Mental Health Resource Review

UPDATED JULY 2014

Zvi D. Gellis, PhD, University of Pennsylvania
Eunhae Grace Kim, MSW, Doctoral Candidate, University of Pennsylvania
Stanley G. McCracken, PhD, University of Chicago
 
 Anxiety Disorders in Older Adults Literature Review

Search Strategy

This review of the literature on Late Life Anxiety was undertaken to determine the extent of the problem, and the effectiveness of various psychosocial and pharmacological treatments. The term effectiveness is defined here as producing or capable of producing a desired effect in a controlled study. This review consists of systematic reviews, meta-analyses, other reviews of the literature, experimental and quasi-experimental designs, and case studies with older adults (65+) as participants, reported in English language peer-reviewed journals.

Keyword terms included: aged, aging, elderly, geri*, older adult, senior, anxiety, anxious, anxiety disorder, intervention, treatment, and randomized controlled trials. We conducted searches on the following databases: PubMed (1990-2013); PsychINFO (1972-2013); Ageline (1978-2013); Social Work Abstracts (1977-2013); and Social Sciences Abstracts (1983-2013). Relevant journals were hand searched to identify recent publications that would not have been cited or indexed. Unpublished literature was not included in the review.

Background and Significance

Epidemiological evidence suggests that anxiety is a common and major problem in later life, yet it has received less attention than depressive disorders. Anxiety disorders are often associated with common age-related medical and chronic conditions such as asthma, thyroid disease, coronary artery disease, dementia, and sensory loss (Diala & Muntaner, 2003). Anxiety in later life has been identified as a risk factor for greater disability among older adults in general, and has also been associated with less successful recruitment into, and outcomes of, geriatric rehabilitation services (Bowling, Farquhar, & Grundy, 1996). Researchers and practitioners are beginning to recognize that aging and anxiety are not mutually exclusive; anxiety is as common in the old as in the young, although how and when it appears is distinctly different in older adults. Additionally, there is a need for more effectiveness research on evidence-based treatments for late life anxiety (Mitte, 2005).

Recognizing an anxiety disorder in an older person poses several challenges. Aging brings with it a higher prevalence of certain medical conditions, realistic concern about physical problems, and a higher use of prescription medications. As a result, separating a medical condition from physical symptoms of an anxiety disorder is more complicated in the older adult. Diagnosing anxiety in individuals with dementia can be difficult, too: agitation typical of dementia may be difficult to separate from anxiety, impaired memory may be interpreted as a sign of anxiety or dementia, and fears may be excessive or realistic depending on the person’s situation.

Epidemiology: Anxiety Disorders

Although anxiety disorders, like most psychiatric conditions, may be less common among older adults than among younger people, epidemiological evidence suggests that anxiety is a major problem in late life (Salzman & Lebowitz, 1991; U.S. Department of Health & Human Services, 1999). A recent review by Wolitzky-Taylor (2010) reported the prevalence estimates of anxiety disorders in older adults, ranging from 3.2% (Forsell et al., 1997) to 14.2% (Ritchie et al., 2004). For example, the National Comorbidity Survey-Replication (NCS-R) reported 7% of older adults 65 and above met the anxiety disorder criteria within the past one year (Gum et al., 2009). Meanwhile, another study found that 33.7% of its participants, who were 55-years-old and older and currently diagnosed with Generalized Anxiety Disorder (GAD), reported an onset of GAD symptoms prior to being 50 years old (Chou, 2009).

One study involving interviews with nearly 6,000 people nationwide reported lifetime prevalence rates of 15.3% for DSM-IV-diagnosed anxiety disorders in respondents over age 60 (Kessler, Berglund, Demler, Jin & Walters, 2005). Another study of approximately 500 community-dwelling triethnic elders reported prevalence rates of 11.3% in blacks, 12.4% in Hispanics, and 21.6% in non-Hispanic whites age 75 and older (Ostir & Goodwin, 2006). Myers et al. (1984) report a six month prevalence of anxiety disorders in late life ranging from 6.6% to 14.9% across three Epidemiologic Catchment Area (ECA) sites. Comparable data from the Netherlands indicate a prevalence of 10.2% (Beekman et al., 1998). Anxiety disorders overall appear to be the most common class of psychiatric disorders among older people, more prevalent than depression or severe cognitive impairment (Beekman et al., 1998; Kessler et al., 2005; Regier et al., 1988).

Epidemiology: Phobias and Generalized Anxiety Disorder

Prevalence estimates for Generalized Anxiety Disorder among older adults range from 1.2% (Gum et al., 2009) to 7.3% (Beekman et al., 1998). Few studies have reported the prevalence estimates of social phobia among older adults and those estimates were relatively low, ranging from 0.6% (Trollor et al., 2007) to 2.3% (Gum et al., 2009; Wolitzky-Taylor, 2010).

Phobias and GAD account for most anxiety disorders in late life (Beekman et al., 2000; Flint, 2005; Hybels & Blazer, 2003; LeRoux, Gatz & Wetherell, 2005; Wolitzky-Taylor & Castriotta, 2010). Reviews summarized the prevalence of specific anxiety disorders in older community-based epidemiological samples as follows: phobias, including agoraphobia and social phobia, 0.7-12.0%; GAD, 1.2-7.3%; obsessive-compulsive disorder, 0.1-1.5%; and panic disorder, 0.0-0.3% (Alwahhabi, 2003; Beekman et al., 1998; Beekman et al., 2000; Krasucki, Howard, & Mann, 1998). Prevalence of GAD in older adults was estimated at 1.9% in the ECA sample and 7.3% in the Dutch sample (Beekman et al., 1998; Beekman et al., 2000; Blazer, 1997). Among people 55 years of age and older, Douchet, LaDouceur, Freeston & Dugas (1998) found that 12.8% meet criteria for GAD. By comparison, ECA prevalence rates for older adults are 1.8% for major depression, 2.8% for dysthymia, and 4.9% for severe cognitive impairment (Blazer, 1997; Regier et al., 1988).

Epidemiology: Subthreshold Anxiety Symptoms

The prevalence of clinically significant anxiety, including symptoms that do not meet criteria for a specific disorder, is common among older adults and may be as high as 20-29% (Davis, Moye, & Karel, 2002; Lenze et al. 2005). Grenier et al. (2011)’s large study reported the sum of the syndromal and subthreshold anxiety estimates as 26.2%. This includes anxiety symptoms associated with common medical conditions such as asthma, thyroid disease, coronary artery disease, and dementia, as well as adjustment disorders following significant late life stressors such as bereavement or caregiving. There is also controversy over whether the prevalence of anxiety has been accurately determined in older adults, because DSM-IV criteria may not apply as well, anxiety symptoms may be expressed as somatic features or behavior changes (e.g., aggression, assaultive behaviors), and the clinical presentation of anxiety in late life may be more likely to include depressive symptoms (Beck, 2004; Diefenbach & Goethe, 2006; Fuentes & Cox, 1997; Kim, Braun, & Kunik, 2001; Palmer, Jeste, & Sheikh, 1997).

Risk Factors

Aging per se is not a risk factor for anxiety but rather a protective one (Acierno et al., 2006). However, several biological, psychological, and social risk factors for anxiety disorders have been identified for older adults. Biological risk factors include: chronic health conditions (Schoevers et al., 2003), poor self-perception of health (van Zelst et al., 2003), and functional limitation (Schoevers et al., 2003). Psychological risk factors include: external locus of control, poor coping strategies, neuroticism, and psychopathology (Schoevers et al., 2003; van Zelst et al., 2003). Social risk factors include: low frequency of contact (Forsell, 2000), smaller network (Beekman et al., 1998), lack of social support (Forsell, 2000; Beekman et al., 2000), loneliness (van Zelst et al., 2003), stressful life events (van Zelst et al., 2003), lower education level (Beekman et al., 1998), being female (Schoevers et al., 2003; van Zelst et al., 2003).

Comorbidity Issues

Medical Comorbidity

The high comorbidity of anxiety with medical illness is multidimensional. Anxiety is complex and may be a reaction to a medical illness, may be expressed as somatic symptoms, or may be a side effect of medications. Studies have found an association between anxiety and medical illnesses such as diabetes (Blazer, 2003), dementia (Wrag & Jeste, 1989), coronary heart disease (Artero, Astruc, Courtet, & Ritchie, 2006; Kuzbansky, Cole, Kawachi, Vokonas, & Sparrow, 2006; Todaro et al., 2007), cancer (Deimling et al., 2006; Goodwin, Zhang, & Ostir, 2004; Ostir & Goodwin, 2006) chronic obstructive pulmonary disease (Karajgi, Rifkin, Doddi, & Kolli, 1990; Vogele & von Leupoldt, 2008), postural disturbance & vestibular disease (Gagnon et al., 2008), chronic pain (El-Gabalawy et al., 2011), and Parkinson’s disease (Stein, Heuser, Juncos, & Uhde, 1990; Pontone et al., 2009). For example, several studies have found that 18% (Yohannes et al., 2000) to 50% (Dowson et al., 2001) of older adult patients with chronic obstructive pulmonary disease reported significant anxiety symptoms. Todaro et al. (2007) reported that 36% of study cardiac patients (Mean Age: 60) were currently diagnosed with an anxiety disorder and 45.3% in their lifetime. Another study noted that anxiety symptoms were found to be associated with future development of coronary heart disease (Caminero et al., 2005). In several studies of Parkinson’s disease patients, approximately 40-43% reported significant anxiety symptoms (Menza et al., 1993; Pontone et al., 2009). Comorbid anxiety and medical illness is associated with increased mortality. For example, anxiety is associated with greater risk for mortality for patients after heart surgery (Tully et al., 2008) while panic attacks are associated with increases in risk for cardiovascular mortality (Smoller et al., 2007). At least one tri-ethnic study found that anxiety was associated with increased risk for death from all causes in persons 75 years and older (Ostir & Goodwin, 2006).

Psychiatric Comorbidity

Depression: As with young adults, anxiety in older adults has been found to often co-occur with depression (Beck, 2004; Beekman et al., 1998; Blazer, 1997; Byers et al., 2010; Heck et al., 2011; King-Kallimanis et al., 2009; Schoevers et al., 2003; Steffens et al., 2005;). Furthermore, anxiety symptoms have been found to lead to depressive symptoms (Wetherell, Gatz, & Pederson, 2001). In fact, community survey research has revealed that the comorbidity of anxiety and depression has been found to be as high as nearly 50% among older adults (Beekman et al., 2000). In the community study, 25% of older adults with anxiety also had major depression. Related to this, up to 50% of older adults with major depression had a comorbid anxiety disorder (Beekman et al., 2000; Blazer, 2003; Jeste, Hays & Steffens, 2006). Large community-based studies have shown a positive association between the comorbid GAD and depression, and its chronicity (Schoevers et al., 2005) and severity (Hopko et al., 2000) compared to GAD or depression alone. Depressed older adults with GAD symptoms have shown greater suicidality (Lenze et al., 2000; Bartels et al., 2002), treatment non-responsiveness (Mulsant & Wright, 1996), and a likelihood of treatment dropout (Flint & Rifat, 1997) when compared to those without anxiety.

Mood & Personality Disorders: Older adults with GAD often also suffer from other psychiatric disorders. The majority of GAD patients have mood disorders (Flint, 2005; Lenze et al., 2005). For example, bipolar disorder has been found to often co-occur with anxiety for older adults (Sajatovic et al., 2006). Approximately 20% of older adults with bipolar disorder report lifetime rates of generalized anxiety disorder (Goldstein, Hermann & Shulman, 2006). In addition, personality disorders often co-occur with GAD (Mackenzie et al., 2011). When compared to those without anxiety, older adults with anxiety have reported a greater prevalence of personality disorders such as avoidant and dependent personality disorders (Coolidge et al., 2000).

Cognitive Impairment: Older adults with anxiety often also suffer from cognitive impairment and dementia (Beaudreau et al., 2008; Forsell et al., 2003; Potvin et al., 2011; Seignourel et al., 2008; Sinoff & Werner, 2003; Wilson et al., 2011). Approximately 5% to 21% of older adult dementia patients have anxiety disorders (Feretti et al., 2001; Skoog, 1993). These prevalence estimates are greater when compared with those for cognitively intact persons (Hwang, Masterman, Ortiz, Fairbanks, & Cummings, 2004; Lyketsos et al., 2002; Tatsch et al., 2006). Individuals with anxiety symptoms have done poorly on assessments of cognitive functioning (Schultz, Moser, Bishop, & Ellingrod, 2005; Sinoff & Werner, 2003). Also, when compared to those without psychiatric disorders, those with GAD have shown poorer short-term memory (Mantella et al., 2007). Studies using community samples have found Alzheimer’s disease to be positively associated with anxiety symptoms (Geda et al., 2004; Hwang et al., 2004).

It is possible that the prevalence of anxiety is higher in primary care settings than in the community at large. Krasucki et al. (1999) found that, in primary care settings, 30% of older adults present with generalized anxiety symptoms. Distressed older adults seeking help typically present to their primary care physician (Smyer & Gatz, 1995). Prevalence estimates of anxiety symptoms among older adult patients range from 15% in the geriatric hospital (Ames et al., 1994) to 56% in the general hospital (Ames & Tuckwell, 1994). Meanwhile, prevalence estimates of anxiety disorders range from 1% in the general hospital (Ames & Tuckwell, 1994) to 24% in primary care (Tolin et al., 2005). Older adults with anxiety disorders are less likely than older adults with depression, dementia, or any other mental disorder to receive treatment from a mental health specialist (Ettner & Hermann, 1997).

In an analysis of data from the 1997 National Ambulatory Medical Care Survey, a national probability sample survey of physician office visits, anxiety disorder diagnoses were assigned for 1.3% of visits by older patients, with anxiety disorder not otherwise specified as the most frequent diagnosis (Stanley, Roberts, Bourland, & Novy, 2001). Because evidence suggests that only approximately one-third of such cases are detected in primary care (e.g., Kessler, Lloyd, Lewis, & Gray, 1999), these data likely represent a substantial underestimate of the prevalence of anxiety in that setting. Furthermore, Levy, Conway, Brommelhoff, & Merikengas (2003) found that, compared to younger adults, older adults tend to minimize and underreport their anxiety symptoms. Thus the prevalence rate of older adults who experience anxiety may be underestimated (Levy et al., 2003).

There is a dearth of research on anxiety and anxiety disorders in older adults with hearing or visual impairment, with previous studies in this population focusing primarily on depression and functional impairment. However, one recent study by Brenes et al. (2005) found significantly higher levels of anxiety in a national sample of 1,002 older disabled women who reported experiencing visual problems. Overall, it appears that anxiety symptoms and syndromes are quite common in old age, and may be detectible at even higher levels in older adults with visual deficits.

Consequences of Anxiety Disorders

The consequences of anxiety in late life are potentially serious. In a prospective investigation, anxiety did not generally remit spontaneously over 2 to 3 years (Livingston, Watkin, Milne, Manela, & Katona, 1997). Hypertension, hypoglycemia, and coronary heart disease can be worsened through chronic stress and anxiety (Hersen & Van Hasselt, 1992). Compared with men reporting no symptoms of anxiety, men in the Normative Aging Study reporting two or more anxiety symptoms had elevated risk of fatal coronary heart disease (Kawachi, Sparrow, Vokonas, & Weiss, 1994). Higher levels of anxiety have been associated with greater use of pain-relieving medications and more postoperative disability days for surgical patients (Taenzer, Melzack, & Jeans, 1986). Anxiety was also related to pain in a sample of nursing home residents (Casten, Parmelee, Kleban, Lawton, & Katz, 1995).

