Clinical practice guidelines for management of depression in elderly

INTRODUCTION Depressive disorders are one of the common psychiatric ailments seen in elderly population. As per the World Health Organization (WHO) prevalence of depressive disorders among elderly is 10 to 20%. Data from India reveals a wide variation in the prevalence rate of depression. Prevalence in community-based studies have varied from 8.9% to 62.16% and clinic based studies have estimated the prevalence of depression to range from 42.4 to 72%. Unfortunately, depression among elderly is often considered as part and parcel of life and is under-recognised and under-diagnosed. Depression in elderly has been shown to be associated with significant negative consequences ranging from poor quality of life, difficulties with activities of daily living, physical comorbidities, premature mortality and cognitive impairments. Although the incidence of depression among elderly is similar to that reported in adult population, depression in elderly is associated with higher risk of suicide, more frequent hospitalization, higher number of consultations with the treatment agencies and family burden. Hence, it is very important to recognise depression among elderly and manage the same. Timely recognition and adequate management of depression among elderly can lead to improvement in quality of life, maintaining optimal levels of function and independence, reduction in morbidity, reduction in mortality due to suicide, development of medical illnesses and treatment costs. Indian Psychiatric Society (IPS) published Clinical Practice Guidelines (CPGs) for management of depression among elderly, for the first time in the year 2007. IPS also published revised CPGs for management of depression in adult patients in the year 2017. Current version of the CPGs is an update of the earlier version of CPGs for management of depression in elderly. The current version of the CPGs for depression in elderly must be read in conjunction with the previous version of CPGs for depression in elderly and revised CPGs for management of depression in adult population. These guidelines provide a broad framework for assessment, management and follow-up of elderly patients presenting with depression. Most of the recommendations made as part of the guidelines are evidence based. However, these guidelines should not be considered as a sustitute for professional knowledge and clinical judgment. The recommendations made as part of these guidelines have to be tailored to address the clinical needs of the individual patient and treatment setting. DIAGNOSTIC COMPLEXITIES OF DIAGNOSING DEPRESSIVE DISORDERS IN ELDERLY Depressive disorders in elderly can include a spectrum of disorders (Table-1). Depression in elderly is also known as late life depression, which is further understood as late onset depression and early onset depression. There is lack of consensus on the age cut-off used to define late onset depression, with some of the authors considering the age cut-off of 60 years, whereas others define it as experiencing first episode of depression ≥ 65 years of age). While assessing depression among elderly, it is important to remember that although many elderly have depressive symptoms, they do not fulfil the criteria of major depression. Presence of physical illness and atypical presentations further complicate the clinical picture. Hence it is postulated that although the presence of standard diagnostic criteria is a necessary for of depression in elderly, this is not sufficient condition for diagnosis of depression in elderly. Due to these intricacies, the concept of 'subthreshold’ depression, 'subclinical’ depression, ‘minor’ depression, ‘milder’ depression etc have been described. Accordingly, depression in elderly is often broadly classified as Major and Non-major Depression. The nonmajor category includes minor depression, dysthymia, adjustment disorder with depressed mood and mixed anxiety and depressive disorder.Table 1: Spectrum of Depressive Disorders in ElderlyIn general it is suggested that prevalence of minor depression is more than that of major depression. Some of the studies suggest that with increasing age prevalence of major depression decreases and that of minor or sub-threshold depression increases. Minor depression in elderly is associated with significant number of disability days and concomitant anxiety disorder. Proper recognition of minor depression is of paramount importance because it is often the forerunner of the major depression among elderly subjects. The spectrum of depressive disorders among elderly also includes dysthymic disorder and adjustment disorder with depressed mood, which are also seen in 2% and 4% of the population respectively. Minor depression is defined as presence of clinically significant depressive symptoms which do not meet the threshold duration criterion or the number of symptoms necessary for the diagnosis of Major depressive disorder (MDD) as per the current nosology. Some of the authors have further characterised minor or subsyndromal depression among elderly into 2 subtypes. According to some authors the first subtype of minor depression consists of syndromes qualitatively similar to major depression and dysthymia but it is characterised by presence of fewer symptoms or with less symptom continuity. The second type of subsyndromal depression is considered to be qualitatively different from MDD and is associated with lower suicidal thoughts and feelings of worthlessness or guilt but similar levels of worries about health and “weariness of living”. Judd et al described 2 subtypes of subsyndromal symptomatic depression (SDD) for minor depression as SDD with mood disturbance (minor depression) and SDD without mood disturbance. Minor depression was described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) as a condition requiring further research to determine both diagnostic utility and criteria refinement. In DSM-5, minor