Depression in later life

119 Pages·2014·1.903 MB·English

by  Baldwin, Robert C

O P L

OxfOrd Psychiatry Library
Depression in Later Life

O P     L
OxfOrd Psychiatry Library
Depression in Later Life
Second Edition
Robert C. Baldwin
Consultant Old Age Psychiatrist and
Honorary Professor of Psychiatry,
Manchester Mental Health and Social Care Trust,
Park House
North Manchester General Hospital,
Manchester, UK
1
3

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Contents
Symbols and abbreviations vii
 Introduction 
2 Classification and epidemiology 3
3 Clinical features 
4 Self-harm and suicide 2
5 Aetiology 25
6 Medical co-morbidity and depression in later life 37
7 Assessment and management 43
8 Depression in primary care 65
v
9 Prognosis 75
0 Prevention 79
 Resources 83
Appendix  The sample rating scales 89
Appendix 2 The geriatric depression scale 9
Appendix 3 The patient health questionnaire (PHQ-9) 93
Appendix 4 The World Health Organization well-being index 95
Appendix 5 The Hamilton rating scale for depression 97
Appendix 6 Montgomery and Äsberg depression rating scale 0
Appendix 7 Cornell scale for depression in dementia 05
Index 07

Symbols and Abbreviations
α alpha
≥ equal to/greater than
> greater than
< less than
% per cent
ACE angiotensin-converting enzyme
ADH antidiuretic hormone
AIDS acquired immunodeficiency syndrome
BABCP British Association of Behavioural and Cognitive Psychotherapies
BAP British Association of Psychopharmacology
bd bis in die (twice daily)
CANMAT Canadian Network for Mood and Anxiety Treatments
vii
CBT cognitive behavioural therapy
CG clinical guideline
CHD coronary heart disease
CNS central nervous system
COPD chronic obstructive pulmonary disease
CRF corticotropin-releasing factor
CT computerized tomography
DALY disability adjusted life year
DEDS depression-executive dysfunction syndrome
DSM Diagnostic and Statistical Manual
ECG electrocardiogram
ECT electroconvulsive treatment
EEG electroencephalogram
FSC fronto-striatal circuit
GDS geriatric depression scale
GHRF growth hormone-releasing factor
GI gastrointestinal
GP general practitioner
HADS hospital anxiety and depression scale
HDRS Hamilton depression rating scale
HIV human immunodeficiency virus
HPA hypothalamic-pituitary-adrenal
S 5HT 5-hydroxytryptamine
n
o IADH inappropriate antidiuretic hormone
ti
a IAPT Improving Access to Psychological Therapies
vi
re ICD International Classification of Diseases
b
ab IPT interpersonal therapy
d
n kg kilogram
a
S L litre
l
o
b lb pound
m
y MADRAS Montgomery-Äsberg depression rating scale
S
MAO-A monoamine oxidase A
MAOI monoamine oxidase inhibitor
MCI mild cognitive impairment
mg milligram
MHRA Medicines and Health products Regulatory Authority
mmol millimole
MoCA Montreal cognitive assessment
viii MRI magnetic resonance imaging
mRNA messenger ribonucleic acid
ms millisecond
NARI noradrenaline reuptake inihibitor
NASSa noradrenaline and specific serotonin antidepressant
NICE National Institute for Health and Care Excellence
NSAID non-steroidal anti-inflammatory drug
OMC orientation-memory-concentration
PET positron emission tomography
PHQ patient health questionnaire
PST problem-solving treatment
rCBF regional cerebral blood flow
RCT randomized controlled trial
rTMS repetitive transcranial magnetic stimulation
SNRI serotonin/noradrenaline reuptake inhibitor
SPECT single photon emission computerized tomography
SSRI selective serotonin reuptake inhibitor
TCA tricyclic antidepressant
tds ter die sumendum (three times daily)
TRH thyrotropin-releasing hormone
UK United Kingdom
US United States
WML white matter lesion
Chapter 
Introduction
Lilly is 88, and her daily requests to be taken to see a doctor about her ‘stomach wind’
are wearing out her 60-year-old recently retired son, who is finding himself waking
early in the morning with worry. John is 72 and devastated at the unexpected loss of his
wife just before their 50th wedding anniversary. His family and friends are sympathetic,
but, 6 months on, he is fretful, miserable and feels he will burden people by talking
about it. Wong-Chai has had arthritis for the last 20 of her 75 years. Once proud and
indomitable, she has lately found her joint pain unbearable and has wondered about
‘going to sleep and never waking up’. Raj is 85 and lately finds himself unable to concen-
trate, so much so that he keeps losing things. His sleep and appetite are poor, and he
has stopped going to the local day care centre. His doctor said it is his age, but his family
fear the start of dementia. Jack, aged 76, has turned up in the emergency department, 1
feeling nauseous and dizzy. Recently, he has lost weight and feels very tired, lonely, and
miserable. He admits to taking four sleeping tablets last night ‘just to get a bit of peace
for the night’. The doctor tells him not to worry—that dose will not harm him. A week
later, he is back with a serious paracetamol overdose.
What links these vignettes is depressive disorder. Although dementia is regarded as
the typical mental health condition of later life, in fact, depression is more common.
Often overlooked, depression is a very serious problem in later life. It reduces the qual-
ity of life and adds to the disability associated with all the major medical illnesses that
afflict older people. It often complicates the course of dementia as well as being a risk
factor for it.
Epitomized by the statement ‘Who would not be depressed at that age?’, it is tempt-
ing, but completely inaccurate, to assume that depression must be the norm in later
life. In the main, health professionals see older people who are most susceptible to
depression, those with frailty and chronic medical illnesses. The trap is to ‘normalize’
depression in ill older people, with the result that major depression can be overlooked.
In reality, many older people live contentedly, with their quality of life improving with
age (Netuveli et al. 2006). Of those who do become depressed, many have a diagnos-
able mental health disorder, and there are interventions which can help significantly.
There are already textbooks on depression; why then is one needed specifically for
depression in later life? First, there is the self-evident fact that the world’s population is
fast growing older. This brings with it increasing rates of many of the common health
problems, including depression. Second, although depression in later life shares many
of the core features with depression at other times, there are some important differ-
ences. Third, late-life depression frequently occurs in the setting of significant medical
morbidity which complicates both the diagnosis and treatment. Last, depression in this