Anxiety symptoms and disorders are associated with increased fatigue, greater levels of chronic physical illness, increased disability, lower levels of well-being, worse life satisfaction, and inappropriate use of medical services among older adults (Martin, Bishop, Poon, & Johnson, 2006; Brenes et al., 2005; de Beurs et al., 1999; Hunt, Issakidis, & Andrews, 2002; Jones, Ames, Jeffries, Scarinci, & Brantley, 2001; Wetherell et al., 2004; Wittchen, Carter, Pfister, Montgomery, & Kessler, 2000). Furthermore, a sample of older adults with GAD reported impairments on quality of life (QOL) measures that were worse than impairments reported by another group of age-matched individuals who had serious medical conditions such as myocardial infarction or type II diabetes (Wetherell et al., 2004). It was also found that the reported QOL impairments for the individuals diagnosed with GAD was comparable to those reported for people with major depression. In cases of comorbid anxiety and depressive disorders, the likelihood of poor outcomes increases. Comorbid anxiety in late-life depression is associated with poor treatment response and increased likelihood of dropout (Lenze, Mulsant, et al., 2003). Also, older people with anxious depression report increased suicidality and reduced psychosocial support (Jeste et al., 2006).

In addition to direct relationships with poorer health care outcomes, anxiety and depression have been associated with markedly higher health care costs among age-matched groups of primary care patients, even after adjustment for medical comorbidity (Simon, Ormel, VonKoff, & Barlow, 1995). During office visits, older adults with anxiety spend 50% more time with their primary care physician than older adults with no psychiatric diagnosis do (Stanley et al., 2001). Taken altogether, these findings support the importance of treatment of anxiety in late life.

Treatments

Pharmacological Treatment

In part because of the tendency for older adults to present to primary care physicians, anxiolytic medications, including benzodiazepines, are the most common treatment for late life anxiety (Lenze, Pollock, et al., 2003). ECA data suggests that benzodiazepine use among the elderly is approximately 14%, higher than the rate for younger adults (Swartz, Landerman, George, Melville, Blazer, & Smith, 1991). A community survey of older adults in southern California showed that 20% had used benzodiazepines at least twice in the previous 12 months; these individuals were more than twice as likely as nonusers to take 10 or more drugs (Mayer-Oakes et al., 1993).

Benzodiazepine users are also more likely than nonusers to experience accidents requiring medical attention, due to increased risk of falls, hip fractures, and automobile accidents (Tamblyn, Abrahamowicz, du Berger, McLeod, & Bartlett, 2005). Older patients taking benzodiazepines are also more likely to develop disabilities in both mobility and activities of daily living (ADLs) (Gray et al., 2006). Benzodiazepines can impair memory and other cognitive functions (Wengel, Burke, Ranno, & Roccaforte, 1993). These medications can also cause tolerance and withdrawal, interactions with other drugs, and toxicity (Krasucki et al., 1999; Salzman & Lebowitz, 1991).

Although safer medications than benzodiazepines, particularly selective serotonin reuptake inhibitors (SSRIs), are often used to treat geriatric anxiety, they can cause unpleasant side effects, and some older people prefer not to take them. Furthermore, SSRIs have not completely replaced benzodiazepines as a treatment for anxiety in older people (Keene, Eaddy, Nelson, & Sarnes, 2005). Safe and effective alternative treatments for anxiety that are appealing to an older population are clearly needed.

Psychosocial Treatment

The efficacy of evidence-based psychosocial interventions has been tested using randomized trials for geriatric anxiety and reviewed with emerging evidence of support for their use (Ayers, Sorrell, Thorp, & Wetherell, 2007) (Level A; see Chapter 1, Introduction for description of Levels).

Several studies have provided some support for the use of relaxation training and cognitive behavior therapy (CBT) for treatment of anxiety (Barrowclough et al., 2001; Gorenstein et al., 2005; Mohlman et al., 2003; Stanley, Beck, et al., 2003; Stanley, Hopko, et al., 2003; Wetherell, Gatz, & Craske, 2003) (Level A). In recent years, CBT has been shown to be superior to waitlist conditions, medication management-only conditions, supportive control conditions (e.g., supportive counseling, minimal contact, discussion group), and usual primary care (Barrowclough et al., 2001; Gorenstein et al., 2005; Mohlman et al., 2003; Stanley, Beck, et al., 2003; Stanley, Hopko, et al., 2003; Wetherell et al., 2003) (Level A). In a study by Gorenstein and colleagues (2005), greater reductions in anxiety were not seen until a 6-month follow-up visit. In some of the other studies, compared to waitlist or supportive control conditions, CBT also provided greater reductions in comorbid depression, as well as improvements in QOL (Barrowclough et al., 2001; Stanley, Beck, et al., 2003; Stanley, Hopko, et al., 2003; Wetherell et al., 2003). However, in a recent study comparing CBT plus medication management with medication management alone, the combined approach was not found to be superior in reducing anxiety, worry, and total distress (Gorenstein et al., 2005). While some studies suggest that CBT is promising for the treatment of anxiety, Stanley, Beck, and Glassco (1996) found no differences between CBT and supportive psychotherapy on anxiety and depression reductions. Finally, in another review by Wetherell, Sorell, Thorp, and Patterson (2005), the authors assert that progressive muscle relaxation, CBT, and even supportive therapy have empirical support for their use in treating geriatric anxiety (Level B). However, the authors report that, when compared to waitlist and supportive control conditions, the psychological treatments with the greatest effect sizes (20 or greater) are relaxation training (for anxiety symptoms) and CBT (for anxiety disorders). These mixed results warrant further understanding and research as to the most effective treatment approaches for late life anxiety.

Summary: Take Home Points for Teaching

• Anxiety is a common problem in late life.
• Anxiety is more prevalent than depressive disorders in later life.
• Generalized Anxiety Disorder (GAD) is the most common (prevalence rate 1.2-7.3%).
• Subthreshold anxiety symptomology is higher than GAD (prevalence rate 20-29%).
• Prevalence of anxiety symptoms is likely higher in primary care settings (~30%) than in the community at large or any other setting.
• Less common are phobias, Obsessive-Compulsive Disorder, and panic disorders.
• Comorbidity with depression is high (nearly 50%).
• It is difficult to disentangle anxiety from depression during assessment.
• Risk factors for anxiety include chronic health conditions, poor health self-perception, poor coping strategies, lack of social support, and lower level of education.
• Comorbidity with medical illnesses is high.
• Negative outcomes of anxiety include poor health outcomes, poor life satisfaction, significant functional impairment, increased Emergency Room and primary care visits, and higher medical costs.
• Pharmacological Treatments: Benzodiazepines are the most common medication treatment for late life anxiety; SSRIs are safely used but have unpleasant side effects.
• Psychosocial Treatments:
  • Evidence has been found for Cognitive Behavioral Therapy (CBT) (Level A), Relaxation Training (Level A), and to a lesser extent Supportive Therapy (Level C).
  • CBT has the strongest evidence to date for treatment of Generalized Anxiety Disorder in comparison to control groups.
  • CBT is better tolerated than pharmacotherapy.
  • Relaxation training is viewed as a low-cost, effective intervention.
  • CBT protocols can include problem-solving skills training, behavioral activation, sleep hygiene, life review, and memory aids.
  • CBT can be conducted in individual or group formats.
  • CBT has been found to be more effective than Supportive Therapy or Attention Placebo conditions.
  • CBT combined with medication management has been found to be no better than CBT alone.

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Document Date: September 9, 2009

UPDATED SEPTEMBER 2014

Zvi D. Gellis, PhD, University of Pennsylvania
Bonnie L. Kenaley, PhD, Boise State University
Stanley G. McCracken, PhD, University of Chicago

Depressive Disorders in Older Adults

Overview of Aging Population

• In 2010, 40.3 million individuals were 65 years or older, representing 13% of the total population, with a rapid growth projected during the next two decades.
• Between 2000 and 2010, the male population aged 60 to 74 increased by 35.2%, narrowing the gender ratio gap.
• The elder racial minority groups are projected to increase with non-Hispanic whites increasing by 54% from 2012 to 2030 and 125% for racial and ethnic populations during the same period.

The 2010 Census Bureau found that 40.3 million individuals were 65 years or older, representing 13% of the total population, with a rapid growth projected during the next two decades (U.S. Department of Commerce, 2011). Elders between 60 and 64 years of age showed the largest percent increase in population (55.6%) since 2000 (U.S. Census Bureau, 2010). This age group grew at a faster rate (15.1%) than individuals under the age of 45 (U.S. Census Bureau, 2011) and is expected to rise to 72,091,915 in 2030 and 88,546,973 in 2050 (U.S. Department of Commerce, 2010). Examining age in five-year cohorts, the U.S. Department of Commerce (2010) found an increase in the elder population, except for those between the ages of 75 and 70 years. Interestingly, there was a 30.2% increase in the 90- to 94-year-old population in 2010 compared with the same age group in 2000 and a 29.5% increase in the 95- to 99-year-old population in 2010 compared with the same age group in 2000.

A remarkable change was found between 2000 and 2010 regarding the sex ratio of elders. Defined as the number of males per 100, the sex ratio gap narrowed due to a 35.2% increase in the male population aged 60 to 74 compared with their female counterparts’ increase of 29.2%. The racial composition of elders is diverse, which demands tailoring of access to and treatment of minority populations. In 2011, 21% of individuals age 65 years or older were members of racial or ethnic populations (U.S. Department of Health & Human Services, 2012). Of the elders included in the 2011 census, 9% were non-Hispanic African-Americans, 4% were non-Hispanic Asian or Pacific Islander and the categories of Native Alaskan or American Indian and biracial add a population of less than 1%. The estimates of older growth by racial groups are projected to increase with non-Hispanic whites increasing by 54% from 2012 to 2030 and 125% for racial and ethnic populations during the same period (U.S. Census Bureau, 2011). Added to this trend is the increasing proportion of African-American, Latino, and Asian-Americans (Areàn et al., 2005; Gelllis & Taguchi, 2003; Harada & Kim, 1995), who tend to have more obstacles than Caucasians in accessing mental health services.

Prevalence and Characteristics of Depression in Older Adults

• Nearly 5 million of the 31 million Americans over 65 suffer from clinically significant depressive syndromes.
• Estimates of major depression in large-scale community studies are generally low, ranging from 1% to 4.6%.
• For elders living in home health care settings, estimates for major depression range from 6.4% to 13.5%.

Nearly 5 million of the 31 million Americans over 65 suffer from clinically significant depressive syndromes. Estimates of clinically significant depressive symptoms range from 10% to 48% (Dozeman et al., 2010; Koenig, Meadors, Cohen, & Blazer, 1988; Peterson, Williams-Russo, Charlson, & Myers, 1996; Steffens et al., 2000; Williams-Russo, Sharrock, Mattis, Szatrowski, & Charlson, 1995). The prevalence rate for dysthymia is approximately 2%, although estimates for minor depression are higher, ranging from 4% to 50% (Buchtemann, Luppa, Branesfeld, & Riedel-Heller, 2012; Blazer, 2002; Beekman et al., 1995; Thota, Sipe, & Byard, 2012). Late-life depression is associated with increased risk of lifetime chronic depression (Murphy & Byrne, 2012).

Prevalence estimates of major depression in large-scale community studies are generally low, ranging from 1% to 4.6%. For elders living in home health care settings, estimates for major depression range from 6.4% to 13.5% and 27.5% for subthreshold depression (Bruce et al., 2002; Gellis, 2010; Shao, Peng, Bruce, & Bao, 2011). In fact, depression is twice as prevalent in home health care as in primary care; it is persistent, intermittent, and is associated with medical illness, pain, and disability (Brown, Kaiser, & Gellis, 2007; Lyness, King, Cos, Yoediono, & Coaine, 1999). Late-life depression is one of the most common psychiatric disorders to present in primary care and home health care settings (Bruce et al., 2002; Gellis & Kenaley, 2008; Gellis et al., 2007; Lyness et al., 1999; Reynolds & Kupfer, 1999). In fact, depression is the third most common reason for consultation with a primary care provider (Singleton, Bumpstead, O’Brien, Lee, & Melzer, 2001).

Elders with major depression in primary care are more likely to die than their counterparts without depression, as elders present their depression as somatic symptoms, causing delay in treatment (Gallo et al., 2013). However, patients with major depression in primary care using intervention practices were 24% less likely to have died compared with their non-depressed peers (Gallo et al., 2013). Estimates for rates of major depression in medically-ill older adults range from 10% to 12% (Fiske, Wetherell, & Gatz, 2009). Thirty-nine percent of elders residing in assisted living facilities have depression (Jang, Bergman, Schonfeld, & Molinari, 2006; McDermott, Gillespie, Nelson, Newman, & Shaw, 2012). In long-term care settings, prevalence rates for major depression may range from 5% to 54% (Blazer, 2002; McDougall, Matthews, Kvaal, Dewey, & Brayne, 2007; Morrell et al., 2011; Seitz, Purandare, & Conn, 2010; Singleton et al., 2001) and clinically significant depressive symptoms range from 14% to 82% (Hyer, Carpenter, Bishmann, & Wu, 2005; McDougall, Matthews, Kvaal, Dewey, & Brayne, 2007; Seitz et al., 2010). Depression is underdetected in long-term care facilities and, if detected, is inadequately treated (Teresi, Abrams, Holmes, Ramirez, & Eimicke, 2001; Brown, Lapane, & Luisi, 2002). In fact, 28% of older adult residents with depression have received ineffective or no treatment at all (Morrell et al., 2011).

Recent research has shown significant racial or ethnic differences in prevalence rates for depression. A study examining the National Survey of American Life found lifetime major depressive disorder (MDD) prevalence estimates at 17.9% for non-Hispanic whites, 12.9% for Caribbean Blacks, and 10.4% for African-Americans, yet 12-month MDD estimates across groups were similar (Williams, et al., 2012). In a secondary data analysis of the National Survey of American Life among older adult Medicare recipients, depression diagnosis rates were estimated at 7.2% for Hispanics, 6.4% for non-Hispanic whites, 4.2% for African Americans, and 3.8% for others (Akincigil et al., 2012).

Steffens and colleagues (2009) found whites and Hispanics experience nearly three times the prevalence of depression compared with African Americans. Widowed, separated, or divorced elders experience higher prevalence rates of MDD (Chou & Cheung, 2013) than those who were married. As many as 15% of older Latinos, 12% of older Asian-Americans, and 10% of older African Americans meet criteria for minor depression (Arean & Alvarez, 2001). In contrast to Zalaquett and Stens’ study (2006) that found no gender differences in the manifestation of depressive symptoms, Teng, Yeh, Lee, Lin, and Lai’s study (2013) found that depression was seen more often in men than their female counterparts. However, a systematic review of the incidence of late-life depression in elders 70 years and older found that major depression was more often found in females (Büchtemann, Luppa, Bramesfeld, & Riedel-Heller, 2012). 