depression can be subsumed under the category of “Other specified depressive disorder, depressive episode with insufficient symptoms”, which is characterised by presence of depressed affect and at least one of the other eight symptoms of MDD, which is associated with clinically significant distress or impairment that persists for a duration of at least 2 weeks. It further requires that the person should never have met the criteria of any other depressive or bipolar disorder, does not currently meet active or residual criteria for any psychotic disorders and as well as does not meet the criteria for mixed anxiety and depressive disorder. DSM-5 has a separate category for the depressive disorder due to another medical condition and describes it as medical disorder with depressive features (i.e., full criteria of MDD is not met), major depressive like and mixed-mood features. Many elderly patients also present with late-onset dysthymia. Patients with late onset dysthymia are considered to differ from those with young onset dysthymia, in terms of absence of personality disorders and if present, these consist of obsessive–compulsive personality disorder and avoidant personality disorder. There is some evidence to suggest that clinical features of dysthymia in elderly differ from young onset in terms of higher prevalence of comorbid medical illness, presence of cognitive deterioration, and presence of frequent adverse life events and fewer “depressive cognitions” symptoms but similar neurovegetative and other somatic symptoms. ASSESSMENT AND EVALUATION A comprehensive assessment of depression in elderly is of paramount importance to evaluate the risk factors, comorbidity and associated etiological factors, severity of depression, risk of self-harm and level of dysfunction. Additionally, assessment also involves establishing a good therapeutic alliance, deciding about treatment setting and patient's safety. It is important to remember that assessment is a continuous process and patient should be assessed regularly, as per the need and phase of the treatment. Comprehensive assessment requires elicitation of detailed history including assessment for presence of physical comorbidity, physical examination and mental state examination. All efforts must be made to collect the history from multiple sources, especially from the family members. The complete psychiatric evaluation involves reviewing history of the present episode and current symptoms, a psychiatric history including evaluation of symptoms of mania to rule out bipolar disorder, evaluation of treatment history in terms of current treatments and responses to previous treatments, history of medical illnesses, history of substance use disorders, personal history (e.g., psychological development, response to life transitions, and major life events), psychosocial history, review of current medications, thorough physical examination with review of all the systems, mental status examination and diagnostic tests as indicated (Table-2).Table 2: Components of assessment and evaluationWhile assessing elderly for depression, it is important to remember that elderly patients often under-report their depressive symptoms and they may not acknowledge being sad, down or depressed. Common depressive symptoms (such as lack of enjoyment in normal activities, loss of interest in life, apprehension about future, poor sleep, recurrent thoughts of death, persistent unexplained pain, poor concentration or impaired memory) are often misattributed to old age, dementia or poor health. Due to this depression among elderly is often under-detected and untreated for a long time. Many elderly patients with depression often tend to report more somatic and cognitive symptoms than affective symptoms. It has been reported that women more often report mood-related symptoms when compared to men. Patients who do not acknowledge having depressed mood may report a lack of feeling or emotion or acknowledge a loss of interest and pleasure in activities. In view of the reporting of fewer depressive symptoms by elderly patients with depression, some of the authors have suggested the use of the term “depression without sadness”, which is considered as a variant of depression, which is specifically seen in primary care populations and comprises of symptoms of apathy, loss of interest, fatigue, difficulty sleeping, and other somatic symptoms, but not sad mood. However, it is unclear whether “depression without sadness” is an idiopathic depression, a depression secondary to medical illness, or a non-affective syndrome related to chronic medical disease. Other barriers to accurate diagnosis of depression among elderly include prevalent stigma and confounding effect of medical co-morbidity. Stigma often prevents effective health care seeking behavior and the accurate reporting of symptoms. Medical comorbidity among elderly patients with depression is a rule rather than an exception. Psychological stress of having an illness, ensuing functional disability, and life changes necessitated by chronic illness may precipitate depression in susceptible individuals. Many physical illnesses have been shown to have high prevalence of depression (Table-3). Accordingly, any elderly individual presenting with first episode depression in the late age must be properly evaluated for underlying physical illnesses. There is significant overlap of symptoms of depression and various medical illnesses and it is often difficult to segregate the attribution of symptoms. Symptoms such as weight loss, fatigue and insomnia may overlap with patients suffering from various physical illnesses. At times, evolution of depression may be indicated by appearance of new onset somatic symptoms, when the physical health was static. Efforts must be made to evaluate anhedonia and depressive ideations like self-deprecation, guilt, etc. The diagnosis of “depression due to a general medical condition” can be used for medical illnesses with