Journal of Clinical Outcomes Management. 2017 March;24(3)
References
Identifying LLD
In order to make the diagnosis of LLD, the clinician should be aware that clinical presentations may be varied, and symptoms may not be readily evident [13]. LLD is often under-recognized and under-treated, particularly in busy primary care settings where concerns about physical symptoms may take precedence over screening for behavioral health conditions [14]. Other barriers include phenomenologic differences (prominence of executive dysfunction, neurovegetative and somatic features) in depressed older adults compared to younger counterparts, under-reporting of emotional symptoms, and stereotypical views of emotional dysfunction being a “normal” part of aging [15,16]. Recognition of risk factors for depression can aid in making the diagnosis. Risk factors can be categorized as biological or psychosocial in nature ( Table 2 ) [17]. The most significant risk factors for depression in the elderly include female gender, past history of depression, sleep disturbance, disability, and bereavement [12]. Protective factors include physical health, self-efficacy, social connectedness, and religious involvement [17].
Accurate identification of LLD also requires recognition of the differences in the presentation of LLD compared with onset in earlier life. Depression in younger adults is often marked by depressed mood and loss of interest [18]. In contrast, older adults may present with increased anger or irritability [5]. Younger adults are more likely to report suicidal thoughts while older patients report feelings of hopelessness and thoughts of death [18]. LLD is often characterized by increased somatic complaints, hypochondriasis, or pain [5,18,19]. Another major difference lies in the presentation of cognitive difficulties. Younger patients typically complain of poor concentration or indecisiveness. Geriatric patients may present with cognitive changes including objective findings of slower processing speed and executive dysfunction on neuropsychological testing [17].
Depression rating scales may aid in identification of LLD. They are not a substitute for clinical diagnosis but can be useful as screening tools. Two commonly utilized depression rating scales are the Geriatric Depression Scale (GDS) and the Patient Health Questionnaire-9 (PHQ-9). GDS is a 30-item instrument developed specifically for older adults. Shorter 15-item, 5-item, and 4-item versions exist. The scale utilizes a Yes/No format and can be self- or clinician-administered [20]. One advantage of the GDS lies in its focus on psychological and cognitive aspects of depression rather than neurovegetative symptoms that may overlap with medical illnesses common in older adults [21]. The PHQ-9 is a 9-item self- or clinician-administered screening tool designed for use in primary care settings and has also been validated in geriatric populations [22,23]. The 9 items on this scale correspond to the DSM-5 criteria for major depression. A shorter 2-item version (PHQ-2) has also been validated, and a positive screen on this test should prompt administration of the full-length version. Both versions have approximately 80% sensitivity and specificity in detecting depression. An added advantage of PHQ-9 over GDS is that it can be useful in monitoring treatment response over time [22,23]
Comprehensive Assessment of LLD
The comprehensive assessment of patients with LLD can be carried out by health professionals in both mental health or primary care settings. In a multidisciplinary approach, psychiatrists and mental health professionals have collaborated with primary care providers using depression care managers with successful outcomes in managing depression in older adults [24,25]. Complete evaluation of a patient with suspected LLD begins with a history and physical and mental status examination. Other essential components of the evaluation include assessment of cognition, functional status, and suicide risk. Laboratory and neuroimaging studies may be necessary as well. Due to the comprehensive nature of this assessment, a multidisciplinary approach with collaboration between primary care, psychiatry, psychology, and ancillary services such as social work may be necessary. Multiple patient interactions may be required to complete a thorough evaluation.