Risk and Protective Factors for Late-Life Depression

• Significant life events—assuming a caregiver role; bereavement; living in a rural area; being single or divorced or a widow or widower; suffering chronic and multiple comorbid medical conditions; and polypharmacological use—are risk factors for depression.
• Protective factors include positive beliefs and attitudes, exhibiting a higher sense of mastery, greater religiosity, and more positive attitudes toward aging.
• Though depression is not a normal experience of growing older, older adults are at increased risk for experiencing this disorder.

The etiology of depression is often unclear and is fraught with multiple concurrent factors that increase an older adult’s chance of developing depressive symptoms. Such factors include the occurrence of significant life events, such as assuming a caregiver role and bereavement (Cole & Dendukuri, 2003; Magnil, Janmarker, Gunnarsson, & Björkelund, 2013; Montesó et al., 2012). In a study of rural dwelling elders, Montesó and colleagues (2013) found that both widowers and widows were at risk for experiencing depression, yet males were more vulnerable for depression than females. In a systematic review of risk factors for depression in community-dwelling elders that involved a qualitative and quantitative synthesis of the data, Cole and Dendukuri (2003) examined 20 studies and found that females were more at risk for depression compared with males. However, the risk for depression, considering gender, may change due to the situation.

Chronic medical conditions may contribute to the development and continuation of depressive symptoms and disorders. Insomnia, especially characterized by difficulty in initiating sleep and maintaining sleep, daytime sleepiness, and prior history of depression increase the risk for depression (Jaussent et al., 2011). Other medical conditions such as diabetes, cardiovascular disease, and arthritis increase the risk of late-life depression. Depressed elders are at a four-fold risk for diabetes and cardiovascular disease, especially those who experienced myocardial infarction, heart failure, or coronary artery bypass surgery; depressed elders with arthritis have a nine-fold risk of falls (Teng et al., 2013). Elders living in long-term homes who suffer from nervous system disorders are at an 11-fold risk of experiencing depression (Wang et al., 2012). In fact, elders with low functioning due to other medical conditions are at increased risk for depression (Montesó et al, 2012;Yang, Berman, Schonfeld, & Molinari, 2006). Additionally, the loss of ability to perform activities of daily living due to medical ailments also increases the risks for elders to experience late-life depression (Yang et al., 2006; Montesó et al., 2012), with men being more at risk compared with women (Montesó et al., 2012). The older adult’s perception of their health status also influences the risk for depression, with those who report a poor rating experiencing more depressive symptoms than those who have a more positive perception of their health status (Yang et al., 2006).

The aging process presents the occurrence of medical conditions which require pharmacological treatment; sometimes the use of several medications. A polypharmacological regimen in treating a medical and/or psychological disorder(s) increases the risk of depressive symptoms (Kao, Wang, Tzeng, Liang, & Ling, 2012), as well as increasing the risk of falling by six-fold (Teng et al., 2013). The use of sedatives and hypnotics is a strategy to treat insomnia and anxiety, often-occurring ailments in elders. However, while these drugs may resolve the adverse effects of the disorder(s), their side effects or interactions with other drugs may cause depressive symptoms (Magnil et al., 2013). Additionally, medical conditions may require ancillary devices which increase the risk of depression in elders by five-fold (Kao et al., 2012). Other risks for major and subthreshold depression include poor social supports, lack of engagement in leisure activities (Lee et al., 2013; Magnil et al., 2013), high stress levels (Lee et al., 2013), and low education (Teng et al., 2013). Elders with war-related experiences are at higher risk for depression compared with their peers lacking such stressful histories (Strauss, Dapp, Anders, von Renteln-Kruse, & Schmidt, 2011).

Protective factors that guard against the manifestation of depressive symptoms and disorders include having a positive attitude toward aging, practicing a religion, life satisfaction, and a sense of mastery (Hashe, Morrow-Howell, & Proctor, 2010; Jang et al., 2006). Elders residing in long-term care homes who are satisfied with their life are less likely to experience depression compared with those whose perceptions are less positive (Hashe et al., 2010). Elders who have positive beliefs and attitudes exhibit a higher sense of mastery, greater religiosity, and more positive attitudes toward aging, resulting in a decreased risk for depression (Jang et al., 2006). Additionally, instrumental and emotional support from family members as well as assistance from formal organizations improves the psychological well-being among older adults and moderates the association between functional disability and depression (Chao, 2012). In fact, concordance in the perception of financial, physical, caregiving, social, and environmental needs between community-dwelling elders and their formal or familial caregivers improves the elder’s quality of life and decreases the risk for major depression (Hourties, van Meijel, Deeg, & Beekman, 2012).

Comorbidity of Depression in Older Adults

• Comorbidity of depression with physical disorders is common and negatively influences the course of the depression and increases functional impairment, health costs, and use of health services.
• Common medical illnesses known to be associated with depression include cerebrovascular disease, heart disease, stroke, hypertension, diabetes, cancer, neurological conditions, and osteoarthritis.

Depressed elders often experience comorbid medical issues and functional disability (Alexopoulos et al., 1996; DaSilva, Scazufca, & Menezes, 2013; Dauphinot et al., 2012; Proctor et al., 2003), with 23.8% experiencing one or two medical conditions, and 27.7% manifesting three or four medical illnesses (Spangenbrg, Forkmann, Brahler, & Glaesmer, 2011). Medical conditions known to be associated with depression include heart disease, asthma, hypothyroidism, stroke, dementia, diabetes, cancer, chronic pain, and arthritis (Chou & Cheung, 2013; Gellis et al., 2012; Krauskopf, 2013; McCarthy et al., 2009). Adjusting for demographic factors, socioeconomic conditions, physical morbidities, and dementia, high functional disabilities are associated with major depression (DaSilva et al., 2013). Recent neurological and immunological studies have found that depressive symptoms may be linked to impaired late-life autonomic nerve or peripheral nervous system performance (Dauphinot et al., 2012), affecting heart rate, digestion, respiratory rate, salivation, perspiration, pupillary dilation, urination, sexual arousal, and ultimately causing immune deficiency.

Negative outcomes of comorbid medical conditions and associated depression include poor social support, impaired functional status, increased disability, and increased rates of mortality and suicide (Brown, Kaiser, & Gellis, 2007; Center for Disease Control and Prevention, 2013; Preyde & Brassard, 2011; Teng et al., 2013). In a national longitudinal study (Teng et al., 2013), older adults with chronic depression have a higher risk of mortality compared with those with less chronic conditions. The risk for mortality increased for older adult males with depression and cardiovascular conditions; the risk for mortality in older adult females increased with non-cardiovascular conditions. Depression associated with physical illness increases levels of functional disability (Gellis & Kang-Yi, 2012; Proctor et al., 2003), use of health services (Beekman, Deeg, Braam, Smit, & van Tilburg, 1997; Saravay, Pollack, Steinberg, Weinsched, & Habert, 1996), and health care costs (Callahan, Kesterson, & Tierney, 1997; Manning & Wells, 1992; Preyde & Brassard, 2011; Simon, VonKorff, & Barlow, 1995), particularly among older adults. It also delays or inhibits physical recovery (Covinsky, Fortinsky, Palmer, Kresvic, & Landefeld, 1997; Katz, 1996).

While elders only make up 13% of the population, they account for approximately 20% of all suicides and have a higher completion rate compared with their young counterparts (Center for Disease Control and Prevention, 2013; Hoyert, Kung, & Smith, 2005; Peaerson & Brown, 2000). In the U.S., suicide rates for males and females age 65 years and older were elevated with a ratio of 150 suicides per 100,000 between 2000 and 2010 (Lapierre et al., 2011). White males 85 years and older have the highest suicide completion rates (45 per 100,000) (Centers for Disease Control and Prevention, 2013). Social inequalities play a role in suicidal ideations and suicide in older adults, including financial strain and an annual income of less than $20,000 (Gilman et al., 2013). Additionally, elders who are divorced or separated, living alone, have previous psychiatric history, a previous suicide attempt, less than a high school diploma, a lack of social support, and suffer from comorbid medical conditions have an increased risk for suicidal ideations or suicide (Gilman et al., 2103; Peters, Kochanek, & Murphy, 1998; Wiktorsson, Runeson, Skoog, Ostling, and Waem, 2010). Retrospective studies identified that greater than 70% of late-life suicide victims had contact with their primary care provider within 3 to 6 months prior to their death (Conwell, Olsen, Caine, & Flannery, 1991; Conwell, 1994; Diekstra & van Egmond, 1989; Frierson, 1991; Tadros & Salib, 2007; Uncapher & Areán, 2000). Elders with late-life depression are more likely to present somatic symptoms during their visits to their primary care physicians compared with their younger counterparts who present with more psychiatric symptoms (Tadros & Salib, 2007), which decreases the likelihood of detecting depressive symptoms and initiating treatment. Additionally, the majority of older patients who experience late-onset and untreated depressive symptoms usually suffer high rates of comorbid illness and/or fears of pain or dependency on others (Duberstein, 1995).

Beliefs and perceptions by health professionals also contribute to not detecting depression and suicidal ideations, hence increasing the risk for suicidal attempts and completions. In a study of 159 staff members at four long-term care facilities, Tracey and Heck (2013) compared the beliefs of depression as a normal aging process between paraprofessional staff (certified nursing assistants) and professional staff (social workers, licensed practical nurses, registered nurses, and mental health counselors) working at  long-term care facilities. Interestingly, professional staff viewed depression as a normal part of aging and that older adults are less likely to commit suicide compared with paraprofessional staff who believed that depression and suicide were not normal behaviors in elders (Tracey & Heck, 2013). These findings indicate the need for training for those working with the older adult population, involving normal geriatric development, methods for identifying depressive symptoms, and prevention and treatment for depression in different elder care settings. 

Depression Screening

• The goal of screening is early identification and, thus, prevention through early intervention.
• Key criteria to be used by agency personnel to justify mental health screening for late-life depression include the following:
  • Is the national incidence of depressive disorders in the older adult population high enough to justify the cost of screening in an agency?
  • Does the problem have a significant effect on the quality of life of the older adult?
  • Depression symptomatology varies significantly for each elder.
  • Is effective treatment available?
  • Are valid and cost-effective screening instruments available?
  • Are the adverse effects (if any) of the screening tests acceptable to social workers and older adult clients?

A number of standardized self-report rating scales for assessing the presence and severity of depressive symptoms include the Center for Epidemiological Studies-Depression Scale (CESD), Geriatric Depression Scale (GDS), Zung Self-Rating Depression Scale, Beck Depression Inventory (BDI-II), the Patient Health Questionnaire-9 (PHQ-9), and clinician-interview instruments, including the Hamilton Rating Scale for Depression (HAM-D), the Montgomery Asberg Depression Rating Scale (MADRS) and the Cornell Scale for Depression in Dementia (CSDD). All of these measures are frequently used in long-term care settings (see citation and download information in Table 1 in this chapter's resource document). Older adults are not averse to screening for depression, outside of the time and effort required to complete a short interview or form, if the need for the screening is explained clearly and the screening is conducted in an empathetic manner (Gellis, 2009; Gellis & Kenaley, 2008: Gellis & Taguchi, 2003).

• For DSM diagnosis:
  • Structured Clinical Interview for DSM-5 (SCID)
  • Mini-International Neuropsychiatric Interview (MINI) is available in several languages. Register and download the instrument free at: https://www.medical-outcomes.com/indexSSL.htm.
• Steps in screening:
  • Obtain the person’s agreement to be screened.
  • Explain the purpose for the screening.
  • Administer and score the screening tool per the instructions.
  • If the screen is positive, make initial treatment referrals for further diagnostic assessment to the older person’s primary care physician for possible psychotherapy and antidepressant medication.
• The social worker is in a unique position to:
  • Identify resources if financial barriers exist.
  • Address stigma through psychoeducation.
  • Encourage client follow-through with the referral.

Evidence-Based Treatment

Pharmacological Interventions

• Antidepressants are widely used and are safe and effective for the treatment of moderate to severe depression in older adults. All antidepressants are equally effective, though the most widely studied are tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs). Medically-ill older adults have fewer adverse effects with SSRIs, which has led them to be more widely prescribed in primary care settings.
• As older adults are prescribed more medications for other medical diseases, the likelihood of self-medication, multiple drug use, drug interactions, and unpleasant side effects increases.

Based on several literature reviews of pharmacologic treatment for late-life depression, antidepressants are reported as a safe and first-line treatment for depressed older adults (Barkin, Schwer, & Barkin, 2000; Mamdani, Parikh, Austin, & Upshur, 2000; Chelmali, Chahine, & Fricchione, 2009; Salzman, Wong, & Wright, 2002; Solai, Mulsant, & Pollock, 2001). Almost all antidepressant medications are equally effective for treating major depression (Blazer, Hybel, Simensick, & Harbin, 2000; Salzman et al., 2002).

During the past two decades, over 30 randomized placebo controlled clinical trials as well as many comparative trials (Das Gupta, 1998; Salzman et al., 2002) have been conducted that have documented the efficacy and safety of tricyclic antidepressant (TCA) and selective serotonin reuptake inhibitor(SSRI)antidepressant medications for older adults with depression. Dolder, Nelson, and Stump (2010) conducted a review of 14 studies examining the efficacy and safety of two more recently developed antidepressants, escitalopram, an SSRI and duloxetine, a serotonin-norephinephrine reuptake inhibitor (SNRI). In contrast with those who received escitalopram, duloxetine-treated patients experienced improvement in their depressive symptoms. Both medications were generally well-tolerated; however the adverse side effects experienced included constipation and dry mouth, two pharmacological side effects common in older adults. Naturalistic studies have shown that medically ill older adults have more adverse effects to TCAs than to SSRIs (Cole, Elie, McCusker, Bellavance, & Mansour, 2001; Landreville, Landry, Baillargeon, Guerette, & Matteau, 2001), and the use of SSRIs in primary care has become more common (Crystal, Sambamoorthi, Walkup, & Akincigil, 2003).

As older adults are prescribed medications for mental health conditions and comorbid illnesses, the likelihood of self-medication, multiple drug use, drug-drug interactions, and unpleasant side effects increases. Common side effects of SSRIs include nausea, constipation/diarrhea, weight changes, sexual dysfunction, gastrointestinal bleeding, dry mouth, and hyponatremia (Dolder, Nelson, and Stump, 2010; Chemali et al., 2009). The antidepressant dose for older adult patients is “generally one-third to one-half of that recommended for a younger adult patient because of anticipated effects of aging on the pharmacodynamic effects of antidepressants and on pharmacokinetic parameters including drug distribution, metabolism, and elimination” (Ellison Kyomen, & Harper, 2012, p. 2009). Non-adherence to medication, especially antidepressants by older adults with major depression, is a major concern in treatment management (Grenard et al., 2011). In fact, between 24% and 28% of older adults are non-adherent in taking their medications (Keaton et al., 2009). For older patients, initial partial response of antidepressants may take up to 6 to 8 weeks, although subjective sense of improvement earlier in treatment may occur and suggests the likelihood of continued benefits (Ellison et al., 2009). 

