Carolyn Chew-Graham1 and Cornelius Katona2
1 Research Institute, Primary Care and Health Sciences and National School for Primary Care Research, Keele University, Keele, UK
2 Department of Psychiatry, University College London, London, UK
This chapter considers the presentation and management of anxiety and depression in older people, and explores the challenges clinicians face in responding to the needs of older people with these common mental health problems. Depression severe enough to warrant intervention is one of the commonest mental health problems facing older people, affecting more than 1 in 10 older people in the community. There are a number of risk factors for depression, which the GP needs to be aware of (Box 4.1), and some of these are also risk factors for anxiety, particularly chronic physical conditions and loneliness.
Depression is associated with disability, increased mortality, including from suicide, poorer outcomes from physical illness, and increased use of primary and secondary and social care resources. Major depression is a recurring disorder and older people are more at risk of recurrence than the younger population.
Anxiety disorders are also common in older people. ‘Anxiety’ covers the terms generalised anxiety disorder (GAD), panic and phobic disorders. GAD is a common disorder, of which the central feature is excessive worry about a number of different events associated with heightened tension. Anxiety and depression often coexist (or overlap) in older people and may also be comorbid with physical conditions (leading to poorer outcomes in those conditions).
Patients with anxiety disorders may complain of worry, irritability, tension, tiredness or ‘nerves’, but older people may present with somatic symptoms that may cause diagnostic difficulty for the GP and (if not identified) may result in unnecessary investigations for the patient – with the resultant worries aggravating the depression and anxiety symptoms. The GP needs to be aware of the link with alcohol misuse and should always explore alcohol consumption in older people who present with symptoms of depression or anxiety.
Older people consult their primary care practitioner more frequently than younger people, and those who are depressed consult twice as often as those who are not. Despite this, depression is diagnosed less often in older people. Older people who are depressed can present with nonspecific symptoms rather than disclosing depressive symptoms. Standard diagnostic criteria (ICD 10, DSM – for anxiety and depression) have been developed to reflect symptoms observed in younger people. They have inherent limitations for diagnosis of depression in older people, whose presentation may differ because of ageing, physical illness or both. Other clinical features often found in older people include: somatic preoccupation, hypochondriasis and the morbid fear of illness, which are more common presentations than the complaint of low mood or sadness. In addition, physical symptoms, in particular seemingly disproportionate pain, are common and the primary care clinician may feel they represent organic disease. This can cause problems for the GP, as a depressed patient’s hypochondriacal complaints can be quite different from the bodily symptoms one might expect from knowledge of the patient’s medical history. Subjective memory disturbance may be a prominent symptom and lead to a differential diagnosis of dementia, but true cognitive disturbance is also common in late-life depression. The GP should assess memory using the GPCOG (see ‘Resources’ below) or the Abbreviated Mental Test Score (see Appendix 4).
Depression in older people (particularly when there is no history of depression earlier in the patient’s life) is associated with increased risk of subsequently developing a ‘true’ dementia. Lastly, a persistent complaint of loneliness in an older person (even when that person is known to live with others) should prompt enquiry into mood, feelings, views on the future, and a more systematic enquiry about biological symptoms of depression, along with a formal assessment, including a risk assessment.
Older adults may have beliefs that prevent them from seeking help for mental health problems, such as a fear of stigmatisation or concern that antidepressant medication is addictive. They may not consider themselves candidates for care because of previous experience of help-seeking. In addition, older people may be reluctant to recognise and name ‘depression’ as a specific condition that legitimises attending their GP, or they may misattribute symptoms of major depression for ‘old age’, ill health or grief and use normalising attributional styles that see their depression as a normal consequence of ill health, of difficult personal circumstances or even of old age itself. GPs may lack the necessary consultation skills and confidence to correctly diagnose depression in older people, and anxiety is particularly under-diagnosed. They may also be wary of opening a ‘Pandora’s box’ in time-limited consultations and instead collude with the patient in what has been called ‘therapeutic nihilism’. Additionally, a lack of congruence between patients’ and professionals’ conceptual language about mental health problems, along with deficits in communication skills on the part of both patients and professionals, can lead to uncertainty about the nature of the problem and reduce opportunities to talk about appropriate management strategies.
The use of case-finding questions (Box 4.2) should be part of usual practice for GPs in consultations with older people who have risk factors for depression and anxiety (Box 4.1) or where the GP has a clinical suspicion that depression may be present. The questions should be used as prompts by the GP, rather than formal ‘screening’ questions whose wording has to be adhered to rigidly.
The GP should cover five areas in the primary care consultation when anxiety and/or depression are suspected in an older person: history, mental state, risk assessment, focused physical examination and appropriate investigations. The latter should include full blood count (FBC), urea and electrolytes (U&Es), liver and thyroid function tests, vitamin B12 and folate, glycosylated haemoglobin (HbA1C), bone profile and any further tests dictated by clinical presentation. It is particularly important to establish risk of self-harm. This is often overlooked when the predominant symptom is anxiety, but older patients are at risk of self-harm and self-neglect, and the GP should be aware of this. GPs may shy away from asking about suicide for fear of ‘putting thoughts into the patient’s head’. Providing an opportunity to disclose suicidal thoughts or plans may, on the contrary, be a huge relief for patients who may until then have felt ashamed of these thoughts and fearful of disclosing them. Assessment of severity of anxiety (using GAD-7 – see Appendix 1) and depression (PHQ-9 – see Appendix 2) should be considered in order to contribute to the management plan.
