Elizabeth J. Santos, MD, Geriatric Psychiatry and Interdisciplinary Geriatric Fellow, Program in Geriatrics and Neuropsychiatry, Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA.
Lisa L. Boyle, MD, Geriatric Psychiatry and Interdisciplinary Geriatric Fellow, Program in Geriatrics and Neuropsychiatry, Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA.
Jeffrey M. Lyness, MD, Associate Professor and Director, Program in Geriatrics and Neuropsychiatry, Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA.

Dysthymic disorder is a chronic depressive illness that affects approximately one to five percent of seniors. Often undetected and untreated, dysthymia is associated with significant psychological distress, medical burden, and functional impairment. Dysthymic disorder in the older population can be challenging to diagnose because of comorbid medical conditions and life losses. Dysthymic seniors often present differently than younger patients. The general practitioner plays a crucial role in identifying and providing interventions for older dysthymic patients. Careful evaluation, psychoeducation, and therapeutic interventions are essential to alleviate further suffering and to improve quality of life and function for these patients.
Key words: dysthymic disorder, depression, psychological symptoms, medical comorbidities.

Marie Crowe, RPN, PhD, Associate Professor, Department of Psychological Medicine, Christchurch School of Medicine and Health Sciences, Christchurch, New Zealand.
Sue Luty, FRANZCP, PhD, Associate Professor, Department of Psychological Medicine, Christchurch School of Medicine and Health Sciences, Christchurch, New Zealand.

Because there are particular corollaries to the treatment of depression in older adults, which include contraindications to the use of antidepressant drugs in combination with many medications, there is a need to examine nonpharmacological forms of treatment. This paper is based on a review of the literature on nonpharmacological treatments for depression in older adults. Electroconvulsive therapy has a role in severely depressed older adults because of its rapid effectiveness in life-threatening situations while psychotherapy, either on its own or in combination with antidepressants, is effective in the treatment of mild to moderate depression.
Key words: older adults, psychotherapy, depression, electroconvulsive therapy.

Tony Lo, MD, Resident, Department of Psychiatry, University of Calgary, Calgary, AB.
Nadeem H. Bhanji, BSc(Pharm), MD, FRCP(C), Assistant Professor, University of Calgary; Staff Psychiatrist, Carewest Glenmore Rehabilitation Hospital; Elderly Psychiatrist, Department of Psychiatry, Peter Lougheed Centre; Assistant Professor, University of Calgary, Calgary, AB.

Major depression and subsyndromal depression are common in older persons. Unrecognized depression results in increased morbidity and mortality. Recognition of depression is challenging due to patient- and clinician-related factors. Diagnosis in the older person is confounded by medical comorbidities as well as normal changes. Depression in older adults manifests differently: somatic complaints, nonspecific symptoms, and cognitive difficulties are common, as are behavioural changes, including apathy and irritability. Anhedonia better reflects depression, since depressed mood is often denied by the older person. Depression is likely to be missed if only typical symptoms are sought. Appropriate recognition can lead to improved treatment and outcomes.
Key words: depression, older adult, diagnosis, recognition, management.

I am writing this editorial as August is coming to an end and we are all a bit wistful about the winding down of summer. This has been a long arduous summer for me: no opportunity for vacation, covering two clinical services simultaneously in two separate hospitals because of physician shortages, and, most difficult to deal with, the death of my father. I can say honestly that I feel depressed today. However, I know that I am not clinically depressed. I am optimistic for the future, and I appreciate the fact that my children were home for their grandfather’s death and felt they were able to alleviate his distress and mine. I have no vegetative signs of depression. I simply have a low mood that would be natural for anybody under my circumstances. It is already improving.

However, I think the use of the word depression for a normal transient mood fluctuation as well as for a serious disease sometimes causes many of us to underestimate the gravity of the diagnosis. Depression, the disease, causes tremendous suffering and loss of life. When it accompanies other common morbidities in older adults, such as cardiac disease, it further worsens the prognosis. Depression is a serious disease in the older population, and now that effective treatments are available, it is important that the diagnosis be actively considered and searched for. Unfortunately, current medications do have side effects and limitations, so they cannot be prescribed indiscriminately. As in all areas of medicine, proper prescribing is dependent on accurate diagnosis. However, age-related changes and comorbidities can often make the diagnosis of depression in older adults challenging. We are confident that this edition of our journal, with its focus on depression, can help.