Biological Interventions

During the past decade several advances have been made in the use of biological treatment modalities for late-life depression, especially for the severely depressed elder. In a review of 22 studies (van Schaik et al., 2012), including three randomized clinical trials, continuation or maintenance electroconvulsive therapy (ECT) proved to be efficacious, safe, and well-tolerated by clients age 55 years or older. Considering the side effects of ECT, high-dose right side unilateral (RUL) electrode placement brief pulse ECT results in milder cognitive side-effects, yet has equal efficacy compared with bilateral electrode placement ECT, and greater efficacy compared with lower doses of RUL ECT (Alexopoulos & Kelly, 2009). Approved by the U.S. Food and Drug Administration in 2005, vagus nerve stimulation plus treatment as usual has shown efficacy in treating resistant depression when compared with treatment as usual (Alexopoulos & Kelly, 2009). Another new and efficacious advancement is the use of deep brain stimulation, which stimulates portions of the basal ganglia resulting in reduction of symptoms or remission of depression. These advancements have shown efficacy for elders with persistent and major depressive symptoms and the possibility for increasing their quality of life and functionality. 

Psychosocial Interventions

• Late-life depression is pervasive, debilitating, and intimately linked with the presence and development of medical disorders. Patients with depression go undetected or untreated despite the patient’s ongoing involvement with a primary care clinician.
• Older adults often prefer to receive treatment for depression, along with care for medical conditions, in primary care settings.
• Psychosocial interventions have been demonstrated to be effective among older adults, particularly those who reject medication because of unpleasant side effects or who are coping with low social support or stressful situations.
• Psychosocial interventions alone are effective with older populations including minorities. Cognitive therapies, including Problem-solving Therapy, are particularly promising among older men and women of diverse ethnic backgrounds.

The majority of primary care patients prefer counseling over medication, which should be kept in mind since patient attitudes and preference affects acceptance of and adherence to the prescribed treatment for depression. Late-life depression is pervasive and has debilitating psychological and medical effects and costs (Ellison et al., 2012) and is likely to go undetected and untreated (Brown, Lapane, & Luisi, 2002; Duberstein, 1995; Teresi, Abrams, Holmes, Ramirez, & Eimicke, 2001). More than one-third of suicide victims have at least one prior suicide attempt, which increases the number of attempts and completed suicides (Rihmer & Gonda, 2011). Elders who attempt suicide are often more frail, more isolated, more likely to have a plan, and determined to complete the suicidal attempt compared with younger suicidal individuals (Administration on Aging, 2012). Elders are more serious in their attempts, with firearms being the most commons means to commit suicide (67%), followed by poisoning (14%), and suffocation (12%) (Administration on Aging, 2012). The lethality of late-life suicide suggests that suicide prevention and interventions must be aggressive (Administration on Aging, 2012). Collaborative care models in primary care (e.g., IMPACT) have demonstrated greater improvement in depression symptoms and reduced suicidal ideation as compared with primary care physician treatment alone (Katon et al., 2010). A randomized clinical trial (Gallo, 2013) examining the efficacy of another suicidal intervention, PROSPECT– Prevention of Suicide In Primary Care Elderly: Collaborative Trial, found that patients with major depression who received the intervention were 24% less likely to die than were the patients with depression who received usual care treatment, indicating that a prevention model is effective in reducing suicidality in elders. The Administration on Aging (2012) suggests the suicide prevention guidelines listed in this chapter's resource document.

Manualized depression interventions that have been modified for older adults and have met evidence-based guidelines include cognitive-behavioral therapy (CBT), problem-solving therapy (PST), behavioral therapy, cognitive bibliotherapy, brief psychodynamic therapy, and life review therapy (Dickens et al., 2013). Evidence-based therapies such as CBT, PST, and interpersonal therapy (IPT) are effective intervention alternatives or adjuncts to medication treatment (Dickens et al., 2013; Gath & Mynors-Wallis, 1997; Gellis et al., 2007; Gellis et al., 2008; Gellis & Bruce, 2010; Hegel, Barrett, Cornell, & Oxman, 2002; Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012; Jacobson & Hollon, 1996; Pen, Huan, Chen, & Lu, 2009; DeRubeis, Gelfand, Tang, & Simons, 1999; Schulberg, Pilkonis, & Houck, 1998). Psychosocial interventions have been demonstrated to be effective among older adults, particularly the 24% to 28% who are non-adherent in taking their medication because of unpleasant side effects or who are coping with low social support or stressful situations (Choi & Morrow-Howell, 2007; Gellis, 2006; Gellis et al., 2012; Keaton et al., 2009).

There is evidence that psychosocial interventions alone are effective with older populations, including minorities (Coulehan, Schulberg, Block, Madonia, & Rodriguez, 1997; Mossey, Knott, Higgins, & Talerico, 1996; Munoz et al., 1995). Cognitive therapies, including PST, are particularly promising (Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012; McCusker, Cole, Keller, Bellavance, & Berard, 1998; Nezu, 2004; Robinson et al., 1995) among older men and women of diverse ethnic backgrounds (Gil et al., 1996). Patient attitudes and preference for treatment type has been shown to affect acceptance of and adherence to the prescribed depression treatment (Schulberg, Magruder, & deGruy, 1996), and the majority of primary care patients prefer counseling over medication (Brody, Khaliq, & Thompson, 1997; Landreville et al., 2001).

Literature reviews on the effect of CBT on late-life depression noted that CBT was at least as or more efficacious than pharmacotherapy and other forms of psychotherapy such as IPT, brief insight-oriented therapy, PST, and reminiscence therapy (Areán & Cook, 2002; Cuijpers, van Straten, & Smit, 2006; Laidlaw, 2001; Pinquart & Soerensen, 2001; Zalaquett & Stens, 2006). Hofmann and colleagues’ 2012 review of a representative sample of 106 recent meta-analyses revealed that CBT was more effective than waiting list control groups, but equally effective in comparison to reminiscence therapy, psychodynamic therapy, and interpersonal therapy. Considering long-term effects of CBT for elders with late-life depression, one meta-analysis revealed that treatment gains of CBT were maintained at the 11-month follow-up. However, overall, the meta-analyses indicated minimal long-term effect and the interactions of effects of CBT with antidepressant therapy (Hofmann et al., 2012), contradicting previous studies (Areán, Gum, & McCulloch, 2003). The later study’s sample was limited to low income elders, though, a factor that may have contributed to more successful outcomes. Factors that contribute to success of CBT therapy in reducing or ameliorating late-life depression include the elder’s ability to be open to new experiences, be less negatively affected by past stressors, be accountable for stressful life situations, and be open to seek emotional support when symptomatic (Marquett et al., 2013).

In a study of older low-income primary care patients with MDD, Spanish-speaking and English-speaking patients responded equally well to CBT alone versus case management (Miranda, Azocar, & Organista, 2003). Moreover, CBT and supplemental case management were associated with greater improvement in symptoms and functioning than CBT alone for Spanish speakers, but CBT was less effective for those whose first-language was English. Even so, a dearth of studies exists to inform social workers about the use of CBT and associated strategies for successful implementation of CBT among diverse populations, especially older gay populations. 

Problem-solving Therapy (PST)

• PST has been found to be effective in frail, homebound, medically-ill individuals, and a short (6-week) course of treatment is as effective as medication in individuals with major and minor depression.

PST interventions for depression by non-medical mental health practitioners have demonstrated effectiveness for homebound, frail, medically-ill populations (Gellis & Bruce, 2010; Gellis, Kenaley, & Ten Have, 2014; Gellis, et al., 2007; Gellis et al., 2012; Mynors-Wallis, Gath, Davies, Gray, & Barbour, 1997). Adjunct written educational materials for patients and family members have been shown to improve medication adherence and clinical outcomes (Robinson et al., 1997). Some studies have found that six sessions of PST are as effective as pharmacotherapy among ambulatory primary care patients with minor and major depression (Hegel et al., 2002; Mynors-Wallis, Gath, Lloyd-Thomas, & Tomlinson, 1995). 

Cognitive-behavioral Therapy (CBT)

• CBT (either individual or group) is at least as or more efficacious than pharmacotherapy and other forms of psychotherapy such as IPT, brief insight-oriented therapy, PST, and reminiscence therapy.
• Combined case management and CBT may have more efficacy than CBT alone for low-income and/or certain minority group member. 

Interpersonal Therapy (IPT) 

• IPT, another evidence-based intervention for late-life depression, focuses on relationships and conflicts with family and friends. Its purpose is to improve communication in those relationships, and develop or enhance the social support network.

IPT is another evidence-based intervention for late-life depression that focuses on the depressed person’s relationships and conflicts with family and friends (Hinrichsen, 1999). The overall purpose is to improve communication in those relationships and to develop or enhance the social support network of the identified depressed patient (Weissman & Markowitz, 1994). Several meta-analytic reviews noted findings of the efficacy of IPT for depression (de Melo, de Jesus, Bacaltchuk, Verdeli, & Neugebauer, 2005; Parker, Parker, Brotchie, & Stuart, 2006; Thase et al., 1997; Weston & Morrison, 2001).

Other Therapies and Interventions

• Adjunct written educational materials for clients and family members improve medication adherence and clinical outcomes.
• Treatment protocols for late-life depression are typically time-limited (6-20 sessions) psychotherapeutic interventions.
• The goal of brief interventions is to treat the problem, specifically, changing the behavior of individuals who are experiencing mental health problems in later life. These psychosocial interventions include assessment and direct feedback, contracting and goal setting, cognitive and behavioral techniques, and the use of educational and other written materials.
• There is unfortunately less available evidence on culturally appropriate mental health treatments for older adults.

Educational materials written for patients and family members have been shown to improve medication adherence and clinical outcomes (Robinson et al., 1997). Interventions for depression generally range from 6 to 20 sessions, each lasting about an hour (Gellis et al., 2007; Hegel et al., 2002; Nezu, 2004; Nezu & Nezu, 2001). Review the list of interventions for approaching late-life depression in this chapter's resource document.

To address individual and geographic barriers and reduce health costs, telehealth applications (defined as remote patient monitoring, internet, audio, and video technologies) to provide medical and mental health services have been used for the past five decades (van den Berg, Schumann, Kraft, & Hoffmann, 2012). Depression treatment has been shown to be effective when integrated with telehealth technology among depressed older adults with comorbid diseases (Gellis & Kang-Yi, 2012; van den Berg et al., 2012). A recent study examining the collaboration of CBT and telehealth revealed favorable findings in decreasing insomnia and reducing depression (Lichstein, 2013). However, further investigation with a more robust design is warranted to confirm the effectiveness of CBT with telehealth in medically-ill elders. A recent randomized trial of the “Tele-HEART” program providing remote patient monitoring of cardiac disease symptoms and integrated depression care found a 50% reduction in depression symptoms over a 3-month period and cost reductions in emergency department use over a 12-month period (Gellis et al., 2012).

Past research examined the use of internet and telephone therapy to provide depression treatment with positive outcomes (Speck et al., 2008). Since telephone therapy is generally not covered by reimbursement models, cost-benefits must be taken into consideration. Kiosses and colleagues (2010) examined PATH depression intervention compared with usual care for cognitively-impaired depressed older adults and found that depression significantly decreased over 12 weeks compared with usual care. In another randomized control trial with 138 older adults aged 50 years, participants received either problem solving treatment and behavioral activation (PEARLS) or usual care with reported improvements in depressive symptomatology for the intervention (Ciechanowski et al., 2004). The Healthy IDEAS study, examining the impact of an intervention for depression delivered by case managers in community-based agencies to 94 high-risk, diverse older adults, found that, at 6 months, participants significantly improved their knowledge of how to obtain help for their depression and reported increased activity and reduced pain (Quijano et al., 2007).

While life-review therapy has been shown to be efficacious in treating elders with depression, the use of new media and e-mental health has further advanced life-review therapy. Preschla and colleagues (2014) conducted a six week life-review therapy in a face-to-face setting with touch screen computer supplements from the e-mental health Butler system, consisting of exercise instructions (mindfulness, relaxation, and guided exercises) and autobiographical retrieval practice to assist positive valuated life episodes. The study found that this innovative intervention decreased depressive symptoms, and increased self-esteem and sense of well-being (Preschla et al., 2014). 

Cost of Depression

The detrimental effects of late-life depression both for individuals and society include enormous costs due to use of health care services and an increased need for nursing care (Lavretsky and Kumar, 2002; Lyness et al., 2009; Blazer, 2003; Beekman et al., 1997; Luppa et al., 2007). In fact, the cost incurred by those who are depressed is significant with the total ambulatory and inpatient costs for depressed older adults being 47% to 51% higher compared with their counterparts without depression after adjusting for chronic medical illness (Katon, 2003). Average six-month total costs were $1,045 to $1,700 higher for the depressed elders compared with the non-depressed elders (Katon, 2003). In a randomized control study, Luppa et al. (2010) found elders with depression had higher pharmaceutical costs, medical supplies costs, and home care costs compared with elders without depression. Additionally, the study found the annual direct costs of elders with depressive symptomatology exceeded the total direct costs of non-depressed elders. Due to the decrease in functionality and co-occurring medical illnesses, depression in late-life is associated with use of health services (Beekman, Deeg, Braam, Smit, & van Tilburg, 1997; Saravay, et al., 1996) and health care costs (Callahan, et al., 1997; Simon et al., 1995; Unützer et al., 1997). It also delays or inhibits physical recovery (Covinsky, Fortinsky, Palmer, Kresvic, & Landefeld, 1997; Katz, 1996). 

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Document Date: September 9, 2009

Stanley G. McCracken, PhD, University of Chicago
Zvi D. Gellis, PhD, University of Pennsylvania.

Schizophrenia in Older Adults Literature Review

This review includes a brief discussion of psychotic symptoms in older adults (psychotic symptoms in individuals with dementia are discussed in more detail in the review on dementia), a review of the literature on classification and diagnosis, course and progression of the illness, cognitive impairment and functioning, and treatment (both pharmacological and psychosocial). Since Kraepelin first described dementia praecox, hebephrenia, and paranoia (1919, cited in Harvey, 2005), there have been controversies about nearly every aspect of schizophrenia-like disorders in elderly people. There are controversies about the classification of schizophrenia and other psychotic conditions that first appear after the age of 40 or 45, about the course and progression of the illness in individuals with onset prior to 40, and about the treatment of these disorders after age 60. The confusion arises in part because study findings may differ greatly depending on the population from which the sample was selected (e.g., community-dwelling or institutionalized older adults), whether subjects with comorbid disorders (e.g., dementia and substance abuse) were included in the sample, the age range of subjects included in the study, and the age at which psychotic symptoms first appeared (e.g., before 40, 40-60, after 60, or all three groups). Additionally, diagnostic nomenclature and definitions have changed considerably over time in different diagnostic manuals. For example, in 1980, the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III, American Psychiatric Association [APA], 1980) prohibited a diagnosis of schizophrenia in an individual whose symptoms arose after the age of 45, and until 1992, the World Health Organization’s, International Classification of Diseases (ICD) included the diagnosis “Late Paraphrenia” that was applied to many individuals who developed schizophrenia-like symptoms late in life (World Health Organization [WHO], 1992). For purposes of the review and in accordance with recommendations of the International Late-Onset Schizophrenia Group, early onset schizophrenia (EOS) will refer to conditions that appear prior to age 40, late onset schizophrenia (LOS) to conditions that appear from 40 to 60, and very late onset schizophrenia (or schizophrenia-like psychosis) to conditions that appear after 60 (Howard, Rabins, Seeman, Jeste, & the International Late Onset Schizophrenia Group, 2000). Many of the studies looking at these three groups have used ages 45 and 65 as the dividing lines between EOS and LOS, and LOS and VLOS; these differences are noted below as needed.

