Depression
Depression is the most common psychiatric diagnosis over the age of 65 however it is often not appreciated in the ED. Geriatric depression has several features which make it different from our usual picture of the younger depressed person:
Older people who are depressed are:
- LESS likely to complain directly of depressed mood, sadness, or dysphoria
- MORE likely to complain of somatic complaints often to the point of hypochondriasis
- MORE likely to demonstrate psychomotor retardation to the point that the depression can be mistaken for dementia
- MORE likely to express worthlessness or self-devaluing
- MORE likely to complete a first attempt at suicide – particular risk factors are male gender, living alone, co-morbid illnesses, substance/alcohol use
Given the atypical presentation of this potentially high-risk condition, it’s valuable to keep depression in mind when evaluating the frequent flyer, or the vague historian with multiple complaints or the older person with weakness who just isn’t the same as he usually is.
Sleep changes: sleepy through the day or sleepless at night;
Interest: loss of interest in activities that used to interest them;
Guilt (worthless): depressed elderly tend to devalue themselves;
Energy: lack of energy or general fatigue is a common presenting complaint;
Cognition/Concentration: reduced cognition &/or difficulty concentrating;
Appetite/Weight: usually declined;
Psychomotor: agitation (anxiety) or retardations (lethargic);
Suicide or a preoccupation with death
Assessment for Depression
One validated quick tool is the ED-Depression Screen Instrument – Fabacher, 2002” Validation of a Brief Screening Tool to Detect Depression in the Older Patient – from Science Direct: Fabacher et al Am J Emerg Med 2002;20:99-102
Three questions:
- Do you often feel sad or depressed?
- Do you often feel helpless?
- Do you often feel down-hearted or blue?
Discussion: Depression
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Ok so I diagnose a depressive episode, what should I do in the ER setting?
I do wonder if there is a standard depression screening tool similar to the Columbia like for suicidal patient
helpful
Good info
good refresher
good info.
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agrees
Helpful tools
indeed, elderly patients are more prone to be less identified of having depression
everyone should be screened for dementia
very important screening proccess
important screening
good info
Ok
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this would be a good addition to our questioning to try and get the patient the necessary care they require
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extremely important
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With seniors it’s very difficult to diagnose depression especially if its masked by dementia or even delirium. That’s why it is important for the patients doctor to get the family involved or at least for the doctor to listen to the family’s concerns. any change from baseline behavior is always a concern and should be addressed and treated accordingly.
Agree
May be difficult to differentiate between dementia and depression.
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Many people are depress due to loneliness, loss of independence and illness.
depression is very common in general but missed in older people
very informative
very easy to mistake for dementia
great tools
easy tools to remember
simple tools, great information
we can use yesavage scale
standard
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very commonly missed
its easy to miss in yourself let alone patients
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social work involvement
we will have to keep trying
It’s important to ask the questions as written.
I agree depression is underdiagnosed in the elderly. I also think they deny when asked. We use a tool in the ED in triage . However, the symptoms often appear to be depression.
Depression is very underdiagnosed in this population.
many patients will shows signs of depression but will not state outright
Many older patients are depressed because of life events -loss of a loved one, loneliness, discomfort from chronic disease, loss of mobilit
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Intersting
yes
very
Very helpful.
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great reminder to assess for depression
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Helpful aids
Yes, events, history of loss of friend, love one. Chronic pain. Taking pills all day.
There are many things that can contribute and/or exacerbate depression in elderly patients.
I think depression in our older adults occurs more often than we realize. Social isolation, loss of autonomy, loss of mobility. So much loss. Need strong social supports and inclusion to social activities such as a day program or senior’s center.
Agree
this is helpful
very helpful information
helpful
great delineation
Pay attention to Patients comments and mood, great reminder.
very important
I like the 3 questions and both SADPERSONS and IS PATH WARM
Its a geat reminder that we must always pay attention patients statements,feelings and mood.
Tres muy buenas preguntas para conocer el estado de ánimo del paciente
The three questions are great for getting some feedback from the patient to probe further and identify depression or rule it out.
Can see how these things could be overlooked in the ED.
Good to know
Good to know
good
good to know
very helpful
Very good
important to assess for depression
SIGECAPS is also an important tool to use as part of the objective assessment process as some patient may not answer the any of the three question truthful
agreed, often overlooked
good to incorporate such information because i feel that depression is commonly overlooked but could really make a difference in a person who is properly treated
Very important information to consider when assessing an older client
Good info
I’ve noticed that the somatic complaints far outweigh the psychological confessions of feelings of guilt and depressed mood. Many older clients have expressed that it is “natural” to feel down when you are older. WE have a responsibility to probe this and help as best we can
like the info, good mnemonics from other post.
difficult to pick up depression in elderly as for many aging is depressing and they have many medical/social confounders
Many elderly patients suffer from missed or undiagnosed depression. We feel elderly may always feel tired/depressed & this is not so.
good info
I think often overlooked!
Depression can mimic delirium or dementia and is treatable
Depression is often overlooked. think many of the older males I see in the overnight hours in my ED are depressed (usually also widowed or otherwise partnerless and usually with vague or minor complaint during visit).
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I have used the geriatric depression scale, but they may not want to answer that many questions (15), Those 3 questions would be a quick screen to see if there may be a problem and the person’s willingness to discuss it.
extremely useful and easy to remember !
good acronym, makes remembering easier
helpful
mental health is often ignored in the LTC setting. Taking the time to ask these questions may help medical professional dig further into the feelings of older adults who may be socially excluded and deprived from stimuli
Older adults are at an increased risk of developing depression as many of their friends and loved ones are passing away and they may feel socially isolated.
definitely agree that older adults are more likely to experience depression, loved ones around them are passing, they are more likely to be alone, less likely to have more family interaction unless they live with their families and are often by themselves with less ability to do works of life
Many older patients are depressed because of life events -loss of a loved one, loneliness, discomfort from chronic disease, loss of mobility
Helpful
HELPFUL.
helpful
good info
S: Male sex
A: Age
D: Depression
P: Previous attempt
E: Excess alcohol or substance use
R: Rational thinking loss
S: Social supports lacking
O: Organized plan
N: No spouse
S: Sickness
I like this one.
