HUMAN PSYCHOPHARMACOLOGY. VOL. 10, S235-S241 (1995)

Detection and Management of Depression in the Elderly Physically I11 Patient MAVIS EVANS Department of Old Age Psychiatry, Clatterbridge Hospital. Clatterbridge. Bebington. Merseyside. UK.

Depression is common in the elderly especially the elderly physically ill. It is a condition with high morbidity and mortality, especially if untreated. Depression at all ages costs society many millions of pounds for drug, GP and hospitalisation costs. In the elderly these costs can be compounded by the increased strain on patient and relatives leading to admission into residential care.

The diagnosis is often missed as medical staff assume symptoms are understandable, due to the physical problems, or d o not ask suitable questions during physical assessment. A short screening scale for depression in this population (ELDRS) was developed and validated against structured questionnaires and psychiatric interview. A prevalence of 20% depressed was found in a population of acute geriatric medical inpatients.

An open treatment trial of fluoxetine in patients diagnosed with the aid of the scale (n= 72) showed a significant response to treatment (p<O.O3) and a marked reduction in death rate. Advent of the SSRIs which are well tolerated by the elderly including those with multiple physical problems and concomitant medication have increased the importance of correct diagnosis in this population. Such patients can now be safely and effectively treated with consequent reduction in associated morbidity and mortality.

THE SIZE OF THE PROBLEM Community surveys have shown that > 11 per cent of the over 65s are depressed (Copeland et af., 1987), and in hospital general medical wards > 20 per cent are depressed (Gregory er af., 1992). There is also a link the other way between physical and psychiatric problems; 40 per cent of psychiatric patients aged > 65 have a chronic physical illness (Murphy, 1982).

Those aged >75 use hospital resources more frequently than those aged < 65, and this is a grow- ing problem. The ‘old old’ are becoming a larger percentage of the population, and not only do they need hospital resources for physical problems, but if there is a psychiatric problem such as depression associated as well, they use more resources both in hospital and in the community (Cavanaugh et af., 1983). As people get older, resource implications are greater: of those aged >85, 80 per cent have some incapacity for which they need help (Ross- man, 1979), perhaps from family, perhaps from state services.

THE COST TO SOCIETY If one is depressed it is hard to concentrate, it is hard to have confidence in oneself, to believe one can do something. Coping with everyday living becomes more difficult. In the elderly, cognitive

0 1995 by John Wiley & Sons, Ltd CCC 088 5-6222/9 5/S4023 5-07

impairment is closely linked with depression and this can lead to major difficulties in remembering to buy the right food, to turn off the gas, and so on, not as a dementia but as part of the depression, and so more community support is needed. This puts a much increased strain on relatives and can lead to entry into residential care (Lindesay and Murphy, 1989). The reason why this is important is because in the majority of cases depression is reversible (Gregory et al., 1992; Evans and Lye, 1992). If it is diagnosed and treated, these people might not need residential care. Once in it is extremely difficult to get out: their rented flat or house will have been given to someone else, or their own flat or house will have been sold to pay for their residential care. So it tends to be a one-way traffic.

Depression at any age costs many millions of pounds for drug costs, hospitalization costs and costs to GPs (Kind and Sorensen, 1993). But what about depression in the elderly? This generation of the elderly is the ‘stiff upper lip’ generation, they tend not to complain of feeling unhappy, or feeling miserable; they complain of loss of appetite, or of a headache, or of being unable to sleep properly, that is they somatize. This can lead to unnecessary investigations, and even prescriptions for medica- tion to treat the symptom and not the underlying depression. There is no way of measuring this cost.

S236 M . EVANS

DEPRESSION IN THE COMMUNITY Data collected in London in the 1970s, from 396 randomly selected elderly persons living in the community, was reanalysed to look for links for depression (Evans et af., 1991). Subjects had been given the CARE, a large, structured questionnaire that takes approximately 1 %-2 h to give. The CARE has questions on psychological, physical and social factors. A number of the factors did not correlate with depression:

financial worries not going out as often as one would like to living alone receiving meals on wheels being dependent on others having visual difficulties practising any form of religion.