Methods

An electronic search was conducted using MEDLINE, PsycINFO, Social Work Abstracts, Cochrane, DARE, PubMed, Google Scholar, and Ageline. The following search terms were grouped and used in the electronic search: (elderly, older adult, aged, geri*, gero*, senior, late onset, very late onset) AND (schizophrenia, psychosis, psychotic disorder, paraphrenia, paranoia) NOT (dement*, alzheimer, deliri*, bipolar, manic, mania, depress*, mood disorder) NOT (child*, adolesc*, youth). In addition, bibliographies of reviews and of two recent books on schizophrenia in late life (Cohen, 2003; Harvey, 2005) also were searched to identify additional relevant papers. The search focused on a variety of different studies published in the last 10 years and included systematic reviews, meta-analyses, other reviews of the literature, experimental and quasi-experimental designs. In some areas, we included descriptive studies and case reports. Initial review of papers identified in the electronic searches focused on the title of the papers and eliminated a very large number of studies of psychotic symptoms in the context of a variety of different medical conditions. The initial plan was to focus only on studies with samples of adults sixty or over. However, since most of the studies examining psychosocial interventions typically included both middle-aged and older adults, studies in this area are included if the response of older adults was reported separately or if there was no difference in response among the different age groups.

Epidemiology of Psychotic Symptoms in Older Adults

Psychotic symptoms in the elderly are more often associated with medical conditions, dementia, and other organic changes than with other psychiatric disorders. The prevalence of psychotic disorders, specifically schizophrenia and schizophreniform disorder, is low among adults over 65. Investigators in the Epidemiologic Catchment Area study (ECA), which examined rates of mental disorders in samples of community-dwelling adults 18 and over at five sites throughout the U.S., placed the prevalence for these disorders in adults 65 and over at 0.2% for 1 year and at 0.3% for lifetime (Keith, Regier, & Rae, 1991). The Surgeon General’s report on mental health placed the 1-year prevalence rate at 0.6% in this age group (U.S. Department of Health and Human Services, 1999). This is about half the rate for all adults 18 and over, and a fraction of the rate of cognitive impairment, including organic psychoses, which ranges from 16.8% to 23% (Keith et al., 1991; Myers, Weissman, & Tischler, 1984). However, when samples are taken from other sites, the rate of psychotic symptoms can rise significantly. In general, the prevalence of psychotic disorders among elderly ranges from 0.2% to 4.75% in community samples, and from 8% to 10% in geropsychiatry units and nursing homes (Zayas & Grossberg, 1998). These figures do not reflect the prevalence of psychotic symptoms in individuals with mood disorders or dementia. While the prevalence of psychotic disorders is relatively low among community-dwelling older adults, the presence of psychotic symptoms is much higher. Ostling and Skoog (2002) found that 10.1% of their sample of community-dwelling non-demented adults over 85 experienced psychotic symptoms, most of which were associated with depression, disability in daily life, and visual deficits. The rate of psychotic symptoms among individuals with dementias can be over 60% (Zayas & Grossberg, 1998). In addition to association with psychotic disorders, mood disorders and dementias, psychotic symptoms can be produced by a number of different medical conditions and their treatment, e.g., delirium; sensory impairments; drugs and medications; medical and surgical procedures; and neurological, infectious, metabolic, and endocrine disorders (Desai & Grossberg, 2003). Even in a specialty geropsychiatry clinic, the majority of older adults presenting with psychotic symptoms are diagnosed with dementia, major depression, delirium, and organic psychoses related to medical conditions and treatment (Holroyd and Laurie, 1999).

Diagnosing Schizophrenia in Older Adults

When an older adult experiences psychotic symptoms it is important to perform a differential diagnosis to identify the reason for these symptoms, and in particular, to rule out/identify medical and pharmacological precipitants of these symptoms. Desai and Grossberg (2003) presented a decision tree for diagnosing psychotic symptoms in older adults. A number of the steps in their decision tree involve medical determinations, which of course means that a physician must be involved in determining the etiology of the psychotic symptoms. However, this is not markedly different from making decisions about psychotic symptoms in a younger person, in that medical and drug-related causes always must be ruled out before one makes a diagnosis of a psychiatric disorder. The difference is that with older adults, there is a higher likelihood that the symptoms are caused by delirium, dementia, and the presence or treatment of other medical conditions. Much of the information needed to make a determination about the etiology of psychotic symptoms can be gathered by a social worker and shared with the physician, such as information about the presence and change in functioning, losses, and other stressors, quality of life, living situation, symptoms, personal and family history, the use of drugs and medications, and even some information about the individual’s medical history. The first step in the decision tree is to take a thorough history to determine whether the individual has experienced psychotic or other psychiatric symptoms, has had a current or prior psychiatric diagnosis or treatment, or has a family history of psychiatric problems (e.g., psychotic or mood disorders, suicide, dementia). This history should be taken from both the individual and one other person who is quite familiar with him or her. The initial purpose of this assessment is to determine the nature of the symptoms, when they started, and their relationship with any stressors, along with the degree of impairment and distress that the symptoms are causing. Cognitive impairment is associated with schizophrenia; however, the progression of cognitive decline in an aging individual with schizophrenia parallels the decline seen in normal aging (an issue that will be addressed in more detail later). Significant cognitive decline should raise the index of suspicion about the presence of dementia, which may be comorbid with another psychiatric disorder. Similarly, recent changes in orientation, awareness of the environment, or ability to attend should alert one to the possibility of delirium. Finally, the social worker should gather information on the use of prescribed medications; alcohol and other non-medical drugs, over-the-counter drugs, and herbal preparations. This information is provided to the physician who will review the client’s medical condition, including considering the possibility of structural brain lesion or stroke (Desai & Grossberg, 2003). After secondary causes have been ruled out or identified, psychotic symptoms related to a previous psychiatric diagnosis should be considered. In cases where there is no prior history of psychiatric disorders, the individual may be experiencing a late-life psychotic disorder or late-life mood disorder with psychotic features.

Older Adults with Early Onset Schizophrenia

There are two conflicting views of EOS. The first is that schizophrenia has a course that is chronic and, if not deteriorating, is stable and usually nonremitting (Kraepelin, 1919, cited in Harvey, 2005). The second is the idea that positive symptoms (such as hallucinations and delusions) “burn out” over time and are replaced by increasing negative symptoms (such as reduced affective experience and expression and reduced verbal output), (Harvey, 2005). This section reviews both the issue of recovery from schizophrenia across time and changes in the pattern of symptoms and functional impairment over time. Changes across time have been studied in both long- and short-term longitudinal studies and in cross-sectional studies comparing older with younger clients with schizophrenia and comparing older adults with schizophrenia with older adults with no mental illness or with other mental illness, including dementia. These studies have sampled individuals living in the community and individuals living in institutions, such as long-term care facilities and hospitals. Taken together, the research findings indicate a wide variety of outcomes among individuals with EOS, including a substantial proportion of individuals who recover over time, and a wide variety of symptom patterns among individuals with EOS, much of which depends on whether the participants were from community or institutional settings.

Long-term Recovery

Harding (2003) reviewed 10 long-term (>20 years) longitudinal studies looking at recovery from schizophrenia over time. The studies conducted in Europe and Japan consisted primarily of individuals living in urban areas, whereas the U.S. studies sampled individuals living in rural areas. A number of these studies included individuals who were older adults at the time of follow-up investigations, and most studies examined both clinical improvement and social or functional improvement. Finally, the subjects in most of the studies had the onset of symptoms during the 1930s, 40s, and 50s—prior to the development of antipsychotic medications. Thus it is likely that few of the subjects would have received medication treatment for the initial episode of their illness, and none would have received treatment with atypical antipsychotic medications. The criteria and methods used to identify individuals with schizophrenia varied widely among the studies, with some studies using broader and others narrower definitions of schizophrenia. From the methods reported, the majority of the subjects in the studies would likely meet DSM-IV criteria for schizophrenia. Global ratings of recovery were made for participants in the studies. “Recovered = having no further symptoms, no use of psychotropic drugs, living independently in the community, working, and relating well to others, with no behaviors that are considered to be odd or unusual; significantly improved = all of the above but one domain of functioning,” (Harding, 2003, p. 22). The rate of recovery or significant improvement ranged from 46% to 84% for clinical recovery and from 21% to 77% for social recovery; thus, there is considerable variability in the rate of recovery, particularly for social/functional recovery. Findings from these 10 longitudinal studies challenge the notion that schizophrenia has a chronic, deteriorating course with little hope of recovery. Clearly, these findings contradict the Kraepelinian notion of a chronic, unremitting course—some people do recover over time. However, data from cross-sectional and more recent short-term follow-up studies indicate that a number of older adults with schizophrenia do have substantial levels of impairment.

Symptoms in Late Life

In contrast to the global assessment of the presence and severity of various symptoms characteristic of the long-term longitudinal studies reviewed by Harding, more recent cross-sectional and short-term follow-up studies have conducted formal assessments of symptom severity and functioning using standardized instruments. The classical view of schizophrenia is that the severity of psychotic symptoms in later life is much reduced (referred to as symptom burn-out) and that these symptoms are replaced by greater negative symptoms. Several factors should be considered when examining the literature in this area. First, does the sample include only older adults or both middle-aged and older adults? Second, was the sample drawn from institutionalized individuals, community-dwelling individuals, or both? Third, does the sample include individuals with co-morbid conditions, such as substance abuse problems, medical conditions, or dementia? Finally, is the study biased by attrition due to the high mortality rate, including from suicide, of individuals with schizophrenia. That is, are people with certain symptom patterns more likely to die early than those with other kinds of symptoms.

Several cross-sectional studies have examined positive symptoms (e.g., delusions, hallucinations, paranoia) and negative symptoms (e.g., anhedonia, blunted affect, and avolition) in older adults. Davidson and colleagues (1995) examined the severity of positive and negative symptoms in adults ranging in age from 25 to 95, all of whom were chronically hospitalized at the time of the study. Subjects were divided into 10-year age groups (e.g., 25-34, 35-44,…85 and over). Although they found a linear decrease in severity of positive symptoms from ages 25 to 95, individuals over 65 continued to experience significant psychotic symptoms. The researchers also found an age-related increase in severity of negative symptoms and cognitive impairment, and a positive correlation between negative symptoms and cognitive impairment (Davidson et al., 1995). Harvey and associates (1998) investigated older adults (>65) with schizophrenia who either were chronically hospitalized, were living in nursing homes, or were acutely admitted to a gero-psychiatry unit of the hospital. Individuals who were acutely admitted had been living in the community, either with relatives or in community residences (both with and without professional staff onsite). They found that each group could be differentiated from the other two. Nursing home residents were older, had the least severe positive symptoms, and had the most severe adaptive deficits. Chronically hospitalized and acutely admitted individuals were similar in severity of positive symptoms. Compared to chronically hospitalized and nursing home residents, individuals acutely admitted from the community had better cognitive functioning, better adaptive functioning, and less severe negative symptoms. Cognitive impairment was a stronger predictor of adaptive functioning than either positive or negative symptoms, and this was true across all sites and all levels of severity of illness (Harvey et al., 1998). Both the Davidson and Harvey results demonstrate that the positive symptoms of schizophrenia continue throughout life, at least among individuals with chronic symptoms or who require hospitalization due to exacerbation of symptoms.

Although the above cross-sectional studies provide important data, many individuals with schizophrenia do not have numerous hospitalizations in later life (Harvey, 2005). Jeste and colleagues (2003) have conducted a number of studies of community-dwelling adults (40-85 y.o.) with schizophrenia, including a study comparing these individuals with healthy individuals of the same age (Jeste et al., 2003). Adults with schizophrenia were more impaired than the healthy controls on a number of measures, such as life skills, quality of well-being, and cognitive functioning. Adults with schizophrenia experienced an age-related decrease in severity of psychotic symptoms but no age-related decline on quality of well-being or everyday functioning (Jeste et al., 2003). The same researchers compared two community-dwelling groups with schizophrenia: middle-aged and older adults (Eyler-Zorrilla et al., 1995). They found that older adults experienced less severe symptoms overall and were on lower doses of antipsychotic medications than were middle-aged individuals. Depending on which measure was used, the older group experienced less prominent (or equivalent) positive symptoms and more prominent (or equivalent) negative symptoms, and they were more cognitively impaired. This increased global cognitive impairment, however, reflected a normal degree of decline since the degree of change was equivalent to that of a healthy comparison group. Short-term longitudinal data of individuals from their 40s to their 90s, living in a variety of settings (community, nursing home, and hospital), indicate no evidence of improvement in symptoms over periods of 1 to 6 years (e.g., Harvey et al., 2003; Heaton al., 2001). Taken together these data suggest that some older adults with schizophrenia have significant levels of positive symptoms that are stable over time (Harvey, 2005).

In contrast to the number of studies that have examined positive symptoms among older adults, few have examined thought disorder in detail. Bowie and colleagues (2005) divided thought disorder into two components: positive thought disorder (sometimes called disconnection or disorganization syndrome), which involves abnormalities in the production of language such as derailment and tangentiality, and negative thought disorder, which denotes a reduction in the amount of overall amount or information in speech including poverty of speech and poverty of content of speech. They observed 220 middle-aged and older adults (age range 49-97, mean 74.9) with schizophrenia an average of 2.3 years (range 1-6 years). They evaluated cognitive impairment (Mini-Mental State Examination, MMSE, Folstein, Folstein, & McHugh, 1975), disconnection, and verbal productivity (negative thought disorder). Among the study participants, verbal underproductivity worsened over time, particularly among adults 75 and older, but disconnection remained stable. Further, worsening verbal underproductivity was associated with worsening of cognitive impairment as measured by the MMSE (Bowie et al., 2005). One of the implications of the study findings was that some of the observed age-related decrease in positive symptoms may have occurred because some individuals were not reporting these symptoms because they just were not talking very much, about symptoms or anything else.

Cognitive Impairment

From the time of Kraepelin’s work, impaired cognitive functioning has been seen as a hallmark of schizophrenia, and numerous researchers have investigated longitudinal changes in cognitive functioning and its association with other symptoms. One of the key questions is whether the rate of cognitive impairment accelerates, reverses, or stays the same over time. The research findings in this area are controversial. Studies showing cognitive decline have mostly been conducted in individuals over 65 with a chronic course of institutionalization and currently living in hospitals or nursing homes. Studies showing less evidence of cognitive decline (i.e., no more than would be associated with benign aging) have typically included younger, community-dwelling individuals with no evidence of chronic institutional stays and a better lifetime course of the illness (Harvey, 2005; Kurtz, 2005). Deficits in social and adaptive functioning are most strongly associated with cognitive deficits, only weakly associated with negative symptoms, and not associated with positive symptoms; furthermore, functional deficits tend to be preceded by deficits in cognition (Friedman, Harvey, McGurk, White, & Parrella, 2002; Harvey, 2005). There are a number of limitations to this research. One of the most significant limitations is the dearth of longitudinal studies with specific measures of cognitive functioning or performance measures of adaptive functioning—particularly among community-dwelling older adults. Studies with measures testing specific areas of cognitive functioning are needed to identify the specific pattern of cognitive impairments seen among older adults, since the specific pattern of changes has implications for caregiving and even residential status (e.g., nursing home versus community). Performance measures of functioning are important because the validity of caregiver reports differs greatly between, for example, family caregivers and nursing home staff. Poor insight may reduce the validity of self-report of functioning. Furthermore, the likelihood of deterioration of functioning in a specific area is influenced by whether the individual has the opportunity to perform the activity. For example, individuals living in institutional settings are not allowed to cook their own meals, drive, or in many cases, manage their own funds.