Drs. Tony Lo and Nadeem Bhanji highlight the changes in the presentation of depression with their article “Beyond Sad Mood: Alternate Presentations of Major Depression in Late Life,” and Drs. Elizabeth Santos, Lisa Boyle, and Jeffrey Lyness discuss “The Clinical Approach to Dysthymic Disorders in Older Adults.” Drs. Marie Crowe and Sue Luty discuss “Nonpharmacological Treatments for Older Adults with Depression,” while Drs. Lakshmi Ravindran, David Conn, and Arun Ravindran review “Pharmacotherapy of Depression in Older Adults.” Drs. Marnin Heisel and Paul Links discuss the “Primary Care Prevention of Suicide Among Older Adults.”

As well, we have our usual collection of columns. Dr. David Goukassian discusses “Mending the Rift: DNA Repair and Aging” while Drs. Nages Nagaratnam and Gowrie Pavan write about “Mutism in the Older Adult.” Dr. Kevin Billups informs us about “Erectile Dysfunction as an Early Marker for Cardiovascular Disease” in our CVD column, while our Dementia column, by Drs. Raj Shah and David Bennett, is about “Diagnosis and Management of Mild Cognitive Impairment.”

Enjoy this issue,
Barry Goldlist

Eric M. Morrow, MD, PhD, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.
William E. Falk, MD, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.

Anxiety in older patients, when excessive in degree and duration, can cause significant impairment and, if left untreated, may result in profound comorbidity--in particular, depression. Anxiety symptoms emerging in the older patient necessitate an extensive medical and psychosocial workup. There is a paucity of data for pharmacological treatment of anxiety disorders in older adults. In this review, we will discuss some of the research in the area of diagnosis and treatment of anxiety in older adults. We will also summarize some practice parameters common in our clinic when data are absent or lacking. The use of psychotherapies (such as cognitive behavioural therapy) and of medications such as the SSRIs, as well as benzodiazepines and other agents including the atypical antipsychotics, are discussed. The differential diagnosis of anxiety symptoms in the older patient, including careful attention to underlying medical and neurologic causes of anxiety, are emphasized.

Key words: SSRIs, benzodiazepines, psychotherapy, anxiety, depression, dementia.

D’Arcy Little, MD, CCFP, Lecturer, Department of Family and Community Medicine, University of Toronto; Director of CME, Geriatrics & Aging, Toronto, ON.

The Baycrest Centre for Geriatric Care and the Department of Psychiatry at the University of Toronto held “Psychogeriatrics Update 2004” at the Wagman Centre on the grounds of Baycrest on November 19, 2004. The morning consisted of a plenary session of particular interest to geriatric psychiatrists, community psychiatrists, geriatricians, primary care physicians, and other paramedical personnel working with older patients. This was followed by an afternoon of supplementary small group workshops. The following are some highlights from the plenary session.

Key words: psychogeriatric, bipolar, depression, older adult.

The symposium opened with Dr. Kenneth Shulman’s review of late-life bipolar disorder. Dr. Shulman reminded the audience that bipolar disorder in older adults, while not a major public health problem, represents a paradigm for psychiatry in old age. This particular illness represents a complex mix of genetic, environmental, and biological factors. In addition, the treatment of the illness is often challenging because of the coexistence of other medical problems in older patients, as well as the potential for adverse drug interactions with medications such as lithium.