Factors that did correlate the presence of depres- sion included:

physical disability limiting activity ( p < 0.05): not going out did not correlate, but having a physical disability so that they could not, did correlate

feeling lonely (p<O.Ol): it is not living alone that matters, it is the subjective feeling of loneliness that is important. However, this was from a questionnaire and we could not go back to investigate if subjects felt lonely because they were depressed, so do not know if this was cause or effect having a shopper (p<0 .05) : this is usually a volunteer or someone from the local church who visits, collects the shopping and drops it off with the change, not a home help or a relative. Possibly the need to have a shopper, the fact that someone cannot do their own shopping, explains the link with depression hearing difficulties ( p c 0.02): visual difficulty was not linked, but hearing difficulties were

One factor was found to be negatively correlated with depression, i.e. appeared to be a protective factor: having a home help (p<0-05). Certainly for the UK delegates, with the current cash crises in councils and social services, this is an important finding. There is a great temptation to reduce the hours and the visits of home helps, to see them as a physical service - they are there to keep the house clean, to get the shopping, to vacuum the floor. But

the home help is also, or should also be, a friend. The home help is a companion and should be the same person each week. With the cuts in social service budgets home helps are tending to have many more clients to look after, and are being shifted around more so that they do not have time to form a relationship before they go on to work with someone else. The protective factor is there- fore lost.

DEPRESSION AND PHYSICAL ILLNESS What happens when the two conditions coexist? (a) The death rate goes up. The death rate is increased in the elderly depressed (Murphy, 1983) and the death rate in the physically ill with depression is very much increased (Evans, 1993a). (b) The quality of life is decreased: if someone is depressed, by definition there is an element of anhedonia and dissatisfaction with life. (c) Depression can lead to poor compliance with treatment, difficulty in coping with the doses and the frequency of taking tablets, with getting oneself to a clinic, even with bothering to go. If one feels a burden then why go and see the doctor? No one can help. This attitude is both caused by and maintains the depression. It can lead to poor compliance and it can lead to help-seeking behaviour: ‘I cannot cope’, the agitated, depressed elderly frequently phoning the on-call GP. In my practice I have seen a few elderly with agitated depression who have been threatened with being taken off their GP’s list unless they stop calling him out so often! (d) Depression can also cause rejection of help, irritability and sometimes verbal or even physical aggression, ‘Go away, leave me alone. No one can help me, do not bother me’, and the person rejects help from social services, from health services, and even from relatives and friends.

Is the link between depression and physical illness cause or effect? (a) It can be a psychological effect. Physical illness is still seen as more acceptable than mental illness, so if patients subconsciously take on the sick role, they can get help which can make up for some of the deficits in attention, concentration, self confidence etc, asso- ciated with the depression. They can take on the sick role as a means of coping. (b) It can be coincidental. Physical illness in the elderly is common, depression in the elderly is common, so the two conditions may occur together by chance. (c) Depression can be a reaction to medication for

DEPRESSION IN THE PHYSICALLY ILL ELDERLY PATIENT S231

the physical illness e.g. cimetidine, reserpine; or physical problems can be a reaction to the medication for the depressive illness, particularly the tricyclic antidepressants. Cardiac side-effects from tricyclic antidepressants can cause arrhyth- mias, heart block or sudden death, postural hypo- tension can lead to falls (and fractures), blurred vision can make reading medication instructions difficult. (d) Depression can be a symptom of a physical illness. The elderly somatize and may present with loss of appetite or poor sleep, a physical problem, rather than depression. But some physical illnesses can present as depression. Carcinoma of the pancreas, carcinoma of the lung or hypothyroid disease can present as depression before the physical problem is diagnosed. Other physical illnesses, particularly severe physical ill- ness, have symptoms of anergia, apathy and low mood in the sense of having no energy to feel good about anything, and that can present as a depres- sion when in fact it is a sign of a severe physical illness (Ban, 1984). (e) Depressive behaviour - self-neglect, drinking, smoking, etc. leading to physical illness is also seen.

WHO IS REFERRED? Lipowski (1967) has defined the groups most likely to be referred to a liaison service.

Those in whoin the physician finds the diagnosis uncertain They may have done the physical tests which are negative but the patient still has symptoms. Maybe the symptoms do not quite fit in the physical picture, so we will be asked to assess.

The diugnosis is certain The person presenting who is very unhappy, openly crying or having attempted suicide.

Behavioural problems: irritability, verbal and physical aggression. the rejection of help Sometimes it can be total; we can be asked to go and see someone and we find them curled up in the foetal position under the bedclothes.

Known psychosocial problems: if they are known to have a history of depression I have had referrals almost on the basis of ‘I am not sure if this person is depressed, but they ought to

be’. This at least shows that the physician is thinking about the possibility of depression.

