ELDERLY DEPRESSED PATIENTS – CLINICAL ASPECTS AND DIAGNOSIS

INTRODUCTION
Today, depression has become one of the major health problems, an estimated 350 million people of all ages suffering from depression. In the same time, depression is the leading cause of disability worldwide, and is a major contributor to the overall global burden of disease (1). In Romania, following a study conducted by the Romanian League of Mental Health showed a significant increase in major depressive episode with age, from 2.1% – 2.6% (18-49 years) to 4.4% – 5.2% (over 50 years) with a growth rate of 1.2 percentage points for each age group (50-64 years and above 65 years) (2). Depression is a major cause of disability in the elderly. Among its important consequences include reduced life satisfaction and quality, social deprivation, loneliness, use of health services and home care, cognitive decline, impaired daily activities, suicide(3). In recent years, several studies have evaluated the prevalence of depression in the elderly population, the results were between 1% and 20%. This variability could be explained by methodological differences (3-5). A number of studies have suggested that the prevalence of depressive disorders decreases after age of 65 years (6-14), but most of these studies have included only a few people over the age of 80 years. Another series of studies, including the very old, suggests that on the contrary, depression prevalence increased after the age of 65 years (15-19).
The necessity to provide increased emphasis on depression in elderly derives not only from the causative factors incriminated in occurrence of it, but also on the devastating impact that depression has on this category of persons. An elderly person is more prone to this condition due to changes occurring in the white matter on the front cortex, to predisposing vascular factors, to the presence of associated somatic diseases, to the deficiency of vitamin B12 and/or vitamin B9 (folic acid) (associated with depression), and also due to neurotransmitters reduced level with the age (serotonin, norepinephrine, dopamine). All these physiological changes caused by aging come to be complemented by a series of events that inevitably leave their mark on the mood: retirement, children leaving home, widowhood, aging, associated diseases, institutionalization in a profile center or other moments like that (15-19).
Sometimes, for elderly people, depression can have as a starting point the loss of a loved one, induction of the feeling that they are abandoned by their children or friends that are useless, that they have perished their purpose of life (15-19).
For elderly, as well as for young people, depression is usually accompanied by anxiety. Among the factors that amplify the feeling of anxiety to elderly depressive patients, there are living in new environments (for institutionalized persons), moving them from their home, t e a r i n g f r o m t h e i r p l a c e s , t h i n g s , n e i g h b o r s , acquaintances, together with biologically modifications which accompany aging already mentioned. In such a context the elderly person is no longer in contact with familiar people, places or things. Replacing all that with something new (new people, new living environment or surrounding objects), inevitably may leads to the increase feelings of insecurity, generating feelings of anxiety (15- 19).
The severity of depression in elderly patients range from common mild forms of depression to severe forms of depression, with psychotic symptoms with increased risk of suicide attempt. Sometimes, even if the forms of depression in the elderly patients are mild, are causing much suffering. The risk of suicide that arises from depression is increased in the elderly, especially in the range of 80-85 years old (20-22).
Methods
This research was conducted between May-July 2016, in “Ana Aslan” National Institute of Geriatrics and Gerontology and included a total of 90 patients, aged between 41 and 96 years old who were addressing to medical assistance for various diseases characteristic to the age.
Statistical analysis:
We used descriptive analysis to characterize demographic and repartition into framing by age categories. Discrete variables are described using frequencies and percentages. All statistical tests were 2 tailed; α (level of significance) was 5%. Discrete variables were analyzed
with an x2 test.
Depression and anxiety evaluation.
HADS scale (Hospital Evaluation of Depression and Anxiety Scale) was used for diagnosing and establishing the severity of depression for elderly patients. The main objective of HADS scale is to monitor depression and anxiety in patients hospitalized in non-psychiatric medical institutions, which often have non-specific and less severe symptoms (23). This scale was chosen mainly because depression and anxiety are two common diseases that occurs in selected population and context of the present research. Bases on seven criteria related to depression and other seven related to anxiety, the self-evaluation performed by this scale may take between 3 to 6 minutes, the patient being asked to record symptoms and experiences that occurred in the past week. Each criterion is rated on a scale from 0 to 3 points, giving a total score of maximum 21 points for each, depression or anxiety. For either of the two conditions (depression or anxiety), framing, depending on the score, is the following: 0-7 normal; 8-10 easy; 11-14 moderate; 15-21 severe. Psychometric properties and convergent validity of the scale were confirmed by Bjelland (24) and Zigmond (25). In case of depression, HADS-D scale ensure a specificity of 0.79 and a sensitivity of 0.83, while for anxiety, HADS- A scale demonstrates a specificity of 0, 78 and a sensitivity of 0.9.
