I. Concepts
1.Broad sense of depressive disorder in old age
Depressive disorder in the broad sense refers to depressive disorders seen in the specific group of people in old age (usually greater than or equal to 60 years old), including both depressive disorders with the first onset in old age, as well as depressive disorders with the onset before old age lasting until old age or recurring in old age, and also including various secondary depressive disorders seen in old age.
2.Narrowly defined depression disorder in old age
Depressive disorder in the narrow sense refers to the primary depressive disorder with the first onset in old age, with persistent depressive mood as the main clinical manifestation, with clinical features of low mood, anxiety, sluggishness and a wide range of somatic discomfort. Mental disorders cannot be attributed to physical illness or organic brain pathology. Generally, the course of the disease is long, with a tendency to remission and relapse, and some cases have a poor prognosis and can develop into refractory depression.
3.Characteristics of depressive disorder in old age
The age of onset of monophasic depressive disorder is bimodal, with another peak after the age of 50 years, and about 2/3 of all patients over 65 years old with depressive disorder in old age have late onset. The first onset of depressive disorder in old age is more than 40-50%. Bipolar disorder, on the other hand, is very rare. The prevalence of depressive disorders in old age in Beijing is 12.89%, with 10.43% in men and 16.89% in women.
There are numerous differences between monophasic depressive disorder in old age and young adulthood, and it is thought that depressive disorder in old age may be a subtype of mood disorder, and the name late-onset depression is suggested.
This disorder is one of the most common functional disorders in old age. However, epidemiological studies on depression in old age are still relatively few. It accounts for 7.59%-7.36% of all annual geriatric primary cases. Hospitalized patients account for 21%-54% of all geriatric mental disorder patients.
As people’s life expectancy increases, the absolute number and proportion of elderly people suffering from depressive disorders will grow accordingly. Depression has become one of the major problems that seriously affects the mental health of the elderly.
Another problem closely related to depressive disorders is suicide. The suicide mortality rate for elderly people who commit and attempt suicide is 4.8 per 10,000, ranking fourth among 39 countries reported to the World Health Organization, with the mortality rate for rural elderly women being more than three times that of urban elderly women and the mortality rate for rural elderly men being four times that of urban elderly men. The diagnosis of depressive disorders in the elderly is more complicated than in young adults because of the special characteristics of the physical, psychological, and social relationships of the elderly; on the other hand, the treatment of depressive disorders in the elderly is much more complicated than in young adults because of the physical illnesses that often accompany them and the changes in their physiological conditions compared to their younger years.
Etiology and pathogenesis
To date, the etiology of mood disorders is still unclear, involving biological, social, psychological and other aspects, may be related to genetic, premorbid personality characteristics, biochemical and metabolic abnormalities, neuroendocrine changes, anatomical and pathological changes in the brain and social environment and life events and other psychological factors.
1.Genetic factors
Both domestic and international studies suggest that the role of genetic factors in depression disorder in the elderly is weak.
2.Psychosocial factors
On the one hand, the ability of the elderly to tolerate physical illness and mental frustration is decreasing; on the other hand, there are more and more opportunities to suffer from various psychological stress, so the role of psychosocial factors in the development of depression disorder in the elderly becomes more prominent. For example, the death of colleagues, friends and relatives, especially the death of a spouse, the separation of children from their parents after joining the workforce and getting married, changes in social status (such as leaving the workforce, leg rest), economic difficulties (no financial support), illnesses and many other factors may cause or aggravate the loneliness, isolation, uselessness and helplessness of the elderly, and become a cause of depression and depression. Once they encounter life events, it is not easy to rebuild the stability of the internal environment, and if they lack social support, it is more difficult to maintain the balance of psychological activities, thus promoting various mental illnesses including depression. The fact that even ordinary life events can cause illness is of great importance in the elderly.
Sociodemographic data suggest that older adults who are single, have low education, few hobbies, no independent economic income and few social interactions are at high risk for depressive disorders in old age.
3. Pre-morbid personality traits
The normal aging process is often accompanied by changes in personality characteristics, such as introversion, isolation, passivity, dependence and stubbornness, emotional instability, hypersensitivity, and headstrongness. Patients with geriatric depressive disorder have significant personality deficits, with prominent avoidant and dependent personality traits compared to normal older adults. The presence of physical diseases in the elderly can make these characteristics more prominent.
4.Biochemical metabolic abnormalities
The biochemical basis of depressive disorders involves several neurotransmitter systems, the more certain of which are the norepinephrine system and the 5-HT system, but the specific mechanism of action is unclear, and even fewer studies have been conducted for depressive disorders in old age. Primarily from the nucleus accumbens, 5-HT2 receptor binding is decreased in the pallidum, shell, and prefrontal lobes of the brain, suggesting a decrease in 5-HT nerve cells or an excess of 5-HT in 5-HT2 receptors. NE and 5-HT concentrations in the hindbrain decreased with age. Decreased DA content in the brain is associated with organismal aging.
