Think of depression--atypical presentations in the elderly

Depression in the elderly may have many presentations. Skill is required in differentiating clinical depressive conditions from mild reactive states and senile dysphoria. Screening tests are available that may assist the doctor in the diagnosis of depression. One of these, the Geriatric Depression Scale (short form), is easily completed by patients (Table 3). Exclusion of organic causes of depression and sub-typing of the depression are the first steps. Correct matching of type of treatment--medication, electroconvulsive therapy, cognitive-behavioural therapy or other forms of therapy--to the type of depression usually leads to a good outcome. Extra caution is required in prescribing medications to older people because of altered pharmacokinetics and the frequent co-occurrence of physical disorders. For example, the use of tricyclic antidepressants is precluded by the presence of cardiac conduction abnormalities, urinary outflow problems, narrow angle glaucoma or postural hypotension and the subsequent risk of falls and fractures. Depression in the elderly carries a much greater risk of endogenous and psychotic sub-types and of suicide. The proportion of the population who are elderly is increasing. Depression in older persons is very common, may be difficult to diagnose, is treatable and has a prognosis similar to that of middle aged or younger patients. Doctors should think depression in older patients and bear in mind possible atypical presentations. When the correct diagnosis, usually possible by taking a careful history, is followed by correct treatment, the outcome can be very rewarding for patient and doctor.