Staff-patient problerns These patients tend not to be mentally ill, they tend to be fearful and frightened. Psychiatrists have the time to sit and talk, they can talk things through and help patients get over their fear, whereas the surgeon has got his theatre list, his clinic is waiting, and he does not have that time.

DIAGNOSIS OF DEPRESSION IN THE PHYSICALLY ILL Surveys show that > 20 per cent of those aged > 65 in general medical wards have a depressive illness (Gregory et al., 1992; Hammond et al., 1993), yet liaison figures show referrals between 2 and 5 per cent (Anderson and Philpott, 1991). What is happening to the others? Either the epidemiolog- ical studies must be wrong, which is unlikely - they have been replicated throughout Europe and America (Magni et al., 1986; O’Riordan et al., 1989), or many cases of depression in the physically ill are being missed.

Because of this a questionnaire was developed specifically for the physically ill (Table I). There are many questionnaires for depression and slightly fewer questionnaires for depression in the elderly, but there is no questionnaire specifically for depression in the physically ill. Using other questionnaires on medical wards had led to a number of problems, and so ELDRS (Evans Liverpool Depression Rating Scale) was developed (Evans, 1993b).

The questionnaire is face valid. It was developed to be given by nurses or the houseman on a medical ward. It is preferable to be given by nurses because when a patient gets asked personal questions about such things as suicidal thoughts, the questioner needs to have a relationship with the patient to get a true answer. If someone simply walks up to a patient and asks ‘How are you feeling? Are you depressed? Are you unhappy? Do you want to kill yourself?’ then the answer will usually be ‘No, I don’t’. The key worker nurse system used in the majority of hospitals means that each patient has a nurse who is known to them personally, and who has got to know them over a couple of days. If this nurse uses the questionnaire she will elicit a disturbingly high level of psychopathology. Train- ing and support of nurses involved in this screening

S238 M. EVANS

Table 1. ELDRS questionnaire

Questions to ask the Datient: I . 2.

3 .

4. 5. 6.

7.

8. 9.

10.

Have you been feeling sad or weepy recently? What is your opinion of yourself compared with other people?

Patient has low opinion of himself: Is there anything you feel guilty about or blame yourself for? What‘? (Only include unjustified or unreasonable guilt) D o you worry about many things? Does this bother you? Have you enough energy to d o the things you want to do? Did you get satisfaction or enjoyment from your life as it

What d o you think the future holds for you?

Patient pessimistic about future: D o you sometimes feel life is not worth living? Have you ever felt you would rather be dead? Have you ever thought of harming yourself?

Are you as good as other people your age, better worse or the same?

was before you came into hospital?

Questions to ask relatives or nursing staff: (Answers may be known already from clerking the patient) 11. Is the patient socially isolating himself, e.g. stopped

going out or meeting people, doesn’t mix with other patients on the ward or join in conversations?

12. Does the patient complain of loneliness? 13. Has the patient been eating less well or lost any weight

(in absence of known medical reason)? 14. Has the patient had trouble sleeping: going to sleep, waking

up early or taking medication for sleep? 15. Has the patient been irritable, bad tempered or snappish?

YES/NO

YES/NO

YES/NO YES/NO NO/YES

NO/YES

YES/NO YES/NO YES/NO YESfNO

YES/NO YES/NO

YES/NO

YES/NO YES/NO

to deal with emotions in both the patients and themselves is very important.

Some of the questions look for overt symptoms of depression: sadness, low self esteem, guilt, anxiety and anhedonia. Others are less obvious, e.g. question 5: energy is a somatic symptom but it has been made subjective. It is not ‘Do you have enough energy?’, it is the energy to do the things you want to do. Analysing the individual questions has found this question did correlate with the presence of depression.

Between 5 and 10 per cent of the people screened on the medical wards answered to feeling pessi- mistic about the future and sometimes feeling life was not worth living. Two or 3 per cent disclosed wishing they were dead or thinking of harming themselves. The answers were often qualified with ‘Yes, I have thought of it but of course I wouldn’t do anything’, but even thinking of self harm is a high risk factor for this age group and a good indication of depressive illness.

As well as the 10 questions to ask the patients, there are five additional questions to ask relatives

(or possibly they may already be known by the staff), looking for the biological and behavioural symptoms of depression:

‘Is the patient socially isolated? ‘Is the

‘Does the patient complain of loneliness?’