5. Anatomical structure and pathological changes
The incidence of degenerative brain changes is higher in patients with geriatric depressive disorder than in the general population, but the causal relationship with the disease and its exact impact on the course and prognosis of the disease are not yet certain. The tendency of ventricular enlargement in patients with geriatric depressive disorder and the late onset and significantly increased 2-year mortality in those with ventricular enlargement suggest that organic brain damage may have some etiologic significance for geriatric depressive disorder. Degenerative brain tissue degeneration may be of greater etiological significance for late-onset depressive disorders in old age.
Clinical manifestations
1.Clinical types
Depressive disorders in old age in a broad sense include three clinical types.
(1), depressive disorders with pre-mortem onset continuing into old age or recurring in old age, which are essentially depressive disorders in the general sense, only that the clinical symptoms may become less typical as the patient gets older;
(2), depressive disorders secondary to other diseases in old age, including various physical diseases and foreign substances (secondary depression), secondary depression in old age, the depressive symptoms are often only part of the clinical symptoms of the primary disease, generally do not have the characteristics of major depression, the symptoms are more volatile, the course of the disease is closely related to the primary disease, often with the changes in the primary disease and change;
(3), the first depressive disorder in old age, which is a group of depressive disorders with onset in old age and less clear etiology.
Considering the severity and duration of depressive disorders, depressive disorders in old age can also be divided into major depression (single depressive episode, recurrent depressive episodes and major depressive episode of bipolar depressive disorder), poor mood (neurotic depression) and depressive phase of cyclothymic disorder.
2.Psychiatric symptoms
(1) General clinical manifestations of depressive episodes Depressive episodes can be clinically manifested as depressed mood, slowed thinking, reduced volitional activity and somatic discomfort.
(2) Symptom characteristics of depressive disorder in old age The clinical characteristics of depressive disorder in old age are: less positive family history, neurological lesions and somatic diseases account for a large proportion, more somatic complaints or discomfort, more suspicion; weight change, early awakening, loss of libido, lack of energy, etc. become less prominent due to age factors; some patients with depressive disorder in old age will be irritable, aggressive, hostile as the main manifestation; insomnia Some patients with geriatric depressive disorder may have irritability, aggression, hostility as the main manifestations; insomnia, loss of appetite, emotional vulnerability, emotional volatility; often cannot express sadness well; suicidal ideas are often unclear, such as the patient may say “let me die with a shot!” but denies that he or she has suicidal thoughts. In general, the clinical manifestations of depressive disorders in old age are often less typical, and the following symptoms are more prominent in the clinical manifestations of depressive disorders with pre-mature age onset.
2.1 Hypochondriac symptoms Among patients with depressive disorder in old age over 60 years old, 65.7% of male patients have hypochondriac symptoms. About 1/3 of the older patients have hypochondriasis as the first symptom of depressive disorder. Therefore, the term “hypochondriacal depression” has been proposed. The suspicion often involves the digestive system, and constipation and gastrointestinal discomfort are among the most common and early symptoms in these patients. Patients often start with a less serious physical illness and then worry that their condition will worsen or even become incurable, and despite explanations, they are unable to explain it. Therefore, if elderly people are overly concerned about normal somatic functions and overreact to mild illnesses, the possibility of depressive disorders in old age should be considered.
2.2 Anxiety, depression and agitation Older people are often unable to express their depressed mood well, mostly using the words “no meaning, no spirit, psychological difficulties”, “no energy, do not want to move”, listlessness, depression, decreased interest, do not interact with others, do not go out, do not participate in A few patients are slightly indifferent or sluggish in their emotional response, often accompanied by obvious anxiety symptoms, sometimes hostile and irritable, sometimes somatic anxiety can completely cover up depressive symptoms. Agitation is anxiety and agitation. Agitated depression is most common in older adults. Anxiety agitation is often a secondary symptom of more severe depression and may also become the patient’s main symptom. The clinical manifestation is anxiety and fear, worrying all day long that you and your family will suffer from misfortune, and that you will be in great trouble, so that you will rub your hands and feet, fidget, and be on tenterhooks. The symptoms include insomnia at night or repeatedly recalling unpleasant events in the past, blaming oneself for doing something wrong and causing misfortune to the family and others, and disinterest in everything in the environment. In the lighter cases, the person may talk endlessly about his or her experience and “miserable situation”, while in the more severe cases, the person may tear clothes, pull out hair, roll around on the floor, feel anxious, feel pessimistic and desperate, scandalize and deny himself or herself for no reason on top of the depressed state of mind, and have a decreased self-evaluation, and often have self-blame, self-guilt and misanthropy, and even strangulation, electrocution and suicide attempts.
