difficulty in concentrating and paying attention, feeling tired and listless, losing interest in activities such as sex or visiting friends, and racing of the mind with strong feelings of guilt and of reliving bad past experiences and creating negative thoughts. These effects of low serotonin are very similar to those that characterize depression, which is why researchers believe that one possible cause is low serotonin. Low levels of another neurotransmitter, norepinephrine, which regulates arousal and alertness, may be responsible for the feelings of fatigue associated with depression. These neurochemical links are the basis for the medications developed to treat depression that we will consider a bit later.
The most common theme of psychosocial theories of depression is loss (Langlieb & DePaulo,
2008) . Bereavement or other ways of losing a relationship is the type of loss that has received the most attention, but the loss of anything considered personally important could also be a trigger. Moreover, these losses may be real and irrevocable, threatened and potential, or imaginary and fantasized. The likelihood that these losses will occur
varies with age. Middle-aged adults are more likely to experience the loss of physical attractiveness, for example, whereas older adults are more likely to experience the loss of a loved one.
Behavioral and cognitive-behavioral theories of depression adopt a different approach. The behavioral approach argues that people with depression engage in fewer pleasant activities and receive less pleasure from them than do nondepressed people (Zarit & Zarit, 2006). This link between behaviors and mood is the basis for various therapeutic interventions. The cognitive-behavioral approach emphasizes internal belief systems and focuses on how people interpret uncontrollable events (Beck, 1967). The idea underlying this approach is that experiencing unpredictable and uncontrollable events instills a feeling of helplessness, which results in depression. In addition, perceiving the cause of negative events as some inherent aspect of the self that is permanent and pervasive also plays an important role in causing feelings of helplessness and hopelessness. In short, according to the cognitive-behavioral approach, people who are depressed believe that they are personally responsible for their plight, that things are unlikely to get better, and that their whole life is a shambles.
An alternative psychosocial explanation argues that whether a person experiences depression depends on a balance among biological dispositions, stress, and protective factors (Gatz, 2000). Developmentally, biological factors become more important with age, whereas stress factors diminish. Protective factors, such as psychological coping skills, also improve, which may account in part for the decreased incidence of depression in later life.
Treatment of Depression. As we have seen, depression is a complex problem that can result from a wide variety of causes. However, an extremely crucial point is that all forms of depression benefit from some form of therapy and that they are quite effective (Zarit & Zarit, 2006). Treatment of depression falls roughly into two categories: medical treatments and psychotherapy.
Medical treatments are typically used in cases of severe depression and involve mainly medication, but in some cases of long-term severe depression,
these treatments include electroconvulsive therapy. For less severe forms of depression, and usually in conjunction with medication for severe depression, there are various forms of psychotherapy. A summary of the various treatment options is presented in Table 10.3.
Three families of medications are used to combat severe depression. Each has potentially serious side effects (for a summary, see the Mayo Clinic’s website on side effects of antidepressant medications at http://www. mayoclinic. com/health/antidepressants/ MH00062). One type of first-line medications used to treat depression is selective serotonin reuptake inhibitors (SSRIs; Mulley, 2008). SSRIs have the lowest overall rate of side effects of all antidepressants. SSRIs work by boosting the level of serotonin, a neurotransmitter involved in regulating moods that was discussed earlier. One of the SSRIs, Prozac, became controversial because it was linked in a small number of cases with the serious side effect of high levels of agitation. Drugs such as fluoxetine HCl (Prozac) make people “not sad" which is different from making people happy. Other SSRIs include paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa), and escitalopram (Lexapro). Other types of first-line medications are serotonin and norepinephrine reuptake inhibitors (SNRIs), norepinephrine and dopamine reuptake inhibitors (NDRIs), combined reuptake inhibitors and receptor blockers, and tetracyclic antidepressants.
If the first-line medications do not work, the next most popular medications are the tricyclic antidepressants. Although these are effective in at least 70% of cases, they are most effective with younger and middle-aged people. The main problem with tricyclic antidepressants in older adults is that these people are more likely to have other medical conditions or to be taking other medications that preclude their use. For example, people who are taking antihypertensive medications or who have any of a number of metabolic problems should not take the tricyclic antidepressants. Moreover, the risk of side effects beyond dry mouth, some of which can be severe, is much greater in older adults, although some of the newer tricyclics have significantly lower risk. Because tricyclic antidepressants must be taken
Summary of Depression Treatment Options
Electroconvulsive therapy Clearly effective in severe depression,
depression with melancholia, and depression with delusions, and when antidepressants are not fully effective. Sometimes combined with antidepressants.
Effective in outpatients using manual-based therapies; the relative contributions of each component are not well understood.
Source: U. S. Public Health Service (1993).
for roughly a week before the person feels relief, compliance with the therapy sometimes is difficult.