a known etiologic link to depression. However, some of the authors consider this terminology to be irrelevant to significant proportion of the elderly patients in whom overall medical burden contributes to their depression. Various approaches have been used for diagnosing depression in medically ill subjects. These include exclusive approach, substitutive approach, best estimate approach and inclusive approach. The “exclusive approach” does not consider neurovegetative symptoms (e.g., changes in sleep, energy, appetite, and weight) to make a diagnosis of depression, whereas the “substitutive approach”, replaces the neurovegetative symptoms included in the nosological system by non-somatic cognitive symptoms (e.g., hopelessness) when defining a major depressive episode (MDD). The “best estimate approach” involves use of clinical judgment to consider whether the symptom is caused by a physical disorder or is part of a depressive syndrome. The “inclusive approach” presumes that all the symptoms contribute to the depressive episode, irrespective of the cause. In general it is suggested that, to overcome the under-recognition of depressive disorders among elderly, an inclusive approach to diagnosis may be preferable in older medically ill patients. However, it is also important to consider all the contributing factors towards the depressive symptoms (e.g., medical causes) to avoid use of unnecessary medications.Table 3: Some of the physical illnesses commonly associated with depressionIn terms of physical illnesses, it is important to remember that depression among elderly is often associated with presence of hypertension and accordingly vascular risk factors have received considerable attention in the research. This is known as “vascular depression” and newer studies based on magnetic resonance imaging (MRI) suggest that vascular depression accounts for upto 50% of depression in elderly. Patients with vascular depression are considered to have a distinct clinical and neuropsychological profile, which is linked to the presence of hypertension. The MRI findings in such patients include loss of brain volume and loss of white matter integrity. In general vascular depression has been shown to be associated with poor treatment outcomes, higher risk of development of cognitive impairments. Relationship of vascular depression with development of Alzheimer's disease is non-conclusive, with some reports suggesting that these patients have higher risk of progressing to Alzheimer's disease. A review provided the updated information on features of vascular depression and this include: onset of depression at ≥ 65 years of age, absence of family history of depression, presence of executive dysfunctions, loss of energy, subjective feeling of sadness, anhedonia, psychomotor retardation, motivational problems, reduced processing speed and visuospatial skills, deficits in self initiation and lack of insight; and may not meet the criteria for any mood disorder as per the DSM-5, presence of high cardiac illness burden, presence of increased rates of vascular risk factors (hypertension, etc.), fluctuating course of cognitive impairment due to progression of white matter hyperintensities, greater treatment resistance and poorer outcome, higher risk for cognitive decline and association with increased mortality (Table-4). However, it is important to remember that DSM-5 has not incorporated this entity in its classificatory system. Another entity related to vascular depression is depression-dysexecutive syndrome (DES) which is seen in patients with vascular risk factors and is associated with executive dysfunction due to dysfunction in the frontal-subcortical circuit.Table 4: Features of Vascular Depression in ElderlyDepression is elderly is also often associated with use of certain medications (Table-5). Accordingly obtaining a detailed treatment history is of paramount importance. The treatment history may not be limited only to the prescription drugs, but should extend to evaluation of over the counter drugs and use of medicines from alternative schools of medicine. It is important to evaluate the temporal correlation of use of medications (starting of medications, escalation of dose of medication) and emergence of depressive symptoms to make any conclusion about the association. However, it is important to note that except for few drugs (e.g. corticosteroids, interferon), evidence for risk of development of depression with specific medications is inadequate and perhaps overstated.Table 5: Medications known to cause depressionWhile assessing depression among elderly it is important to remember that many elderly have atypical presentation of their depression. They may present with chronic unexplained physical symptoms, cognitive symptoms, change in behaviour, anxiety and worries, irritability and dysphoria, etc. However, development of a therapeutic alliance and proper assessment often reveals presence of depressive symptoms in these patients. While evaluating elderly patients, it must be remembered that when neurotic symptoms like hypochondriasis, obsessive compulsive features emerge for the first time in life in old age, than more often than not, these are associated with depression. Accordingly, in all such cases, depression must be ruled out properly. Elderly patients presenting with depression should also be properly evaluated for substance use disorders. At times, elderly patients with depression may present with alcohol dependence arising for the first time in the later life. A thorough history from the patient and an informant often provides clarity. Whenever required, appropriate tests like, urine or blood screens (with prior consent) may be used to confirm the existence of comorbid substance abuse/dependence. Elderly patients with depression are at higher risk for self-harm and completed suicide when compared to young adults. Depression is the most common risk factor for suicide in elderly. Hence, every patient