‘Is the patient eating less well or lost any weight?’; again we found that, providing the qualifier ‘in the absence of a known medical illness’ was used, this was linked with depres- sion. For example, three patients who had come in specifically for physical investigations of anorexia and weight loss were found to be depressed. They were given a trial of treatment, all three responded and did not need the gastro- scopies, barium enemas and suchlike.

‘Trouble sleeping?’ It is ‘more than normal’ and usually qualified with ‘before you came into hospital’, as the majority of people have trouble sleeping in hospital. We ask them to qualify the question not just Yes/No but also the type of

patient withdrawing and not mixing?

DEPRESSION IN T H E PHYSICALLY ILL ELDERLY PATIENT S239

Table 2. Results from validation studies of ELDRS THE TREATMENT TRIALS ~~

(a) Sensitivity and specificity to diagnostic question- naire or interview

AGECAT diag Psychiatric interview Sensitivity 87.5 90.6 Specificity 95.5 85.1

(b) Analysis of variance between ELDRS (cutoff 5/6), and other screening scales, HAMD and MADRS, I I = 42

P < 0~0000 HAMD 75.1170 1

MADRS 76.7472 1 <0~0000 ELDRS range 0-1 I , mean 4-929, SD 3.509 HAMD range 1-31, mean 12.69, SD 8.353 MADRS range 0-39, mean 13.74, SD 10.253

(c ) Inter-rater reliability Cohen’s kappa = 0.75

F df

problem, because that can then give a pointer to the type of depression.

‘Is the patient irritable’. Depression in the elderly, especially if there is early cognitive impairment, may present as a behaviour dis- turbance (Murphy, 1989). The questionnaire has now been validated in

hospitals and in nursing homes against the GMS/ AGECAT structured diagnostic questionnaire (Copeland et a/., 1986), the Hamilton Depression Rating Scale, the Montgomery Asberg Depression Rating Scale, and clinical psychiatric interviews. Sensitivity and specificity are given in Table 2. Inter-rater reliability is of nurses and care staff, not always trained nurses; the fact that the person has some measure of relationship with the patient is more important than qualifications.

Initially the questionnaire was validated on acute geriatric medical wards at the Royal Liverpool Hospital with Professor Lye. The project started as a simple validation exercise between ELDRS and the GMS/AGECAT system. If a respondent was depressed, the diagnosis was entered in the case sheet. After the first three or four patients had been diagnosed in this fashion, the fact that the presence of a potentially fatal illness was being reported yet no treatment offered raised ethical problems. The project therefore developed into a prospective study of open treatment of the depressed patients, as well as a validation study. Seventy-two consec- utive patients were enrolled from the latter part of the validation study and followed prospectively for 12 months.

Of the 72 patients enrolled, 23 had a depressive illness, and 35 were psychologically well, 14 had organic problems on AGECAT, four of whom recovered quickly, so were classified as dementia and acute confusion respectively. The depressed patients were put on open treatment of fluoxetine 20 mg in the morning. A11 patients were followed up at home a t 3 months and at 12 months. Inter- views in the patient’s own home ensured that almost the complete sample were followed up.

RESULTS (TABLE 3)

Acute confusion Of the four patients, at 3-month follow-up one had died, one had become chronically confused or demented, and two were psychologically well. At the 12-month follow up they had all died. In this

Table 3. Diagnoses a t 3 and 12 months follow-up

Initial diagnosis Well Depd Dement Dead Other Lost Total

(a) 3 months Dementia Ac. conf. Depn Well

(B) 12 months Dementia Ac. conf. Depn Well

0 2 8

21

0 0 9

13

0 0 3* 2

0 0 0 4

3 4

11 12

0 0 2t 0

0 10 0 4 0 33 3f 35

1 10 0 4 0 23 3 i 35

*Two not on treatment recovered after course of antidepressants; one improved from delusional to non-delusional depression. t o n e acute confusion (well at 12/12). one paraphrenia (demented at 12/12). f: One refused.

S240 M. EVANS

Table 4. Physical diagnoses in patients entering the study, severity is not rated

(a) Initial diagnosis: depressed Psychologically well at 12 months 779 MI, angina, hypertension 809 CVA, blackouts, severe headaches, ECG:

ventricular ectopics 809 TIA's NIDDM, hypothyroid, IHD, ECG:

LBBB 73d COAD on domiciliary oxygen, IHD, ECG:

LBBB and ventricular ectopics, two previous MI'S, polypharmacy (1 1 diff. drugs!)