2.3 Concealed symptoms (somatization symptoms) Many elderly people deny the existence of depressive symptoms and show various somatic symptoms, so emotional symptoms are easily ignored by family members, and only when the elderly are found to have suicidal attempts or behaviors do they go to psychiatry. Some people call this depressive disorder, in which depressive symptoms are masked by somatic symptoms, “occult depression”. These physical symptoms can be manifested as: digestive symptoms: such as loss of appetite, anorexia, bloating, constipation or vague epigastric discomfort; pain syndrome: such as headache, chest pain, back pain, abdominal pain and generalized pain; chest symptoms: such as panic, chest tightness, palpitations, etc.; autonomic nervous system symptoms: such as redness, hand trembling, fever, sweating, and generalized weakness. Among them, headache and pain in other areas without finding organic background are the most common, and peripheral weakness and sleep disorders are also common symptoms. Patients with repeated complaints of somatic discomfort without positive signs should be considered clinically as possible occult depression.
2.4 Hysteresis, the behavioral block of depressive disorder, is usually characterized by the lack and slowness of casual movement, which affects somatic activities, and is accompanied by reduced facial expressions, language block, the patient feels mental retardation and reduced attention, clinical manifestations of slow response, difficulty in thinking about problems and reduced active speech. Most of the elderly depressive disorder patients show sullenness, sad frown, interest, slow thinking, often do not answer immediately to questions, repeatedly asked, only to reply with short and low words. The content of thoughts is poor, and the patient is mostly in a state of silence and slow in action. In severe cases, the patient’s eyes are staring, his emotions are indifferent, and he is indifferent to external movements. Depressive disorder behavioral block is consistent with slow mental processes.
2.5 Delusions Patients with late-onset depressive disorder have more delusional symptoms. Patients with depressive disorder with onset after 60 years of age have more abundant delusional symptoms than those with onset before 60 years of age, and it is believed that delusional depressive disorder is mostly seen in the elderly. The age of onset of monophasic delusional geriatric depressive disorder is later than those of non-delusional geriatric depressive disorder. Among the delusional symptoms, suspicious delusions and delusions of futility are the most typical, followed by delusions of victimization, relationship delusions, delusions of poverty, and delusions of guilt. These delusions are generally predicated on the psychological state of the elderly and are related to their life environment and their attitude toward life.
2.6 Depressive pseudodementia It has been widely recognized that cognitive dysfunction is also a common symptom in elderly patients with depressive disorders, and this cognitive impairment can be improved by antidepressant treatment. About 80% of patients have complaints of memory loss, there is a more obvious cognitive impairment, and 10-15% of them resemble dementia manifestations, such as decreased calculation, memory, comprehension and judgment, which can be pseudo-dementia upon examination. Some of them will develop dementia.
2.7 Volitional behavior and suicidal tendency In milder cases, there is a decrease in motivation and initiative, strong dependence, depression and indecision; in heavier cases, there is a decrease in activities, avoidance of social interactions, slow movement, and an increase in time spent in bed; in severe cases, the patient may be in a state of no desire and completely unable to take care of himself in daily life. Patients with geriatric depressive disorder are at much greater risk of suicide than patients in other age groups. Suicide often occurs in the presence of physical illness and has a high success rate (10% suicide rate). The ratio of suicide attempts to successful suicides is 20:1 for those under 40 years of age and 4:1 for those after 60 years of age. risk factors for suicide are mainly loneliness, guilt, hypochondriac symptoms, agitation, and persistent insomnia. Personality characteristics and the degree of awareness of depressive disorders are important factors in determining the risk of suicide, such as helplessness, hopelessness, and negative attitudes toward life often increase the risk of suicide. There is a tendency for depressive disorders in the elderly to become chronic, and some patients are so overwhelmed by the depressive symptoms that they become increasingly suicidal and commit suicide to find relief. Once they decide to commit suicide, geriatric depressive disorder is often more determined than young patients, and their behavior is more insidious.
2.8 Other depressive disorders in the elderly can be manifested as acute psychotic state (disorder of consciousness), and the rhythmical change of day-heavy state of mind and night-light state of mind is often used as one of the diagnostic indicators of endogenous depression, but the circadian rhythmical change of mind in elderly depressive disorders is often not obvious.
IV. Diagnosis and differential diagnosis
It is best to see a specialist in the Department of Mental Health in order to exclude other disorders.
V. Treatment
1.Mild depression can be treated with psychotherapy alone such as supportive psychotherapy, cognitive-behavioral therapy and family therapy.
2.Moderate depression can be treated with sleep deprivation therapy Sleep deprivation therapy has a long history of being used for the treatment of depression disorders. Generally speaking, sleep deprivation therapy has a fast onset of action and can sometimes lead to a dramatic reduction in depressive symptoms within 24 hours. This is achieved by keeping the patient active and awake during the day, staying awake overnight, and remaining awake during the day the next day without a lunch break until bedtime in the afternoon or evening, for one treatment session. Deprivation of sleep once or twice a week, the interval can be 2 ∽ 3 days, after the improvement of symptoms gradually extend the interval, a course of treatment 8 ∽ 10 times. There are almost no side effects.
3, drug treatment because antipsychotic drugs are prescription drugs, and more side effects need to be used under the guidance of a doctor. And need to be under the guidance of the doctor constantly adjust the amount of medication and observe changes in the condition.