GOOD
nice review
I like the brief screening tool.
Excellent information. Depression is something that we deal with daily.
Always good to ask about patient’s support system at home.
Great mneumonics to remember for screening depression in the elderly.
this review of depression topic is helpful
difficult to diagnose in the ED however screening tools are helpful
I have used CAM for some time and can now incorporate Mini-Cog instead of the time consuming MMSE. The 3 questions for screening for depression are useful although I incorporate mood assessment more naturally in my ADL inquiry
Geriatric depression screen is also a great tool its only 15 q’s and has good accuracy
SAD PERSONS is not a screening tool for depression, it is a tool used to assess suicidal risk, and it has very poor sensitivity.
Having read the Fabacher paper, to me the take home point is that depression is common amongst the elderly and we should make more of an effort to ask about it. Remembering those specific three questions is probably not that important — there were many big limitations to the study that would limit its generalizability (for one thing, less than half my patients speak English). Also I don’t even see what the difference between questions 1 and 3 is. Maybe asking the same question in two different ways just gives the patient a second chance to admit to feeling depressed, if the first question caught them off guard.
The pneumonic is extremely useful for remembering what to assess
I use SIGECAPS and find it extremely useful
I normally use SIGECAPS, but I like this SADPERSONS mneumonic. The simple 3 question approach would be useful for expediency in the ER to establish a raw baseline.
Just wanted to add that SADPERSONS is a mnemonic for suicide risk factors, not for depression.
The three questions are simple, easy to utilize and remember. Comments have been informative also.
Also familiar with SADPERSONS scale
good tools ,I went in the comments and really good suggestion too
Most if not all of us will experience loss as we age. Perhaps it is not only the loss that affects us as how we deal with the loss. No one can predict how one will react to a loss until it happens. I like the SADPERSONS scale along with kindness and compassion.
I also like to go through IS PATH WARM when recalling warning signs for suicide when assessing the older person with suspected/known depression:
I Ideation
S Substance Use
P Purposelessness
A Anxiety/Agitation
T Trapped
H Hopelessness/Helplessness
W Withdrawal
A Anger
R Recklessness
M Mood Changes
American Association of Suicidology (AAS) website (www.suicidology.org)
Screening tools are very helpful.
good
see this often – follow up often difficult
Useful tool
SAD PERSONS is the one I use. Easy to remember and relevant to questions
good tools
I really like this approach. Thanks to the other user LONDON 0536
I also use the Sadpersons scale:
S: Male sex
A: Age
D: Depression
P: Previous attempt
E: Excess alcohol or substance use
R: Rational thinking loss
S: Social supports lacking
O: Organized plan
N: No spouse
S: Sickness
Always best to enquire about patient’s social network
yep, this is true
Often overlooked – great tool – sadpersons
depression hurts us all
easy to treat, often missed
The Fabacher 3-part screen is useful. In patients who are positive, you need to have some way of getting them a more detailed assessment, either before they leave the ED or soon after discharge.
assess all aspects of patient and use mnemonic to assist
What about SI on initial screen
depression its a pathologic condition ever forget
maypores many adults become depressed by the last of their lives or living alone at this stage of his life
Many seniors are depressed by being alone in this stage of life and so lived
surprisingly, depression is so common
Didn’t know depression was so common…
🙂
I also use the Sadpersons scale:
S: Male sex
A: Age
D: Depression
P: Previous attempt
E: Excess alcohol or substance use
R: Rational thinking loss
S: Social supports lacking
O: Organized plan
N: No spouse
S: Sickness
This is helpful.
many patients will shows signs of depression but will not state outright
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Asking if they feel ‘blue’ doesn’t always work. I find many elderly ladies will deflect the question
I frequently find that pts will disclose to suicidal thoughts and concerns if you sit and talk to them and ask the direct questions
I am confused. If the older pt is less likey to complain of depressed mood, sadness and dysphoria, then why are the 3 questions for depression screen weights to mood?
Inquire with older patients to determine where they are at emotionally and how they are coping with the changes and losses in their lives.
Using the screening tool SIGECAPS will successfully reveal depressed geriatric patients.
I always inquire about loss of loved ones, any special dates (wedding anniversary etc) and loss of pets!!
Another difference: when older person decide to take his/her life, the method used is decisive and lethal – unlike the younger person who may pop some pills as a ‘cry for help’.
nursing home patients are quite a challenge new surroundings isolation from family coupled with a diagnosis of dementia to some degree,the families say they are depressed but they often can’t express even those simple 3 questions.
it seems every new admission to LTC is already on an antidepressant; some residents do well adjust and participate; while others just the opposite, the antidepressants don’t seem to help, they die soon after admission.
This Dx is too often missed in the elderly, and yet it is so easily treated.
But which came first, the loneliness or the social isolation and withdrawal due to depression? I see loss of mobility as inability to accept changes in mobility. There are lots of seniors who get a walker, start using assisted transport services and roll with it. And then there are others who can’t accept the changes. Fear of falling, ashamed to use a walker, rather stay in than go out- those are the guys to watch.
Many older patients are depressed because of life events -loss of a loved one, loneliness, discomfort from chronic disease, loss of mobility