Dead at 12 months 758 CCF 738 COAD, lung cancer, ischaemic foot - on

82d NIDDM, COAD, peripheral vascular disease 779 ulcerated leg, recent onset visual hallucinations

Well at 12 months 909 NIDDM, MI, CCF 829 COAD, MI, TIA's, thyroidectomy 779 MI, CCF, gout, hiatus hernia, renal infections 703 CVA, hypertension, diplopia '

Dead at 12 months 873 COAD, peripheral vascular disease 768 gastric cancer, chronic anaemia with repeat

transfusions 699 duodenal ulcer, angina 773 lung cancer

opiate analgesia

(b) Initial diagnosis: psychologically well

COAD, chronic obstructive airways disease; IHD, ischaemic heart disease; MI, myocardial infarction; TIA, transient ischaemic attack; PA, pernicious anaemia; RA, rheumatoid arthritis; AO, osteoarthritis; NIDDM, non-insulin dependent diabetes mellitus; CCF, congestive cardiac failure; CVA, cerebrovascular accident; ECG, electrocardiogram; LBBB, left bundle branch block.

small sample, acute confusion did not carry a good prognosis.

Dernen tia Of the 10 patients with dementia, one died at 3 months, three died at 12 months. One was not traceable and may have been placed in a nursing home or may have died.

Psychologically well At 3 months, 21 of the patients psychologically well were still well, six had died, three had developed a dementia, three were not found and

two had developed a depressive illness. At 12 months four had developed a depressive illness. This is a high incidence of depression over the 12-month period, but with the concurrent chronic physical problems of this group it was not too surprising.

At 12 months, more than one-third remained psychologically well, more than one-third had died, four were depressed, three could not be found and three had dementia. This demonstrates the severity of physical illnesses seen in this sample: the 33 per cent death rate is higher than would normally be expected (5 per cent/year) Murphy, 1983) in this age group.

Depressed When the patients were depressed as well as physically ill the death rate was even higher - nearly 50 per cent. In the first 3 months, nine of the original 23 had died, by 12 months two more. Three patients remained depressed at 3 months, one had improved but not recovered, the other two had not continued their antidepressants on leaving hospital. In one instance it was a hospital error: it was not written up on the take-home prescription and so was not given. In the second case the GP had decided it was unnecessary, 'of course she is depressed, she is physically ill'. Both were restarted on antidepressants, both were seen three months later (effectively at 6 months) and both had recovered from their depression. Even though the numbers were small, the difference between treat- ment and non-treatment was statistically signifi- cant (p c 0.03).

The death rate also showed marked changes . At 3 months the death rate of the depressed group was significantly higher than the other groups, at 12 months this difference was,Lo-st. The death rate dropped and became nearly the same as that of the demented and the well group. The only difference between the groups was that those who had been depressed but had recovered were on antidepres- sants. The high death rate seen in the depressed group occurred before recovery from depression. Depression in the physically ill kills.

What type of physical illnesses were we dealing with? These were patients with one or more chronic physical problems and one or more acute physical problems. A high incidence of heart and chest problems was found, but no illness in particular was linked with depression, recovery or death (Table 4).

DEPRESSION IN THE PHYSICALLY ILL ELDERLY PATIENT S24 1

The results of a placebo-controlled treatment trial of fluoxetine in depressed elderly physically ill are currently being analysed. We have found a statistically significant response to treatment in the seriously physically ill, and have also shown the response rate increases with time - a treatment trial should continue for at least eight weeks. (Georgotas and McCue, 1989).

CONCLUSION Depression in the elderly physically ill is often not diagnosed, as an ‘acceptable’ reason for lowered mood and bleak outlook is present. However, does this therapeutic nihilism stem in part from the difficulty in treating such patients safely? The development of antidepressants such as the SSRIs, with few side-effects and interactions with other medication has enabled treatment to be offered which will improve the quality of life irrespective of improvement or deterioration in physical health. To avoid the increased morbidity and mortality associated with depression it is necessary to be aware of the possibility of depression causing somatic symptoms, the physical illness causing depressive symptoms or both conditions coexist- ing. As shown here, diagnosis can be aided with the use of simple screening scales such as ELDRS, which will be most effective if given by staff who have formed a relationship with the patient.

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