Some clinicians consider anxiety and depression to be part of a continuum and that the overlap between them is particularly broad in older people. Labelling the patient as having one disorder or the other may be less important than assessing the severity and impact of the mood disorder on the patient’s life. This may be a valid perspective in primary care, where people often present with mixed or comorbid problems, but it is important to distinguish which symptoms are most prominent in order to focus explanations and identify appropriate management options. It is vital that the GP explores the patient’s ideas and concerns about their problem, and the expectations the patient may have of both the GP and of any treatment offered. Any explanation given by the GP needs to fit with the patient’s model of their problem. This can require considerable skill and cultural sensitivity on the part of the GP, and may require a number of consultations before an older person is willing to consider ‘anxiety’ or ‘depression’ as a working diagnosis on which to base a management plan.
For both anxiety and depression, the ‘stepped care model’ provides a framework in which to plan individual patient management. The NICE guidelines for anxiety and depression (National Collaborating Centre for Mental Health, 2010 and 2009) offer a stepped care model for the management of people with anxiety, and this approach is appropriate for older people with anxiety symptoms, with or without depression. Thus, discussion with the patient about the symptoms and their meaning should occur, followed by negotiation of a management plan acceptable to the patient. When physical symptoms are the presenting problem, appropriate physical examination may help to reassure the patient that their symptoms are being taken seriously, but repeated investigations should be avoided. Initial management should involve verbal and written information about anxiety, signposting to age-appropriate support groups (e.g. Age UK) or self-help groups (Anxiety UK), and discussion of behavioural activation (BA) techniques (see Chapter 10), with an arrangement to follow the patient up. Appropriate advice about alcohol and physical activity as in the management of depression should be given. A similar approach should be taken when depressive symptoms are predominant.
If there is no improvement of symptoms following such ‘active monitoring’ and support from the GP and referral to third sector services, then discussion with the patient about the acceptability of referral for ‘low-intensity psychological interventions’ should take place. There is evidence that older people are less likely to be referred for CBT-based interventions, despite the fact that the evidence base for their use is similarly good for older people and for adults of working age. If a ‘talking treatment’ is unacceptable to the patient, then the GP should discuss how the patient would feel about taking antidepressants and the rationale for this suggestion.
Management of anxiety and depression in older people should follow that suggested by national guidelines and be no different to that in younger adults, although the likelihood of comorbid physical health problems means that a collaborative care approach may be particularly indicated (Box 4.3).
It is important that GPs are aware of the service offered by their local primary care mental health team, and by local IAPT (Improving Access to Psychological Therapies) services. They should ensure that a range of evidence-based services for all patient groups (specifically including older people) are commissioned by their Clinical Commissioning Groups.
SSRIs are the first-line antidepressants for older people with depression or anxiety (see Chapter 11). Patients starting on SSRIs should be warned about common side effects that can occur in the first few days or weeks of treatment (such as nausea, fatigue, headache and increased anxiety), and possible longer-term side effects (such as reduced libido and weight gain). GPs should be particularly aware of the risk of gastrointestinal bleeding (particularly if the patient is taking aspirin) and hyponatraemia, both of which are commoner and potentially more dangerous in older people. The patient should be warned about the ‘withdrawal’ side effects of stopping an antidepressant abruptly and that it is vital to continue the antidepressant for at least 9 months (longer if this is an episode of recurrent depression). Should an SSRI be ineffective, second-line antidepressants the GP might wish to prescribe include mirtazapine or venlafaxine. Such prescribing decisions need to take account of relevant comorbidities such as cardiovascular disease and of potential drug interactions.
Even if the GP has referred a patient to another service, and especially if the patient has agreed to take an antidepressant, active follow-up and monitoring of the patient is required. The GP can use basic BA techniques, even in a time-limited consultation, making use of available bibliotherapy to support this. Regular review is vital to ensure risk is assessed and responded to.
There are several clinically worrying features at this point. Bridie has failed to respond to two antidepressants. Her forgetfulness may be integral to her depression but may also be a presenting feature of an underlying dementia. Bridie’s escalating alcohol use may well be an important ‘maintenance’ factor making her depression less likely to respond to treatment. It may also be contributing to her cognitive difficulties. In view of the increasingly evident complexity of her mental health difficulties and her lack of response to treatment, it would be appropriate for Bridie to be referred to the local community mental health team for older people.
If Bridie agreed to referral, she may be assessed by a community mental health nurse in the first instance. This assessment could take place either at her home or in a clinic, depending on local arrangements. The assessment would include taking a full history from Bridie herself (including her adherence to recent antidepressant treatment and her recent and longer-term alcohol intake) and, where possible, from her husband. Bridie’s mood would also be assessed, probably with a rating scale designed for older people such as the Geriatric Depression Scale (GDS; see Appendix 3), as would her cognitive function (using a validated rating scale such as the Montreal Cognitive Assessment or the Addenbrooke’s Cognitive Examination (ACE III) (see Appendices 7 and 8). Further investigation would include brain imaging (CT or MRI scan). Treatment should include addressing Bridie’s alcohol use and ‘augmenting’ her antidepressant with a second antidepressant, lithium or an atypical antipsychotic. If there is significant cognitive impairment, however, antipsychotics should be avoided if at all possible. If Bridie continued to deteriorate (e.g., by refusing food or fluid or by manifesting active suicidal intent), inpatient treatment should be considered (which may have to be under the provisions of the Mental Health Act), as might treatment with electroconvulsive therapy (ECT).
Anxiety and depression are common in older people with multi-morbidities and are risk factors for suicide. The primary care clinician has an important role in the detection and management of anxiety and depression, and should be aware of when to refer for specialist input.
GPCOG (The General Practitioner assessment of COGnition): http://www.gpcog.com.au