According to Dr. Shulman, the clinical manifestations of mania in old age are similar to those seen in patients of other ages. However, the symptoms are often not as intense as in younger patients. Furthermore, there is a higher prevalence of cognitive impairment in older adults with mania. Dr. Shulman reviewed data showing that 57% of older patients with a first episode of mania had other neurological disorders.¹

Central nervous system lesions associated with secondary mania in the aging consist primarily of right-sided lesions, especially in the orbitofrontal cortex, and are often vascular in nature. The lesions are often silent cerebral infarctions picked up as hyperintensities on CT scanning. This right-hemispheric predominance is in contradistinction to late-life depressive disorders that have been shown to have an association with left-hemispheric lesions (Figure 1).²

Dr. Shulman then reviewed the practical application of this data. The prevalence of vascular lesions in late-onset mania suggests important components of treatment. The initial workup of late-onset mania should include a detailed neurological exam as well as neuroimaging to detect the presence of associated neurological lesions. An important aspect of management is to optimize the treatment of other medical illnesses and to aggressively treat vascular risk factors.

Dr. Shulman then reviewed the important role of lithium carbonate in the management of bipolar disorder in the aging. This drug has the best evidence as a mood stabilizer in the older patient.³ However, its use declined with the introduction of divalproex in 1993, despite the lack of efficacy or effectiveness data in older adults. Of course, there are special considerations for the use of lithium in older patients. These include drug interactions with medications commonly used in older patients, such as thiazide diuretics, loop diuretics, angiotensin-converting enzyme inhibitors, and non-steroidal anti-inflammatory drugs. Other important considerations include altered pharmacokinetics and the possibility of altered kidney function in the older patient; in light of this, a narrower therapeutic range for lithium in the older population has been advocated, with a target serum lithium level in this population of 0.4-0.8mEq/L.

Dr. Alastair Flint reviewed an approach to treatment-resistant depression in the older adult. He defined treatment resistance as the “failure to adequately improve with an adequate dose [of treatment] given for an adequate duration.” He explicated this concept by stating that treatment-resistant depression can be defined as the failure to adequately improve after two trials of two different antidepressants from two different classes with or without augmentation. Using this definition, a significant number of patients will not undergo remission. He referred to the recognition of this problem as a significant paradigm shift in psychiatry, and urged clinicians to be thinking ahead with respect to each patient with depression and their next therapeutic step(s) should remission not be achieved.
The first steps in treatment-resistant depression are to ensure that the diagnosis is correct, the patient has indeed received an adequate treatment, and that there are not coexistent medical or psychiatric disorders that are interfering with the response to treatment.
In older adults, two important coexistent disorders that need to be considered are dementia (especially frontotemporal dementia) and psychosis. For instance, an early subcortical or frontal lobe dementia can present with significant apathy and loss of motivation that can be confused with depression. In addition, the presence of psychosis is often missed and can present with profound psychomotor retardation that can be confused with severe depression. In cases of profound psychomotor retardation, Dr. Flint encouraged clinicians to consider the diagnosis of psychosis until proven otherwise. This is important because psychotic depression in older adults has been shown to be responsive to electroconvulsive therapy (ECT), but much more resistant to tricyclic antidepressants or a combination of tricyclic antidepressants and antipsychotics.

Other disorders that can coexist with depression and render it less likely to respond to medication include other medical diseases such as cerebrovascular disease, dementia, and other psychiatric illnesses such as anxiety, substance abuse, and personality disorders.
Once other disorders are ruled out, a variety of strategies exist for treatment-resistant depression, including:

1. Optimizing existing treatment
2. Augmenting the antidepressant
3. Combining antidepressants
4. Substituting another antidepressant
5. Considering ECT

Optimizing existing treatment can take the form of increasing the dose of medication and/or the duration of treatment to optimize the effect. Augmentation includes using other agents to enhance the success of antidepressant treatment. This can be accomplished by adding agents such as lithium (to a serum level of 0.5-1.0mmol/L), triiodothyronine (25-50µg/day), anticonvulsants, antipsychotics, stimulants (such as methylphenidate hydrochloride), or tryptophan. Lithium augmentation has the most compelling data in augmentation.

Dr. Flint reminded the audience that electroconvulsive therapy is the most efficacious treatment for depression, especially treatment-resistant depression. Important considerations here include the need to taper the ECT after a response and to start pharmacotherapy during the ECT to maintain the response.