must be properly evaluated for suicidal behaviours. The risk factor for suicide among elderly and those with depression include older age, male gender, severe anxiety, panic attacks, living alone, severe depression, bereavement (especially in men) and presence of comorbid alcohol misuse, physical pain and history of suicide attempts in the past. Clinicians should directly enquire about the presence of suicidal ideations, planning and availability of means of suicide. If the patient has means to suicide then a judgment may be made concerning the lethality of those means. Family history of suicide also must be inquired into and taken into account while assessing the risk of future self-harm. Patients found to have suicidal or homicidal ideation, intention or plans need to be monitored closely and hospitalization should be considered for those at high risk of self-harm/suicide. At times depression among elderly is often confused with dementia. Symptoms like apathy, loss of initiative, social withdrawal and cognitive dysfunction (poor attention and concentration) are present in both the disorders. Compared to dementia, depression often have more rapid onset, have evidence of mood change, diurnal variation with morning worsening of symptoms, intact orientation, fluctuating and inconsistent cognitive deficits, may give more ‘don't know’ answers, significant personal distress, disturbed sleep and appetite and suicidal ideations. However, it is important to remember that many patients with dementia also develop depression and it is often missed in such a scenario. Certain symptoms like psychomotor slowing, emotional lability, crying spells, insomnia, weight loss, inability to verbalize affective state and pessimism are seen in both depressed and non-depressed patients with dementia. Some of the studies suggest that patient's with Alzheimer's disease with depression display more self-pity, rejection sensitivity, anhedonia and fewer neurovegetative signs than non-demented depressed older patients. Specific scales like Cornell Scale for depression in dementia, which is considered to be the gold standard for assessing depressive symptoms among patients with dementia, may be used. Combining data from the patient interview, information obtained by caregivers and use of specific scale have been suggested to provide a reliable and valid assessment. The National Institute of Mental Health has developed criteria for diagnosis of depression in patients with Alzheimer's dementia. This includes a list of 10 symptoms, out of which 3 or more must be present during the same 2 week period and represent a change from previous functioning. Out of the 3 criteria fulfilled, at least one of these must be depressed mood or decreased positive affect or pleasure. Other features of the criteria include social isolation or withdrawal, disruption in appetite which is not related to another medical condition, disruption in sleep, psychomotor changes (agitation or slowed behavior), irritability, fatigue or loss of energy, feelings of worthlessness or hopelessness, or inappropriate or excessive guilt and recurrent thoughts of death, suicide plans or a suicide attempt. These symptoms must be present for at least 2 weeks for considering the diagnosis of depression among patients with definite diagnosis of Alzheimer's disease as per the DSM-IV criteria. The symptoms must be associated with clinically significant distress or disruption in function; symptoms are not part of delirium, are not related to physiological effect of substance and are not accounted by other psychiatric conditions (Table-6).Table 6: NIMH Provisional Diagnostic Criteria for Depression in Alzheimer DiseaseAn important aspect for evaluation of depression in elderly also involves evaluation for nutritional deficiencies which may be responsible for the depressive symptoms and correction of these may be sufficient to manage depressive symptoms. Due attention must be given to psychosocial factors which may be associated with onset, continuation/maintenance of depression among elderly. Various psychosocial factors associated with depression among elderly include loneliness, poor social/family support, isolation/no social interaction, dependency, lack of family care and affection/lack of caregivers, insufficient time spent with children, stressful life events, perceived poor health status, lifestyle and dietary factors, lack of hobby, irregular dietary habits, substance use/smoking, lower spirituality and emotion-based coping. Before considering the diagnosis of unipolar depressive disorders, it is important to ascertain that patient does not have bipolar disorder as use of antidepressants in patients with bipolar disorder can lead to antidepressant induced switch. Elderly patients presenting with depressive disorders often do not come up with history of previous hypomanic or manic episodes. Meticulous history from the patient, family members, review of treatment records often provide important clues and aid in confirming the diagnosis of bipolar disorder. At times use of standardized scales like mood disorder questionnaire can help in detecting bipolarity. Some of the clinical features which should alert a clinician about the possibility of bipolar disorder include presence of psychotic features, marked psychomotor retardation, reverse neurovegetative symptoms (excessive sleep and appetite), irritability of mood, anger and family history of bipolar disorder. Evaluation of history should also take the longitudinal life course perspective to evaluate for previous episodes and presence of symptoms of depression amounting to dysthymia. History taking should look at the relationship of onset of depression with change in season (seasonal affective disorder) and relationship with menopause etc. Response to previous treatment should also be reviewed and whether the patient achieved full remission, partial remission and did not respond to treatment should be evaluated. Elderly patients