One final note should be made about late-life changes in EOS. One should expect large cohort effects among this population. For example, each subsequent 10-year age cohort is more likely to have received antipsychotic medications early in the course of the illness (perhaps during the first episode), more likely to have been treated with atypical antipsychotic medications, less likely to have spent large portions of their lives in institutions, more likely to have received well-designed psychiatric rehabilitation services, and more likely to have used street drugs like marijuana, cocaine, and other illicit drugs. It is unclear what the effect of all this will be on symptoms, cognition, or functioning.

Late Onset Schizophrenia (LOS) and Very Late Onset Schizophrenia(-like Psychosis) (VLOS)

One of the most controversial issues in late-life schizophrenia is the existence of late onset schizophrenia (LOS). As noted earlier, one of the problems is that psychotic symptoms emerge in a variety of contexts in later life—they may be associated with mood disorders, dementia, medical disorders, or drug-related conditions, as well as schizophrenia. Research in this area is limited by the fact that, in the absence of treatment records, it is difficult to reliably determine the age of onset of symptoms of schizophrenia. Common unawareness of the illness as well as memory impairments make retrospective judgments about the timing of symptom onset suspect. This literature also is plagued by classification and terminology issues. The DSM-III prohibited a diagnosis of schizophrenia if the onset of symptoms was after age 45 and DSM-III-R provided a specifier to be used for onset after 44 (APA, 1980, 1987). The term paraphrenia was introduced by Kraepelin (1894, cited in Howard, 2001) and was re-introduced as late paraphrenia by Roth and Morrisey to describe individuals with an onset of schizophrenia after 55 or 60 (1952; Roth & Kay, 1998). The apparent syndromic coherence of paraphrenia (experiencing hallucinations and delusions in the absence of functional deterioration or disturbance of affective response), including predominance among women, and abnormal pre-morbid personality and social functioning led it to be included in the ninth edition of the International Classification of Diseases (ICD-9, WHO 1980) (Howard et al., 2000). However, neither ICD-10 nor DSM-IV or DSM-IV-TR provides a separate code for late onset schizophrenia (WHO, 1992; APA, 1994, 2000). Although neither ICD nor DSM distinguishes between EOS and LOS or VLOS, the debate about whether these are the same or different conditions is by no means settled (Almeida, Howard, Levy, & Anthony, 1995; Jeste, Blazer, & First, 2005; Mazeh, Zemisblani, Aizenber, & Borak, 2005).

There are several ways in which EOS differs from onset in later life. Later onset is characterized by greater prevalence of visual, tactile, and olfactory hallucinations; persecutory, partition (belief that people, animals, materials or radiation can pass through a structure that would normally constitute a barrier), reference, control, and grandiose ability delusions; and third-person, running commentary and accusatory or abusive auditory hallucinations. Later onset also is associated with a lower prevalence of formal thought disorder and affective flattening or blunting. Both formal thought disorder and negative symptoms are very rare in onset after 60 (Almeida et al. 1995; Howard, 2001; Howard et al., 2000; Palmer, McClure, & Jeste, 2001). Individuals with LOS and particularly VLOS appear to have a reduced prevalence of schizophrenia among family members, compared with individuals with EOS (Howard, 2001). Other risk factors for later onset schizophrenia include female gender, cognitive impairment, and possibly sensory impairment (Wynn, Owen, & Castle, 1999). While the lifetime incidence of schizophrenia is the same for men and women, onset during their 20s to mid-30s is predominant among men, whereas women have a second onset peak in their late 40s to mid-50s. The correspondence of this second peak with onset of menopause has led a number of authors to speculate about a potential role of estrogen as a protective factor against development of schizophrenia (Palmer et al., 2001). Although cognitive impairment is a risk factor for development of schizophrenia in late life, schizophrenia should not be viewed as a variant of dementia. Palmer and colleagues (2003) compared 1- and 2-year changes in cognitive functioning among adults with LOS (>45), EOS, Alzheimer’s disease with psychotic symptoms (AD), and normal subjects. They found that EOS, LOS, and normal subjects were comparable and had relatively stable cognitive functioning but that AD subjects had greater declines than either of the other groups, suggesting that there was no evidence of progressive deterioration among community-dwelling individuals with LOS (Palmer et al., 2003). One final comment on LOS and VLOS is the observation that people with onset later in life may respond to lower doses of antipsychotic medication than individuals with onset earlier in life (Wynn et al., 1999).

Treatment

Pharmacologic Treatment

Five reviews of antipsychotic medication treatment of schizophrenia in older adults have been published in the last 5 years. Neither of the two Cochrane reviews found sufficient evidence upon which to base treatment recommendations (Arunpongpaisal, Ahmed, Aqeel, & Paholpak, 2003; Marriott, Neil, & Waddington, 2006) (Level B). Van Citters and colleagues (Van Citters, Pratt, Bartels, & Jeste, 2005) examined both pharmacologic and nonpharmacologic (discussed later) treatments for older adults with schizophrenia. They reviewed five double-blind, randomized controlled trials (RCTs) plus a number of open-label RCTs, quasi-experimental studies, and large prospective single-agent trials. Taken together, these studies show that both typical and atypical antipsychotic drugs are effective in relieving symptoms of schizophrenia in older adults (Level B). Some studies found that atypical antipsychotic drugs were slightly more effective typical drugs at reducing positive, negative, and affective symptoms, and that they had reduced parkinsonism, extrapyramidal symptoms (EPS), and other side effects. Other studies did not find differences between atypical and typical antipsychotic drugs; and the reviewers noted methodological limitations in the studies that did find a difference between atypical and typical antipsychotic drugs. They also noted that all but 3 of the 14 studies they reviewed were funded by pharmaceutical companies and recommended that this support should be considered in evaluating the studies because of the potential for conflicts of interest (Van Citters et al., 2005).

There have been two reviews of atypical antipsychotic drugs in the elderly, including studies of individuals with dementia, as well as those with schizophrenia. Gareri and colleagues (2006) examined adverse effects of nine atypical antipsychotic medications, including a number that are not available in the U.S. They used the WHO definition of an adverse drug reaction as, “a harmful, non-intentional reaction caused by a drug at the commonly used doses for prophylaxis, diagnosis, and therapy” (p. 938). While they noted a reduction in EPS, compared with typical antipsychotic medications, they also noted increased plasma glucose levels in individuals with or without a history of diabetes, elevated triglycerides, and increased risk of death with some of the atypical antipsychotic drugs. The authors reported that antipsychotic drugs have value in treatment of psychotic symptoms in older adults, that doses needed to be individualized and slowly increased, that individual pharmacological characteristics need to be considered to avoid dangerous accumulation of medications and potentially harmful adverse affects, and that drug interactions must always be considered, particularly in individuals with co-morbid conditions (Gareri et al., 2006) (Level E). Jeste and associates (2005) also reviewed the literature on use of atypical antipsychotic drugs in older adults with dementia or schizophrenia. They reported that while trials involving older adults with schizophrenia have found that atypical antipsychotics are associated with improvements in psychopathology, it is not clear that there are differences in efficacy among the different medications (Jeste, Dolder, Nayak, & Salzman, 2005) (Level E). White and colleagues (2006) (Level C) did a naturalistic, retrospective comparison of typical and atypical antipsychotic drugs on chronically hospitalized older adults with schizophrenia. They found that both cognitive functioning and self-care skills declined over time and that there was no difference between the two categories of drugs in their ability to reverse this decline. Furthermore, atypical antipsychotic drugs produced no effect on the progressive worsening of negative symptoms among this group of hospitalized individuals (White et al., 2006). The Agency for Healthcare Research and Quality (AHRQ) released a report looking at the comparative safety of typical and atypical antipsychotic medications based on data gathered in British Columbia (Schneeweiss, Setoguchi, Brookhart, Dormuth, & Wang, 2007). Specifically the researchers compared the risk of death among older adults who filled prescriptions for these two classes of drugs. Since the study was based on prescriptions filled rather than diagnosis, individuals in the study had a range of disorders including dementia, delirium, mood disorders, psychotic disorders, and other psychiatric disorders. Additionally, medical co-morbidity was widespread. The authors found that 14.1% of older adults who took typical antipsychotic medications died, compared with 9.6% of those who took atypical antipsychotic medications (unadjusted mortality ratio: 1.47). The greatest mortality increase was associated with use of higher (>median) dosages and was during the first 40 days after beginning use. This suggests that among this mixed group of older adults, use of atypical antipsychotic medication was not associated with a higher mortality rate, compared with use of typical or conventional antipsychotic medication (Schneeweis et al., 2007).

Overall, this literature suggests the following.

1. Antipsychotic medication is effective in reducing psychotic symptoms in older adults with schizophrenia (Level A).
2. It is not clear whether any drug or category of drugs is any more effective than any other.
3. Adverse effects differ between the typical and atypical medications with typical medication having increased EPS (particularly tardive dyskinesia in older adults) and atypical medication having increased risk of elevated glucose and tri-glycerides; however, risk of death is not higher among users of atypical compared to typical antipsychotic medications.
4. Doses may need to be lower among older adults, particularly among individuals with later onset of the disorder, and should be increased gradually.
5. There is a need to individualize medication management of older adults due to differences in how drugs are metabolized and to the potential of concurrent medical conditions to cause or exacerbate harmful effects and the potential of drug interactions with medications used to treat these concurrent conditions.

Psychosocial Treatments

There are far fewer studies examining the effectiveness of non-pharmacologic treatments of schizophrenia in older adults compared to pharmacological treatments. Van Citters and colleagues (2005) found five studies: two RCTs (Level A), two quasi-experimental studies (Level B), and one noncontrolled prospective cohort study (Level C). These studies investigated three different manualized, psychosocial interventions developed for older adults with psychotic symptoms and disorders: a combined skills training and cognitive behavioral intervention (Cognitive Behavioral Social Skills Training, CBSST), a social skills training program (Functional Adaptation Skills Training, FAST), and a combined skills training and health management intervention for community-dwelling older adults with serious mental illnesses (ST+HM). These interventions were well tolerated by the participants; had low dropout rates; and were associated with positive outcomes, such as reductions in positive symptoms and depression, and improved social and community functioning, cognitive insight (insight about delusional beliefs), and independent living skills (Van Citters et al., 2005). In addition to those reported in the preceding review, three additional studies were located, including a follow-up of the CBSST studies; an intervention, based on FAST, developed for older Latinos with chronic psychosis; and a comparison of three approaches to work rehabilitation for middle-aged and older people with schizophrenia. Granholm and colleagues (2007) reported that the greater skill acquisition, self-reported performance of living skills in the community, but not the greater cognitive insight were maintained at a 12-month follow-up session of CBSST (Granholm et al., 2007). The FAST program was used as the basis for a group intervention targeting areas, such as public transportation, that had been identified as being problematic for middle-aged and older Latinos (Programa de Entrenamiento para Desarrollo de Aptitudes para Latinos, PEDAL). PEDAL was compared to a time-equivalent support group (SG) protocol in an RCT conducted at three psychiatric clinics specializing in care of Latinos. Individuals treated with PEDAL performed better at post-treatment and at 6- and 12-month follow-up examinations on measures of everyday living skills, but there was no change in psychopathology (Patterson et al., 2005). Twamley and colleagues (2005) compared data from three groups of middle-aged and older veterans with schizophrenia: participants in a VA Wellness and Vocational Enrichment Clinic (WAVE), participants in Department of Rehabilitation/Education Services (DOR), and participants in Individual Placement and Support (IPS). WAVE integrated vocational and psychiatric services and offered a variety of wellness programs in addition to psychiatric and vocational services. DOR was run on a traditional vocational rehabilitation model with determination of eligibility (which could take up to 60 days), followed by 3-5 weeks of employment preparation preceding job development. IPS was a train-place model that does not include prevocational classes prior to the job search but does provide time-unlimited follow-along support onsite. The authors found the following rates of paid or volunteer work among the groups: IPS, 81%; WAVE, 44%; and DOR, 29%. IPS performed significantly better than WAVE and DOR, but no difference was found between the latter two approaches (Twamley et al., 2005). Finally, Liberman (2003) reviewed a number of behavioral and cognitive behavioral interventions that had included elderly individuals with severe mental illnesses, including, though not always limited to, schizophrenia. He identified the following principles:

1. Biological and psychological interventions should be integrated, personally relevant goals and quality of life should be seen as more important than syndromal definitions of the disorder, and multimodal treatments should be provided to attain multidimensional improvements in the individual.
2. Older adults with schizophrenia can learn to control their symptoms and manage medications and learn and generalize social and independent living skills for community adaptation.
3. Environmental supports need to be “wrapped around” to ensure that the needs of older adults with schizophrenia are being met, because it is not unreasonable to expect that these persons will need to learn or relearn the full range of skills required to live autonomously in the community.
4. Older adults with treatment refractory psychotic symptoms appear to benefit from cognitive therapy.
5. Social learning and token economy procedures are effective for individuals with schizophrenia of all age groups.
6. Behavior therapy appears to protect against stress-related relapse when effective in promoting coping skills and may reduce the amount of medication necessary for symptom stabilization and relapse prevention (Liberman, 2003).