If none of these medications are effective, a third group of drugs that relieve depression is the monoamine oxidase (MAO) inhibitors, so named because they inhibit MAO, a substance that interferes with the transmission of signals between neurons. MAO inhibitors generally are less effective than the tricyclics and can produce deadly side effects. Specifically, they interact with foods that
contain tyramine or dopamine—mainly cheddar cheese but also others, such as wine and chicken liver—to create dangerously and sometimes fatally high blood pressure. MAO inhibitors are used with extreme caution, usually only after SSRIs and HCAs have proved ineffective.
If periods of depression alternate with periods of mania or extremely high levels of activity, a diagnosis of bipolar disorder is made (American Psychiatric Association, 1994). Bipolar disorder is characterized
by unpredictable, often explosive mood swings as the person cycles between extreme depression and extreme activity. The drug therapy of choice for bipolar disorder is lithium (Buffum & Buffum, 1998). Lithium is very effective in controlling the mood swings, although researchers do not completely understand why it works. The use of lithium must be monitored very closely because the difference between an effective dosage and a toxic dosage is very small. Because lithium is a salt, it raises blood pressure, making it dangerous for people who have hypertension or kidney disease. The effective dosage for lithium decreases with age; physicians unaware of this change run the risk of inducing an overdose, especially in older adults (Buffum & Buffum, 1998). Compliance is also a problem, because no improvement is seen for 4 to 10 days after the initial dose and because many people with bipolar disorder do not like having their moods controlled by medication.
Electroconvulsive therapy (ECT) is an effective treatment for severe depression, especially in people whose depression has lasted a long time, who are suicidal, who have serious physical problems caused by their depression, and who do not respond to medications. Unlike antidepressant medications, ECT has immediate effects. Usually only a few treatments are needed, in contrast to long-term maintenance schedules for drugs. But ECT may have some side effects that affect cognitive functioning (Gardner & O’Connor, 2008). Memory of the ECT treatment itself is lost. Memory of other recent events is temporarily disrupted, but it usually returns within a week or two.
Psychotherapy is a treatment approach based on the idea that talking to a therapist about one’s problems can help. Often psychotherapy can be very effective by itself in treating depression. In cases of severe depression, psychotherapy may be combined with drug therapy or ECT. Two general approaches seem to work best for depression: behavior therapy, which focuses on attempts to alter current behavior without necessarily addressing underlying causes, and cognitive therapy, which attempts to alter the ways people think.
The fundamental idea in behavior therapy is that depressed people receive too few rewards or
reinforcements from their environment (Lewin – sohn, 1975). Thus the goal of behavior therapy is to get them to increase the good things that happen to them. Often this can be accomplished by having people increase their activities; if they do more, the likelihood is that more good things will happen. In addition, behavior therapy seeks to get people to decrease the number of negative thoughts they have because depressed people tend to look at the world pessimistically. They get little pleasure out of activities that nondepressed people enjoy a great deal: seeing a funny movie, playing a friendly game of volleyball, or being with a lover.
To get activity levels up and negative thoughts down, behavior therapists usually assign tasks that force clients to practice the principles they are learning during the therapy sessions. This may involve going out more to meet people, joining new clubs, or just learning how to enjoy life. Family members are instructed to ignore negative statements made by the depressed person and to reward positive selfstatements with attention, praise, or even money.
Cognitive therapy for depression is based on the idea that depression results from maladaptive beliefs or cognitions about oneself. From this perspective, a depressed person views the self as inadequate and unworthy, the world as insensitive and ungratifying, and the future as bleak and unpromising (Beck et al., 1979). In cognitive therapy the person is taught how to recognize these thoughts, which have become so automatic and ingrained that other perspectives are not seen. Once this awareness has been achieved, the person learns how to evaluate the self, world, and future more realistically. These goals may be accomplished through homework assignments similar to those used in behavior therapy. These often involve reattributing the causes of events, examining the evidence before drawing conclusions, listing the pros and cons of maintaining an idea, and examining the consequences of that idea. Finally, people are taught to change the basic beliefs that are responsible for their negative thoughts. For example, people who believe that they have been failures all their lives or that they are unlovable are taught how to use their newfound knowledge to achieve more realistic appraisals of themselves.
Figure 10.2 Percentage of patients responding to psychotherapy versus medications and pill placebo.
Source: Hollon, Thase, & Markowitz (2002).
Which therapy works best? Hollon, Thase, and Markowitz (2002) examined this question in a thorough review of the research. Their conclusions, shown in Figure 10.2, were that no one approach works for everyone. Rather, it appears that there are several options available. Medications have the most research support, although cognitive-behavioral therapy has considerable evidence behind it as well. Most important, though, is that treatment may need to be continuous, as the relapse rate is high for all treatments if they are not ongoing.