are at higher risk of completed suicide when compared with the young patients. Depression is associated with marked dysfunction in the domains of interpersonal relationships, work, living conditions, activities of daily living, instrumental activities of daily living, and other medical or health-related needs. At baseline, these need to be noted and subsequently monitored. If feasible, standard scales may be used to record these dysfunctions. The areas of dysfunction must be addressed by encouraging the patient to set realistic, attainable goals for themselves in terms of desirable levels of functioning. All the elderly subjects with depressive disorders need to be investigated. The list of investigations is generally guided by the physical evaluation and history of medical illnesses. However, it is important to remember that if at all there is no historical evidence of medical illness and nothing significant is found in physical examination to warrant laboratory investigation then also the elderly patients should be subjected to a minimum battery comprising of haemogram, liver function tests, renal function tests, urine analysis, electrocardiography (ECG) and serum electrolytes. Some authors also advise to consider thyroid function tests, vitamin B12 and folate levels and serum levels of drugs received by the patient. Neuroimaging may be considered in those with in late or very late onset first episode depression, those having associated neurological signs and those experiencing treatment resistant depression. Besides, obtaining information from the patients and caregivers, it is also important to evaluate their knowledge and understanding about the symptoms and the disorder, their attitudes and beliefs about the symptoms and treatment, the impact of the illness on them and their personal and social resources. Many a times, elderly patients with depression present to the primary care to the physicians, who may require assistance of screening questionnaires to diagnose depression in elderly. The available questionnaires include Geriatric Depression Scale (GDS), Evans Liverpool Depression Rating Scale (ELDRS), Brief Assessment Schedule (BASDEC) and Patient Health Questionnaire (PHQ-9). However, it is important to note that these are screening questionnaires/scales, and detailed interview will be required for confirming the diagnosis. It also important to remember that level of cognitive impairment and visual deficits must be taken into account while asking the patients to complete these questionnaires or while administrating these questionnaires. Out of these 3 questionnaires, GDS is available in Hindi. Scales can also be used to rate the severity of depression among elderly. The various scales which can be used include Hamilton Rating Scale for Depression (HAM-D), Zung Self-Rating Depression Scale (SDS), Geriatric Depression Scale (GDS), Beck Depression Inventgory (BDI), Montgomery-Asberg Depression Rating Scale (MADRS) and Cornell Scale for Depression in Dementia (CSDD). Among the various scales, GDS is the most well validated scale for use in elderly with intact cognitive functions. Formulating a treatment plan Formulation of treatment plan involves deciding about treatment setting, medications to be prescribed and psychological interventions to be used (Figure-1). Wherever possible, the patients may be involved in preparing the treatment plan. Caregivers must also be consulted in formulating a treatment plan. The role of caregivers becomes more important when the patient is not in a condition to participate in treatment decisions due to severity of the depression, lack of insight or marked cognitive impairment. The treatment plan needs to be practical, feasible and flexible to attend to the needs of the patients and caregivers. The treatment plan initially formulated need to be continuously re-evaluated and updated as per the clinical and psychosocial needs.Figure 1: Initial evaluation and management plan for DepressionDETERMINE A TREATMENT SETTING Patients with depression can be managed on the outpatient basis. However, it is recommended that patients be managed in a setting which is most safe and effective. The decision about treatment setting must take into account symptom severity, comorbid physical and psychiatric conditions, suicidality, homicidal behaviour, level of functioning and available support system. It should also take into consideration the ability of a patient to adequately care for themselves, provide information about the health status to the clinician and cooperate with treatment. Further, this should be an ongoing process throughout the course of treatment. Some of the indications for inpatient care are given in Table-7.Table 7: Indications for admission in elderly patients with depressionAll inpatients should have accompanying family caregivers. In case inpatient care facilities are not available, then the patient and/or family must be informed about such a need and admission in nearest available inpatient facility can be facilitated. ESTABLISH AND MAINTAIN A THERAPEUTIC ALLIANCE Irrespective of the use of various treatment modalities, it is important for the clinicians to establish a therapeutic alliance with the patient. Depression often runs a chronic course and requires patients to actively participate and adhere to treatment for long periods. Another important aspect of successful treatment is tolerating the side effects of various treatment modalities. For these reasons, a strong treatment alliance is crucial. For clinicians, it is important to understand that paying attention to the concerns of patients and their families as well as their wishes for treatment enhances the therapeutic alliance. MONITOR THE PATIENT'S PSYCHIATRIC STATUS AND SAFETY Management of depression is an ongoing process, which requires continuous assessment of course of symptoms and acceptability of treatment. Accordingly, it is important to be on surveillance for emergence of destructive impu