Summary: Take Home Points for Teaching

• Prevalence. The prevalence of schizophrenia among individuals over age 65 is lower than the prevalence among younger individuals. The prevalence of psychotic symptoms is much higher among older adults. However, psychotic symptoms are more often associated with medical conditions and treatment, delirium, dementia, and depression, than with psychotic disorders.
• Diagnosis. Diagnosing psychotic disorders in older adults requires a careful differential diagnosis in collaboration with a physician due to the need to rule out psychotic symptoms secondary to general medical conditions, medication and other drug use, delirium, and dementia.
• Early Onset Schizophrenia (EOS). There is considerable variability in the literature regarding the long-term outcome of early onset (<40) schizophrenia, much of this variability depends on the methodology (long-term vs. short-term follow-up, longitudinal vs. cross-sectional, global ratings of improvement or functioning vs. ratings of specific symptoms or patterns of functioning) and the population that is sampled (community-dwelling vs. institutionalized).
  • Recovery. There is evidence that a substantial proportion of individuals with EOS recover or are significantly improved over time. This is true both for clinical and social recovery.
  • Symptoms.
    • There is evidence that a number of individuals with schizophrenia continue to experience significant positive symptoms in later life and that severity of these symptoms either decreases or stays the same.
    • There is evidence that negative symptoms may increase in severity particularly among individuals living in hospitals or nursing homes; it is not clear that this is true of individuals living in the community.
    • Individuals with schizophrenia experience more cognitive impairment than individuals without schizophrenia but less than individuals with dementia. The rate of decline in cognitive functioning among individuals living in the community is similar to that found among individuals without schizophrenia, but the rate of cognitive decline among individuals living in institutions is more rapid. Cognitive impairment is a stronger predictor of adaptive functioning than either positive or negative symptoms.
• Late Onset Schizophrenia (LOS) and Very Late Onset Schizophrenia (or Schizophrenia-like Psychosis, VLOS). It is important to remember that, in the absence of accurate treatment records, it is difficult determining the exact age of onset of symptoms of schizophrenia. There has been considerable variability over the past several decades in the nomenclature and definitions used to describe the condition experienced by individuals who have an onset of schizophrenia symptoms after age 40 (LOS) or 60 (VLOS).
  • Symptoms. Individuals with onset in later life experience more visual, tactile, and olfactory hallucinations; persecutory, partition, reference, control, and grandiose ability delusions; and third-person, running commentary and accusatory or abusive auditory hallucinations than do those with EOS. They also experience a lower level of formal thought disorder and affective flattening or blunting. Formal thought disorder and negative symptoms are rare in VLOS.
  • Familial and Risk Factors. Individuals with LOS and VLOS appear to have a reduced prevalence of schizophrenia among family members, compared with individuals with EOS. Risk factors for later onset include female gender, cognitive impairment, and possibly sensory impairment.
  • Treatment. It has been reported that people with onset in later life may respond to lower doses of antipsychotic medication than individuals with earlier onset.
• Overview of Treatment Research.
  • Pharmacological Treatments.
    • Antipsychotic medication is effective in reducing psychotic symptoms in older adults with schizophrenia.
    • No any one drug or category of drugs (atypical or typical/conventional) appears to be any more effective than another.
    • Adverse effects differ between atypical and typical medications. Atypical medications have increased risk of elevated glucose and triglycerides; typical medications have increased risk of EPS (particularly tardive dyskinesia). Though a number of reports have noted elevated risk of death in individuals taking some atypical antipsychotic medications, there is evidence that the death rate is higher among individuals taking typical antipsychotic medications, particularly among those taking higher doses and in the first 40 days of treatment.
    • Doses may need to be lower, particularly among individuals with later onset of symptoms, and should be raised slowly. As in other psychotropic medications, the rule appears to be “start low and go slow.”
    • Medication management should be individualized with awareness of differences in metabolism, concurrent medical conditions, and the potential for drug interactions with other medications and with non-medical drug use, particularly alcohol.
  • Psychosocial Treatments.
    • There are relatively few RCTs of interventions addressing schizophrenia in older adults. Existing studies typically include both middle-aged and older adults.
    • Many of the recommendations about psychosocial treatments for older adults with schizophrenia are extrapolations from interventions designed for and evaluated in younger individuals. Most of the interventions studied in older adults are adapted from interventions initially developed for younger adults.
    • The available limited evidence supports the use of interventions based on cognitive behavioral therapy, social skills training, health management, behavior therapy, and individual placement and support approaches.
• Finally, the high probability of a pronounced cohort effect needs to be considered when describing, understanding, and providing services to older adults with psychotic disorders. Each successive cohort of older adults 1) will be more likely to have been treated with antipsychotic medication early in the course of their illness, regardless of date of onset; 2) will have spent relatively more time in the community and less time in institutions; 3) will be more likely to have been exposed to effective evidence-based psychosocial and psychiatric rehabilitation interventions, including community-based interventions of various kinds; and 4) will be more likely to have been exposed to (or still be using) a wide variety of non-medical drugs in addition to alcohol.

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Document Date: September 9, 2009

Zvi D. Gellis, PhD. University of Pennsylvania
Kim McClive-Reed, PhD, University at Albany
Stanley G. McCracken, PhD, University of Chicago

Depression in Older Adults With Dementia

This evidence-based review of the literature on depression disorders among older adults with dementia focuses on prevalence, clinical recognition, assessment, and treatment. A search of the empirical literature was undertaken to determine the extent of the problem and the effectiveness of various pharmacological and non-pharmacological treatments.

Dementia is a constellation of symptoms caused by diseases and disorders that affect the brain, including strokes, Alzheimer’s disease (AD), Parkinson’s disease (PD), and others. Dementia involves progressive loss of memory and other cognitive functions such as problem-solving and emotional control. The earliest diagnosable stage of dementia is referred to as mild cognitive impairment (MCI). As dementia progresses, abilities to independently perform instrumental and basic activities of daily living are generally impaired.

Worldwide, dementia is one of the most disabling health conditions. An estimated 24.3 million people had dementia in 2005, with 4.6 million new cases of dementia occurring annually. The number of people affected is expected to double every 20 years (Ferri et al., 2005). Alzheimer’s and other dementias ranked as the fourth leading cause of disease burden in adults age 60 and older worldwide, outranked only by heart disease and chronic obstructive pulmonary disease (World Health Organization, 2003). Generally, AD is believed to be the most common type of dementia, followed by vascular dementia (VaD), frontotemporal dementia (FTD), dementia associated with PD, and dementia with Lewy bodies (DLB).

Behavioral and psychological symptoms of dementia (BPSD), also known as neuropsychiatric symptoms of dementia, affect up to 95% of those with dementia during the course of the illness (Steinberg et al., 2006) and are frequently the first manifestation of its progress. According to classifications developed during the International Psychogeriatric Association Consensus Conference on the Behavioral Disturbances of Dementia (2002), BPSD fall into two clusters: (1) behavioral and (2) psychological. Behavioral symptoms are usually identified through observation of the patient, and include physical aggression, screaming, restlessness, agitation, wandering, culturally inappropriate behaviors, sexual disinhibition, hoarding, cursing, and shadowing. Psychological symptoms, primarily assessed through interviews with patients and caregivers, include depressive mood, anxiety, hallucinations, and delusions.

BPSD have important implications for the prognosis of dementia in older adults. BPSD reduce patients’ quality of life (Amore, Tagariello, Laterza & Savoia, 2007; Teng, Lu & Cummings, 2007), may accelerate cognitive and functional decline, and are associated with increased mortality (Fitzpatrick, Kuller, Lopez, Kawas, & Jagust, 2005; Potter & Steffens, 2007). Furthermore, these symptoms significantly increase caregiver burden and stress, and are associated with increased rates of depression in caregivers (Black & Almeida, 2004). They have also been found to increase the risk for institutionalization (Coehlo, Hooker & Bookman, 2007). Finally, management of BPSD has been estimated to account for approximately one-third of the total cost of dementia care (Beeri, Werner, Davidson & Noy, 2002).

The behavioral symptoms of dementia, which may be even more apparent and distressing to observers than the psychological symptoms, are generally more prevalent in moderate to severe dementia. However, psychological symptoms such as depression may cause greater distress to the patient, especially during the earlier stages of dementia, as sufferers develop insight regarding the impact of the diagnosis on their future.

Search Strategy

This evidence-based review consists of systematic reviews, meta-analyses, other reviews of the literature, experimental, quasi-experimental designs, and case studies with older adults (65+) as participants reported in English language peer-reviewed journals. Keyword search terms included aged, elderly, geri*, older adult, long-term care, dementia, Alzheimer* depress*, mood disorder, treatment, and randomized controlled trials. Searches were conducted on the following databases: PubMed (1997-2007/December); PsychINFO (1972-2007); Ageline (1978-2007), and EbscoHost Research—Academic Search Premier (through 2007). Google Scholar was also searched using November 2007-February 2008 as the time range to identify recent publications that would not have been cited. Unpublished literature was not included in the review.

Prevalence and Comorbidity of Depression in Dementia

Depressive symptoms are very common in mild cognitive impairment and across the various types of dementia. The reported prevalence of depression in older patients with dementia ranges from 30 to 96% (Amore et al., 2007; Starkstein, Jorge, Mizrahi, & Robinson, 2005), and moderate to high rates of depression or its symptoms are consistently reported for persons with MCI (i.e., 36% by Palmer, Berger, Monastero, Winblad, Backman, & Fraitiglioni, 2007; 63.3% by Solfrizzi et al., 2007; 39% by Hwang, Masterman, Ortiz, Fairbanks, & Cummings, 2004). The wide prevalence range for depression in dementia is due to several factors including differences in researchers’ focus on symptoms versus specifically defined depressive disorders; diverse study samples varying in causes of dementia, stage of illness, country of residence, and placement of older patient; and instrument variation used to assess depressive symptoms and disorders.

Comorbidity of depression in older persons with MCI or probable AD has been associated with greater impairments in activities of daily living (Teri et al., 1999). Likewise, increasing cognitive impairment appears to interact with the presence of depressive symptoms to further impair functional performance, above and beyond the effects of cognitive impairment alone (Schultz, Hoth, & Buckwalter, 2004). The presence of depression in cognitively impaired persons also appears to increase the level of other BPSD. Comorbid depression and dementia are associated with higher rates of institutionalization of older adults, likely due to the negative impact on caregivers (Black & Almeida, 2004; Potter & Steffens, 2007). Untreated depression has also been related to higher treatment costs for persons with dementia (Hemels, Lanctot, Iskedjian, & Einarson, 2001).

Assessment of Depression in Dementia

Detection and assessment of depression in older adults with dementia can be challenging for the clinician. Many long-term care residents with dementia present with signs and symptoms that overlap with depression (for example, anhedonia, irritability, flat affect) (Gauthier, 2003). Based on current evidence-based practice guidelines, screening for depression in this population should occur at least every 6 months (Brown, Raue, & Halpert, 2007) (Level C). The depression screening assessment consists of the (a) Mini Mental State Exam (MMSE; Folstein et al., 1975) used frequently to screen for dementia, and either the (b) Cornell Scale for Depression in Dementia (CSDD; Alexopolous, Abrams, Young, & Shamoian, 1988), or the (c) Short Geriatric Depression Scale (GDS-15 item; Sheik & Yesavage, 1986) depending on patient cognitive functioning (Brown et al., 2007). The guidelines suggest using the GDS for patients scoring 15 to 23 on the MMSE or the CSDD if the patient scores below 15 on the MMSE. The CSDD collects interview information from both the patient and an informant. If patients score 6 or greater on the GDS, or 11 or greater on the CSDD, the primary health care provider should be notified for further evaluation and/or treatment for clinically significant depression (Brown et al., 2007). If the older adult with dementia does not screen positive for depressive symptoms, the guidelines suggest that the individual be reevaluated in 1 month if clinically warranted, otherwise, 6 months later. It is also recommended to interview caregivers and other reliable informants on behalf of the individual with moderate to severe dementia (American Geriatrics Society & American Association of Geriatric Psychiatry, 2003). Attention needs to be paid to the biopsychosocial factors during assessment to obtain a clear picture of the patient. Assertive outpatient and community-based treatment of depression may also improve the course of coexisting dementia and depression and lengthen the time the patient can remain at home before nursing home placement.

A recent study focused on specific factors that might contribute to nursing home placement by examining the detection and course of coexisting dementia and depression (CDD) in elderly patients compared with patients with either disorder alone (Kales, Chen, Blow, Welsh, & Mellow, 2005) (Level C). This was a 1-year prospective study comparing outcomes among 82 elderly male veterans receiving inpatient and outpatient treatment. Subjects were recruited and reassessed at 3, 6, and 12 months after baseline. This study found lower rates of depression detection by treating (i.e., non-study) physicians in CDD patients. Only 35% of the CDD group were correctly diagnosed and received adequate treatment. The CDD group had significantly higher levels of functional impairment when compared to the dementia-only group. The CDD subjects used nursing home care at significantly higher rates. The investigators concluded that undetected, untreated, or inadequately treated depression may result in higher rates of nursing home placement in patients with dementia due to an increase in functional disability.

Course and Presentation of Depression in Dementia

Studies have identified pre-existing depression as a predictor or risk factor for subsequent dementia and estimated that persons experiencing depression have approximately double the risk of developing dementia that those without a prior history of depression have (Palmer et al., 2007; Teng et al., 2007). Although several studies indicate that the risk of depression in older adults with dementia tends to increase as cognitive decline in dementia progresses (Riccio, Solinas, Astara, & Mantovani, 2007; Solfrizzi et al, 2007; Steinberg et al., 2007; Teri et al., 1999), other research indicates a curvilinear, rather than linear, relationship between the symptoms of depression and the worsening of dementia (Bierman, Comijs, Jonker, & Beekman, 2007; Starkstein, Mizrahi, & Garau, 2005; Lopez et al., 2003). Participants in these studies appear to exhibit higher prevalence rates of depression in the early stages of dementia, but these disorders seem to diminish in reported prevalence as cognitive function becomes severely impaired and insight is lost. Yet, this apparent drop in prevalence may be due to differences in the presentation of depression in the later stages of dementia.

Lopez and colleagues (2003) examined the relationship between major depression and other observed psychiatric symptoms across mild, moderate, and severe stages of cognitive impairment. They found that fewer observed symptoms were associated with diagnosed depression as dementia increased. For example, confirmed depression in those with mild dementia was associated with anhedonia, sleep disturbance, depressed mood, and hopelessness, whereas moderate dementia and depression were associated with these symptoms, minus anhedonia, and severe dementia with depression was associated only with hopelessness. Another explanation of the differences in findings on the prevalence rates of depression and over the course of dementia may be disagreement among clinicians and researchers on whether and how to distinguish apathy from depression.

To investigate this further, researchers administered a structured interview intended to measure apathy and depression separately to 150 AD patients (Starkstein, Ingram, Garau, & Mizrahi, 2005). They reported that 12% met distinct criteria for both apathy and depression, while 7% met criteria for apathy only, and 31% met criteria for depression only. Supporting their argument that the two constructs were different, apathy, but not depression, was significantly associated with more severe cognitive deficits. However, in a later study, Starkstein, Jorge, Mizrahi, and Robinson (2006) found that apathy was related to a higher frequency of both minor and major depression, with apathy at baseline significantly predicting depression at follow-up evaluations, findings that support a relationship between the two constructs.

Consequences of Depression in Older Adults with Dementia

The occurrence of depression in older adults with MCI or dementia can lead to a number of negative outcomes. Depression may be a risk factor for progression from MCI to dementia. The occurrence of depression in persons with MCI or dementia has also been linked with increased general severity of cognitive deficits (Nakaaki et al., 2007). Co-morbid cognitive impairment and depression have also been associated with several other negative consequences, including increased risk of death (Sutcliffe et al., 2007). Although suicide attempts have been observed in less than 1% of dementia patients, suicidal ideation, intent, passive death wishes, and feelings that life is not worth living have been reported in 1% to 42% of dementia patients, particularly in those suffering from depression (Thompson, Herrmann, Rapoport, & Lanctot, 2007; Tsai, Tsai, Yang, & Hwang, 2007). Depression has also been associated with reduced quality of life reports from dementia patients and their caregivers (Appleby, Roy, Valenti & Lee, 2007; Hancock, Woods, Challis, & Orrell, 2006; Selwood, Thorgrimsen, & Orrell, 2006; Shin, Carter, Masterman, Fairbanks, & Cummings, 2005; Vogel, Mortensen, Hasselbalch, Andersen, & Waldemar, 2006; Winzelberg, Williams, Preisser, Zimmerman, & Sloane, 2005).

Treatments

Both pharmacologic and nonpharmacologic treatment approaches have been found to be helpful in reducing depression associated with cognitive impairment and dementia among older adults. A wide variety of medications have been used, with varying degrees of success. Nonpharmacologic interventions, such as behavioral modification programs and structured activity programs, have also been found to reduce depression though with modest outcomes. Recently, newer treatments drawn from the field of complementary and alternative medicine, such as dosing with gingko biloba extract, have been used for persons with dementia with some success.

Pharmacological Treatments for Depression in Dementia

Depression is more likely than other BPSD in older adults to respond to pharmacological interventions (Herrmann & Lanctot, 2007). The neurotransmitters/receptors that have been targeted by pharmacological therapies include catecholamine receptors (i.e., serotonin and dopamine receptors), amino acid receptors (i.e., gamma-amino-butyric acid [GABA] and glutamate receptors), and cholinergic receptors (Lanari, Amenta, Silvestrelli, Tomassoni, & Parnetti, 2006).