1. Tohen M, Shulman KI, Satlin A. First-episode mania in late life. Am J Psych 1994;151:130-2.
2. Braun CM, Larocque C, Daigneault S, et al. Mania, pseudomania, depression, and pseudodepression resulting from focal unilateral cortical lesions. Neuropsychiatry Neuropsychol Behav Neurol 1999;12:35-51.
3. Bauer MS, Mitchner L. What is a “mood stabilizer”? An evidence-based response. Am J Psych 2004;161:3-18.

The accredited CME learning activity based on this article is offered under the auspices of the CE department of the University of Toronto. Participating physicians are entitled to one (1) MAINPRO-M1 credit by completing this program, found online at www.geriatricsandaging.ca/cme.htm

Lonn Myronuk, MD, FRCPC, Member of the Canadian Academy of Geriatric Psychiatry, President, GeriPsych
Medical Services, Inc., Parksville, BC.

Depressive symptoms in older adults are common and are associated with subjective distress, increased rates of functional impairment, and death. The natural history of depression in the aged appears to differ from that of the younger population, such that conventional criteria for diagnosis of a major depressive episode may not be met by the older patient. Yet, these subsyndromally depressed patients have equivalent levels of disability and risk of morbidity and mortality. Current thinking advises the inclusion of subsyndromal patients in treatment for depression, in contrast to earlier recommendations.

Key words: aged, depressive disorders, morbidity, mortality.

Rola Moghabghab, RN, MN,¹ Lori Adler, RN, MHSc,² Carol Banez, RN, MAN,¹ Faith Boutcher RN, MSc,³ Athina Perivolaris, RN, MN,³ Donna-Michelle Rancoeur, RN, MSc(A),³ Donna Spevakow, RN, MSN,³ Sandra Tully, RN, MAEd,¹ Susan Wallace, RN, MSc³ and Kevin Woo, RN, MSc.<sup>4

1</sup>Advanced Practice Nurse, University Health Network; ²Administrative Director, Regional Geriatric Program, Toronto Rehabilitation Institute; ³Advanced Practice Nurse, Toronto Rehabilitation Institute; ⁴Advanced Practice Nurse, Mount Sinai Hospital; Toronto, ON.

Confusion related to dementia, delirium and/or depression is a common concern in the older adult. The Registered Nurses Association of Ontario Best Practice Guideline (BPG),"Screening for Delirium, Dementia and Depression in the Older Adult", was implemented as a pilot project by Advanced Practice Nurses on eight different units at Toronto Rehabilitation Institute, University Health Network and Mount Sinai Hospital. This article describes the development of the BPG and its implementation, including the design of an education program and a screening process to assist nurses. Discussion focuses on the facilitators and barriers to BPG implementation and effecting sustainable change in practice.

Kiran Rabheru, MD, CCFP, FRCP, ABPN, Physician Leader, Geriatric Psychiatry Program, Regional Mental Health Care; Chair, Division of Geriatric Psychiatry, University of Western Ontario, London, ON.

Electroconvulsive therapy (ECT) is an effective and relatively safe procedure for treating severe, treatment-refractory mood disorders in special populations, particularly in the elderly. The frail elderly are especially good candidates for ECT because they are often unresponsive to, or intolerant of, psychotropic medications. The central nervous, cardiovascular and respiratory systems require special attention during the course of ECT. With modern anesthesia techniques and careful medical management of each high-risk patient, most elderly can successfully complete a course of ECT. Obtaining informed consent for ECT from incapable patients is a challenging issue with few concrete guidelines.
Key words: electroconvulsive therapy, elderly, depression, special patient population.

Margda Wærn, MD, PhD, Institute of Clinical Neuroscience, Sahlgrenska University Hospital, Göteborg, Sweden.

Seniors who commit suicide often consult their doctors a short time before they take their lives, but few communicate their suicide intent. Rather, they may focus on somatic complaints. This paper reviews the literature on the connection between physical illness and suicide. Recent research shows that over half of those who commit suicide late in life suffer from serious physical illness or impairment. The association between physical illness and suicide may be stronger in men than in women. Since most physically ill persons who commit suicide suffer from depression, depression should be treated aggressively in seniors with concomitant physical disorders.
Key words: suicide, suicide attempts, physical illness, depression, elderly.