Framing by age categories.
Regarding the framing by age categories, we chose to distinguish three of them:
– up to 75 years old, period of transition to old age, or older person period;
– between 75-85 years old, we are talking about old person period;
– over 85 years old, we consider that the old age or the period of great longevity.
Results
Descriptive data. From the group of 90 people included in the survey, 60 person (67%) were women, the remaining 30 person being men (33%). Related to the framing age categories, the vast majority of the patients were aged up to 75 years (68%, elderly), 27% were old person, and only 4 person (6%) were belonging to the period of great longevity.
Regarding their origin, 82 people were urban (91%) and only 8 coming from urban areas. Not surprisingly, due to the age category tracked in the study, 80 persons were retirees (88%) and 10 were employees (12%).
The most common associated somatic disorders for elderly patients that addressed to the geriatrist were cardiovascular ones (in 58% of evaluated patients), followed by metabolic ones, diabetes, liver and kidney diseases.
Depression and anxiety evaluation.
Performing the HADS-D scale to this group of elderly patients has identified the presence of depression in 40% of patients.
64% of elderly depressed patients showed a mild form of depression (23 patients), 31% had moderate depression (11 patients) and only 5% had severe depression.
Anxiety was much more present compared with depression, 69% of patients addressing to the geriatrician experienced different degrees: 29% (18 persons) had mild anxiety, 50% had moderate anxiety (31 patients) while
21% had severe anxiety phenomena.
Regarding the presence of depression according to the age categories of the patients, distribution of this condition was equal between groups of older persons (up to 75 years) and old persons (between 75-85 years) and less common in the group of great longevity people (12%). The patients from older person period (up to 75 years) had a higher proportion (75%) of moderate to severe depressed patients while the same form of depression was present in only 15% of patients over 75 years.
Regarding anxiety framing according to the age categories anxiety was present in major proportion, 73%, in older person (up to 75 years), in 24% of old person period (between 75-85 years) and in only 3% of patients with great longevity. It should be noted that 70% of elderly patients with anxiety showed moderately/severe forms of it.
Not surprisingly is the fact that a differences in the presence of depression and anxiety in the group of patients analyzed, occurred only in the category of employed patients, a mild depression being present in 10% of them, while anxiety was claimed by 80% of them, unlike the retirees sub-group, were the report was more balanced,
44% of patients accusing phenomena of depression and
64% of them accusing symptoms of anxiety.
Discussions
Even if over the last period there have been increasingly more studies on depression and anxiety in different categories of the population, there is yet a lack of information about depression and anxiety in in the population older than 60-65 years. Such research is particularly necessary as the prevalence of depression significantly increases starting with people who belong to the category of older (40% in this study versus 6-10% in the worldwide general population) (26). The same phenomenon is true for anxiety, a prevalence of 14-15% in the worldwide general population (26), is well below 69% prevalence of anxiety in older patients detected in this research.
Beyond the physiological changes caused by aging and favoring the appearance of depression, elderly patients is profoundly affected by the events that put powerful mark on their mood. That is why, in most of the cases, depression is triggered by events with strongly negative connotations (the loss of a loved one, retirement, children leaving home, institutionalization) and is amplified by feelings such as loneliness, hopelessness, insecurity. The intensity of depression is sometimes mitigated by keeping the elderly person in a form of current daily activity (people who are still working or are involved in physical activity or mental one, daily) unlike those at retirement that are no longer involved in the daily activities, even routine ones.
One theory can be that insecurity induces a high degree of anxiety because 69% of elderly patients who addressed to the geriatrician mentioned various manifestations of anxiety, in opposition with 40% of elderly patients that complained about depression.
An interesting research initiative would be to establish whether there is a connection and/or a correlation between the presence of anxiety and depression in elderly patients, the degree of induction of one to another and their degree of augmentation.
Given the size of the lot discussed in this research, we believe that the implementation of similar studies in our country, but on a much larger scale, could shed more light on what turns out to be one of the most oppressive conditions that affect the quality of life for elderly patients.
ACKNOWLEDGEMENTS:
All the authors had an equal contribution and have similar rights. All the authors approved the final version of this article.
DISCLOSURES:
The authors report no conflict of interest for this article.

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