Pharmacological treatment of depression in patients with dementia presents some unusual difficulties for the clinician. Older patients with dementia have more comorbid illnesses than non-demented peers, with approximately 60% of those with AD having 3 or more. This heightened level of comorbidity results in the use of multiple medications. Therefore, drug interactions and polypharmacy may help provoke depressive and other symptoms in some patients with dementia (Daiello, 2007). Given their physical and cognitive frailty, older adults with dementia may also be particularly susceptible to adverse effects. Since dementia patients may be less able to communicate, clinicians and caretakers must carefully observe patient’s behavior for evidence of adverse events when new medications are introduced. Prescription of new medications intended to treat depression in dementia patients should always be made using the familiar axiom for the elderly, “Start low and go slow” (Thompson et al., 2007).

Antidepressants

Antidepressants are frequently prescribed for treatment of depression in older adults with dementia. A recent meta-analysis (Thompson et al., 2007) reviewed treatment of depression with tricyclic antidepressants (TCA; imipramine and clomipramine), and selective serotonin reuptake inhibitors (SSRI; sertraline and fluoxetine) in patients with dementia. The findings indicated that patient treatment response and remission was superior to the placebo response in the combined sample from all studies, but cautioned that significant declines in cognitive scores occurred during the use of TCAs (Level B). Other reviews (Buhr & White, 2006; Sink, Holden & Yaffee, 2005) provide further support for positive effects of treatment with various antidepressants (including sertraline, fluoxetine, citalopram, trazodone, and moclobemide) on depression in dementia, with citalopram and sertraline being the most commonly prescribed (Caballero, Hitchcock, Beversdorf, Scharre, & Nahata, 2006; Starkstein & Mizrahi, 2006) (Level A). Case reports and small pilot studies indicate that other antidepressants, including trazadone and mirtazapine may decrease depression in patients with dementia, but no large trials have been performed in persons with dementia to date (Level D).

Antipsychotics

Different classes of antipsychotics have also been used to treat depression with varying degrees of success (Snowdon, Sato, & Roy-Byrne, 2003). However, older adults with dementia taking haloperidol and other “typical” antipsychotics have been found to be at significant risk of extrapyramidal symptoms including parkinsonism and tardive dyskinesia (Sink et al., 2005). Because of this, many clinicians have recently focused their attention on “atypical” antipsychotics such as risperidone and olanzapine (Herrmann & Lanctot, 2007; Sink et al., 2005), which have been shown to have significant, though modest, effects, and fewer adverse effects than typical antipsychotics at lower doses (Level D).

Caution should be noted as both risperidone and olanzapine have been associated with an increased risk of stroke and associated mortality, and subsequent safety warnings have somewhat limited their use in older patients with dementia. There is some disagreement over the actual risk involved, and it has been suggested that the increased cardiac risk may only occur at high doses (Liperoti et al., 2005). Other authors have pointed out that the patients experiencing stroke events in the original trial of Brodaty, Withall, Altendorf, and Sachdev (2007) had other risk factors for stroke besides the use of risperidone in dementia (Lee et al., 2004). A recent meta-analysis (Katz et al., 2007) concluded that although cerebrovascular events and mortality observations across trials were more frequent in risperidone-treated groups, the frequency did not differ significantly from placebo groups.

Decreased cholinergic activity, primarily resulting from decreased acetylcholine concentrations caused by dementia-related neurological changes, has been associated with decreased cognitive ability in dementia, as well as increases in BPSD, including depression (Garcia-Alloza et al., 2005). Cholinesterase inhibitors, including tacrine, donepezil, rivastigmine, and galantamine, have been used to target these problems by increasing levels of acetylcholine, with some success, particularly in patients with mild to moderate dementia (Birks, 2006). A recent review of the literature on the effects of rivastigmine on BPSD reports that positive effects have been found for patients with a wide range of dementia, and that apathy and anxiety are among the behavioral domains demonstrating the most consistent positive response (Figiel & Sadowsky, 2008) (Level E).

Anticonvulsants

Though inconclusive, some evidence exists that anticonvulsants, through their modulation of GABA, may be another class of agents for treating BPSD and depressive symptoms. GABA concentrations are often decreased in cortical regions of the brain of patients with dementia, and medications that increase GABA levels have been shown to improve mood disorders (Sink et al., 2005). Trials of the anticonvulsant carbamazepine to treat BPSD have yielded contradictory results (Franco & Messinger-Rapport , 2006) (Level B), or have not reported data on depression. At least one clinical trial of valproate resulted in significant improvement in melancholic and sorrowful behaviors (Sival, Haffmans, Jansen, Duursma, & Eikelenboom, 2002), but the results of other small trials are contradictory (Sink et al., 2005) (Level B). Preliminary studies of another anticonvulsant, lamotrigine, in elderly patients with dementia noted improvement in symptoms of agitation and depression (Sajatovic, Ramsay, Nanry, & Thompson, 2007) (Level B).

Memantine, a drug that reduces excessive glutamate receptor signaling, has also been studied in patients with dementia. Glutamate signaling is important for learning and memory, but in some patients with dementia it may increase to “oversignalling” levels that destroy neurons. A recent review and meta-analysis of the research on memantine for the treatment of psychological symptoms (e.g., depression) of dementia showed small but significant improvements with limited adverse effects (Maidment et al., 2008).

The growth of complementary/alternative medicine may yield some helpful treatments for BPSD in the future. In particular, studies provide some support for the theory that Ginkgo biloba special extract EGb 761 enhances cognitive functioning and stabilizes mood in cognitively impaired elderly subjects (Woelk, Arnoldt, Kieser, & Hoerr, 2007). A review of the research (Birks & Grimely-Evans, 2007) concluded that the evidence that the extract has predictable and clinically significant benefit for older people with dementia or cognitive impairment is inconsistent and unconvincing. However, a recent trial of this extract involving patients with dementia found that compared to controls, those taking the extract experienced improvements in apathy and depression (Scripnikov, Khomenko, & Napryeyenko, 2007).

In summary, a wide variety of pharmacological treatments have efficacy (of varying degrees) in the treatment of depression in older adults with dementia, but care must be exercised in their use with generally frail older persons to avoid adverse effects. Alexopoulous, Jeste, Chung, Carpenter, Ross, and Docherty (2005) constructed an expert consensus response after surveying 50 experts in dementia from North America on preferred, alternate, and unacceptable pharmacological treatment choices for BPSD. The general consensus was that SSRIs were preferred for treating depression in patients with dementia. Further research appears to be needed to establish the effects of both older and newer pharmacological options for depression in dementia patients.

Non-Pharmacological Treatments for Depression in Dementia

Clinical guidelines specify the use of non-pharmacological treatments for BPSD before pharmacological treatments are tried (Buhr & White, 2006; Woods, 2004) (Level C). As well as avoiding potential effects of polypharmacy, drug interactions, or exacerbation of comorbid conditions, non-pharmacological treatments may improve the quality of life for the patient with dementia above and beyond the reduction of depression (Cohen-Mansfield, 2005). Yet, the current state of the evidence on non-pharmacological treatments is weak because few randomized controlled studies have been conducted, and therefore, it is difficult to provide information on the therapeutic benefits that these interventions may hold for older adults with dementia in long-term care.

Non-pharmacological therapies that specifically include depression as a target outcome fall roughly into three categories: (a) emotion-oriented therapies including reality orientation, validation therapy, and reminiscence therapy; and (b) brief psychotherapies including cognitive and behavioral therapy.

Emotion-Oriented Therapies

Reality Orientation Groups. Commonly conducted in long-term care settings, the original aim of Reality Orientation, as first developed for older people with mild to moderate dementia, was to reduce confusion by giving repeated orientation clues, e.g., the time of day, date, and season, but this was only partially successful. Researchers suggested that the main benefits were the stimulation from the social group and the positive impact on staff, who acquired a better knowledge of the residents and their earlier lives and interests, through which they were able to provide more person-oriented care (Moos & Bjorn, 2006). Livingston and colleagues (2005) reported the results of 11 studies consisting of randomized and quasi-experimental designs on reality orientation. The largest controlled trial (N=57 subjects) demonstrated no differences between reality orientation and an active ward orientation (Hanley, McGuire, & Boyd, 1981). The smaller sample nonrandomized studies mostly showed benefits of reality orientation in decreasing depressive symptoms or delaying institutionalization. The current research does not offer clear evidence of its benefits for older adults with dementia.

Reminiscence Therapy. Reminiscence therapy encourages persons with dementia to talk about their pasts, and may utilize audiovisual aids such as old family photos and objects to retrieve positive events and emotions. Reminiscence provides dementia sufferers a chance to interact positively with others; can enhance an individual’s sense of identity, sense of worth, or general well-being; and may also stimulate memory processes (Moos & Bjorn, 2006). Two reviews that included information on reminiscence therapy report potentially positive effects on depressed mood in patients with dementia, but caution that most trials were small or otherwise methodologically questionable and therefore the evidence is weak and inconclusive (Douglas, James & Ballard, 2004; Livingston et al., 2005).

Validation therapy. Validation therapy is a type of psychosocial intervention for elderly persons with dementia. Basically, a therapist accepts the disorientation of a person with dementia and validates his/her her feelings (Feil, 2002). This self-affirming intervention is based on the assumption that individuals return to unfinished conflicts in their past, providing a background for meaningful conversations addressing their feelings. Neal and Briggs (2003) reviewed trials of this therapy and reported that only one study (Toseland et al., 1997) showed a trend towards improvement of depression a year after completing validation therapy, but the finding was not statistically significant. Another recent study using validation therapy in a group format found similar results (Deponte & Missan, 2007). The empirical evidence for the usefulness of this therapy for depression in dementia is weak and unconvincing.

Brief Psychotherapies

Cognitive and Behavioral Therapy. Behavioral therapy requires a period of detailed assessment in which the personal triggers, behaviors, and reinforcers (also known as the ABCs: antecedents, behaviors, and consequences) are identified and their relationships made clear to the patient. The therapist will often use some kind of chart or diary to gather information about the manifestations of a behavior and the sequence of actions leading up to it. Interventions are then based on an analysis of these findings. The efficacy of behavioral therapy has been demonstrated in the context of dementia in a few earlier studies (Burgio & Fisher, 2000) (Level B). For example, there is evidence of successful reductions in wandering, incontinence, and other forms of stereotypical behaviors (Woods & Bird, 1999). Meares and Draper (1999) (Level F) presented case studies confirming the efficacy of behavioral therapy, but they noted that the behaviors had diverse causes and maintaining factors, and cautioned that behavioral interventions must be tailored to individual cases.

A recent systematic review examined 20 studies using behavioral management techniques for outcomes of depressive (3 studies) and neuropsychiatric symptoms (17 studies) in older adults with dementia (Livingston et al., 2005). Of the 3 on depression outcomes, one large randomized controlled trial showed significant improvement in depressive symptoms immediately post-treatment and at 6-month follow-up examination in two treatment conditions: (1) one emphasizing patient pleasant events and one emphasizing caregiver problem solving, as compared to treatment as usual and waitlist control conditions (Teri, Logdson, Uomoto, & McCurry., 1997) (Level A). The two smaller randomized trials also demonstrated significant reductions in behavioral symptoms compared to usual primary care (Benedict et al., 2000; Suhr, Anderson, & Tranel, 1999). However, no significant effects were found on depression (Benedict et al., 2000). The results of the larger randomized trial studies were consistent and showed benefits as compared to the control condition, and these beneficial effects were maintained over time.

Hyer and colleagues (1990) compared the effectiveness of a12-week group psychotherapy, in a cognitive behavioral format, to usual care in a small sample of 22 residents. At post-treatment, depression scores decreased in the treatment group but not in the control group. Koder (1998) discussed two case reports in which cognitive behavioral therapy was offered using techniques such as relaxation, distraction, and cognitive restructuring. Over the past decade, there has been an increasing interest in applying some of the brief therapeutic frameworks such as cognitive behavioral therapy (CBT) to dementia. For example, Teri, Curtis, Gallagher-Thompson, and Gallagher-Thompson (1994) reported positive findings from a clinical trial of CBT with people in the early stages of AD. Individual and group CBT has also been used by other researchers with some favorable results (Kipling, Bailey, & Charlesworth, 1999).

Both cognitive and behavioral therapies have obvious limitations, particularly for persons with severe dementia. Nevertheless, owing to the fact that these therapies have relatively simple conceptual models underpinning them, they have been shown to be helpful, even for severe cognitive impairment (Logsdon, McCurry, & Teri, 2007; Yuhas, McGowan, Fontaine, Czech, & Gambrell-Jones, 2006). For example, Douglas, James, and Ballard (2004) believes that a CBT perspective is very suitable for people with dementia, since many of the behavioral difficulties encountered emerge through one or more of the following cognitive features: cognitive misinterpretations, biases, distortions, erroneous problem-solving strategies, and communication difficulties. Hence, CBT offers a framework within which to understand the individual’s distressing experiences, and this understanding allows the clinician to target interventions more appropriately.

Overall, the evidence on non-pharmacological interventions as effective treatments for depression in older adults with dementia residing in long-term care is sparse and deficient. There are several limitations to the literature. First, most research studies have focused on behavioral and not depressive symptom outcomes. Second, the diversity of sample elderly populations makes it difficult to compare results across studies. Third, the majority of studies lack a description of intervention protocols or manuals making it difficult to understand, analyze, or replicate the treatment components. Finally, the inconsistency of follow-up protocols across studies provides further barriers to determine long-term effects of the interventions. A few psychosocial interventions such as group and individual behavioral therapies show some potential but require further investigation, improved study design, and clear intervention protocols for duplication and treatment component analysis.

Summary Take Home Points

• Depression is a common problem in older adults with dementia in long-term care settings.
• Behavioral and psychological symptoms of dementia (BPSD), also known as neuropsychiatric symptoms of dementia, affect up to 95% of those with dementia.
• Reported prevalence of depression in elderly with dementia ranges from 30% to 96%.
• The depression screening protocol consists of the Mini Mental State Exam (MMSE) and either the Cornell Scale for Depression in Dementia (CSDD) or the Short Geriatric Depression Scale (SGSD) depending on MMSE score.
  • The GDS should be used for patient scores of 15 to 23 on the MMSE.
  • The CSDD should be used if the patient scores below 15 on the MMSE.
  • If GDS is 6 or greater or CSDD is 11 or greater the primary health care provider should be notified for further evaluation and/or treatment for clinically significant depression.
• Apathy has been found to be related to a higher frequency of both minor and major depression.
• Depression may be a risk factor for progression from MCI to dementia.
• Expert consensus recommends SSRIs as the preferred pharmacological treatment for depression in patients with dementia.
• Due to physical and cognitive frailty, drug interactions, and polypharmacy may trigger depressive and other symptoms in some patients with dementia and patients may be susceptible to adverse effects.
• Clinical guidelines specify the use of non-pharmacological treatments for BPSD before pharmacological treatments.
• Scientific evidence for emotion-oriented therapies (Reality Orientation, Validation Therapy, and Reminiscence Therapy) is weak.
• Scientific evidence for cognitive and behavioral therapies is somewhat stronger. Results of a few large randomized trial studies were consistent and showed benefits as compared to control groups, and outcome effects on depression reductions were maintained over time.

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Document Date: September 9, 2009