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CHAPTER 21: Depression in the Medically Ill Older Adult

Mark Eldaief, MD, MMSc; Hongtu Chen, PhD; Michael Gaziano, MD; Olivia Okereke, MD, SM

INTRODUCTION

OVERVIEW

Depression is among the most common health conditions affecting older adults. Depression may present in a phenotypically distinct manner in older, as opposed to younger, individuals. For example, in the older adult depression is less likely to present with dysphoria and more likely to be accompanied by irritability and somatic symptoms.1 In addition, psychosocial stressors predisposing to the development of affective symptoms are different with advancing age (e.g., the stressor of losing a loved one becomes more common).1 Still, one of the major factors affecting the inception and prognosis of depression in the older adult is the co-occurrence of medical conditions.

In this chapter, we will address common medical conditions with which coexistent depression is likely to occur in the older adult. We also will give attention to biological and psychosocial mechanisms that might give rise to both the depressive symptoms and the medical condition, and emphasize how this co-occurrence predicts poorer health outcomes for both conditions. We will then survey methods for screening older adults with medical illness for depression, and review methods of differentiating it from symptoms that could simulate it, but which are more likely due to the medical condition. Next, we explore pharmacologic and nonpharmacologic treatment approaches for major depressive illness in the setting of a medical condition, and survey the considerations that must be taken into account in older adults. Finally, we review future methods of treating depression in this clinical setting, including novel techniques for preventing depression in the medically ill older adult (Table 21-1).

TABLE 21-1Biological Factors Underlying Reciprocal Relationships Between Depression and Medical Illness in the Older Adult
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TABLE 21-1 Biological Factors Underlying Reciprocal Relationships Between Depression and Medical Illness in the Older Adult
Medical Condition Biological Factors Linking Depression to the Medical Condition

Parkinson disease

Hypofunctionality of dopaminergic basal ganglia circuits, Lewy Body deposition in limbic regions, increased elaboration of cytokines, activation of the HPA axis, decreased neurotrophic factors and neurogenesis.6

Cerebrovascular disease

Disrupted white matter projections between limbic regions and prefrontal cortex7

Coronary artery disease

Altered heart rate variability, increased platelet aggregation, alterations in homocysteine metabolism, increases in catecholamine release, activation of the HPA axis, elevated immune response8

Cancer

Hypercalcemia from bone metastases, paraneoplastic syndromes (e.g., limbic encephalitis), endocrine abnormalities such as hypoadrenalism and hypothyroidism, depressogenic effects of chemotherapeutic agents (e.g., corticosteroids, vincristine, vinblastine, procarbazine, interferons), depressogenic effects of whole brain radiation.9

EPIDEMIOLOGY OF DEPRESSION IN OLDER ADULTS AND ROLES OF MEDICAL COMORBIDITY

Overall, it is clear that the burden and health impacts of depression among older adults, particularly those with medical illness, are high, and that substantial numbers of cases occur in late-life. Current (12-month) prevalence of major depressive disorder and persistent depressive disorder (dysthymia)—is estimated at 2% to 4%.2,...

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