Mohammed T. Abou-Saleh

CLINICAL FEATURES OF DEPRESSION AND DYSTHYMIA 409elderly patient may include profound psychomotor retardation,even to the point of frank stupor. This psychomotor retardationmimics both dementia and the inanition associated with physicaldisease. Mood can be elevated or irritable but may be ratherlabile, showing a picture of depressive admixture 34,35 . Thesedepressed patients may be unable to provide a meaningful historyand/or cooperate with diagnostic procedures. Similarly, theelderly, manic patient may make inappropriate sexual commentsand/or advances, or be agitated and/or assaultive, and as a resultbe regarded as cognitively impaired. Although bipolar patientshave usually had a history of mood disturbances in the past, theseepisodes may have been ‘‘forgotten’’ or repressed by both thepatients and primary relatives 36 .LATE-ONSET DEPRESSIVE ILLNESSDepression in late life may be characterized as of early or lateonset. Early-onset depression which recurs in later life may havesymptoms similar to previous episodes. Differences in the clinicalpresentation may be observed in both early-onset and late-onsetdepressives 37 . Genetic predisposition, significant losses or multiplelife stressors may interact with age-related biological vulnerabilities.Biological changes due to the physiologic effects of aging havebeen verified by the study by Schneider 38 , showing that unmedicated,elderly depressed subjects demonstrated higher monoamineoxidase (MAO) activity than sex- and age-comparable controls.Recent studies have proposed that neurobiologic and/orpsychosocial factors may predispose an older individual todepression or dysthymia 39 . MRI-defined vascular depression hasbeen identified as a late-onset, non-psychotic type of depression,seen more often in individuals with no family history ofdepression, together with symptoms of anhedonia and increasedpsychosocial impairment 40 . Other studies have verified theincreasing incidence of depression among individuals withcerebrovascular risk factors, MRI findings associated withvascular disease and symptoms of apathy, together withdiminished life quality 41 . Central nervous system degeneration,for example, from the biochemical changes in Alzheimer’s diseaseor other complaints may predispose to an increased incidence ofdepression 42 .Age of onset has been used as a correlate for late-life depressivesymptomatology. Depressive symptoms may be found to be morefrequent among the old-old compared to the young-old, withapproximately 20% compared to less than 10% in the community43 . This higher frequency of depression among the old-old maybe explained by a higher proportion of women, more generalmedical problems, more cognitive impairment and lower socioeconomicstatus. When these factors are controlled, norelationship exists between depressive symptoms and advancingage 44 . Nonetheless, depression is associated with disabilityamong the old-old and a number of studies have illustratedthe association between depression and frailty, functionaldisability and co-morbid general medical problems and/orcognitive impairment 45–47 . Essentially, having more than twoprevious episodes as compared to two or less is related toyounger age, earlier age of onset, dysthymia, feelings ofworthlessness, difficulty concentrating, slowed thoughts, suicidalideation, symptoms of anxiety and decreased perception ofsocial support. Patients with multiple recurrent episodes arealso thought to be at higher risk for more severe illness 48 . Lateonsetdepression is more frequently associated with structuralbrain changes and cerebrovascular disease, while early-onsetdepression seems to be more influenced by family and geneticfactors. Compared with early-onset depressives, patients withlate-onset depression tend to show more loss of interest, lesspathological guilt, more psychosis and more generalizedTable 74.1Somatization: principles of clinical management1. The presentation is considered in the context of psychosocial factors,both current and past.2. The diagnostic procedures and therapeutic interventions are based onobjective findings.3. A therapeutic alliance is fostered and maintained involving theprimary care and/or psychiatric physician.4. The social support system and relevant life quality domains* arecarefully reviewed during each patient contact.5. A regular appointment schedule is maintained for outpatients,irrespective of clinical course.6. The patient dialogue and examination and the assessment of newsymptoms or signs are engaged judiciously, and usually primarilyaddress somatic rather than psychologic concerns.7. The need for psychiatric referral is recognized early, especially forcases involving chronic symptoms, severe psychosocial consequencesor morbid types of illness behavior.8. Any associated, coexisting or underlying psychiatric disturbance isassiduously evaluated and steadfastly treated.9. The significance of personality features, addictive potential and selfdestructiverisk is determined and addressed.10. The patient’s case is redefined in such a way that management, ratherthan cure, is the goal of treatment.* Quality of life is an elusive concept but includes the psychosocial domains ofoccupation, leisure, family, marital, health, sexual and psychological functioning.From Folks et al. 55 , with permission.anxiety. These correlates of depressive symptomatology basedon age of onset suggest a certain heterogeneity in depression ofold age.Atypical Forms of DepressionDepressive illness, particularly of late onset, may present withoutprominent mood disturbance 19 . Atypical forms of depression, ormasked depression, are thus common among older individuals 19 .Masked depression is characterized by the denial of feelings ofdepression or the lack of complaints of sadness or dysphoria. Thedysphoric affect is often prominently masked by somaticcomplaints, e.g. fatigue, pain, gastrointestinal upset, concentrationdifficulties or diminished energy 49 . These individuals whomanifest prominent somatic symptoms of depression are prone toattribute symptoms of depression to their medical illnesses 10 . Twoforms of somatization, hypochondriasis and conversion, maypredominate in the clinical picture. The clinical approach tosomatization is outlined in Table 74.1.Hypochondriasis is a common form of masked depression inthe elderly and may increase the risk for attempted suicide 50 . This‘‘secondary’’ form of hypochondriasis must be differentiated fromprimary hypochondriasis, a persistent somatoform disorder thattends to have its onset in the third or fourth decade of life andpersists. Hypochondriasis per se is not more prevalent in theelderly and its onset in later life should not be considered a part ofnormal aging, but rather reflective of psychologic distress,particularly depression 51–53 . Conversion symptoms or pain thatoccurs in an elderly person should also raise the question as to thepresence of underlying depression, even when no prominent mooddisturbance is found 54,55 . In the nursing home setting, a patientmay not meet the clinical criteria for depression on patientinterview but be observed to have depressive symptoms in thecontext of somatic complaints. Apathy, withdrawal and isolationmay be clues that depression is present. On the other hand, apatient in a long-term care facility may become abruptly agitatedwith sleep disturbance and prominent somatic complaints, whichshould increase an index of suspicion for depression.