impairment and disability, negative rehabilitation outcomes, and increased utilization of health care services (Bieliauskas & Drag, 2013). As such, the cost of depression is high, not only in terms of quality of life but also in healthcare dollars spent. Older adults with depression incur nearly 50% higher medical costs relative to their non‐depressed peers, even when controlled for the presence of chronic medical illness (Katon, 2003). In addition, depression in older adults can be accompanied by significant cognitive impairments and may mimic dementia. Thus, depression‐associated cognitive symptoms in older adults have historically been termed pseudodementia. However, that term is problematic as depression can accompany early cognitive change, posing a diagnostic challenge.
A common reason for referral to a neuropsychologist is to assist in the differential diagnosis of dementia versus depression, where interpretation of quantitative patterns on standardized cognitive testing can assist in the diagnostic differentiation. The cognitive domains of executive functioning, memory, and attention are often impacted in late‐life depression, and the nature and course of those cognitive symptoms differ relative to dementia. Whereas cognitive symptoms in late‐life depression often have an acute onset, Alzheimer’s dementia follows a more gradual and progressive course. Mood symptoms in late‐life depression tend to be more severe relative to Alzheimer's dementia, and the prominent mood symptom is dysphoria, while apathy is more common in dementia (Bieliauskas & Drag, 2013). Potentially further complicating the clinical picture is the understanding that depression is associated with poor adherence to medications across multiple chronic disease states often encountered in the elderly population, including hypertension, coronary artery disease, and hyperlipidemia (Grenard, et al., 2011). In turn, poor medication compliance may exacerbate chronic disease states that can lead to increased risk for cognitive compromise and contribute to accelerated morbidity and mortality.
Anxiety‐related disorders are commonly encountered in older adults, with prevalence estimates ranging from 6 to 12% of the population over age 65 (Skoog, 2011) to over 20% for caregivers of people with dementia (Mahoney, Regan, Katona, & Livingston, 2005). The accurate diagnosis of anxiety in the elderly may be complicated by the overlap of symptoms with physical medical conditions (e.g. shortness of breath, palpitations, tight chest), and thus it commonly goes undiagnosed (Koychev & Ebmeier, 2016). Indeed, it is common for anxiety symptoms to emerge in conjunction with physical illness such as COPD or congestive heart failure or with medication changes, with true physical symptoms of anxiety incorrectly attributed to the physical illness or medication side effects. Unfortunately, as is commonly found in mental health research, the presence of anxiety symptoms is associated with poorer quality of life, increased disability, and elevated mortality risk by physical cause (Brenes, et al., 2005; Bourland, et al., 2000; Tully, Baker, & Knight, 2008), which are factors that may be accelerated without identification and treatment. Importantly, comorbid anxiety and depression are common in older adult clinical populations, with accurate identification of the comorbid symptoms essential as untreated anxiety may impact response to treatment of depression (Andreescu, et al., 2007). Anxiety in dementia is also common and has been found associated with increased behavioural disturbances, which may further burden caregivers (Mega, Cummings, Fiorello, & Gornbein, 1996).
Psychosis, while often encountered in elderly individuals with neurodegenerative and neurological illness (e.g. Lewy bodies dementia), is less commonly encountered in the general non‐demented older adult population. Accurate identification can be challenged by the presence of ocular and auditory pathology, medical issues, and medication effects or the effects of polypharmacy in this population. While prevalence studies of psychotic symptoms in the elderly vary considerably, the incident of first‐onset psychosis was 5.3 per 1000 person‐years for those age 70 to 90 in the non‐demented population (Ostling, Pálsson, & Skoog, 2007). The presentation of psychosis in major depression is common in the elderly, especially in inpatient settings, with 45% of those with late‐life depression identified as having delusions in one study (Meyers & Greenberg, 1986). Often, depression with psychosis in the elderly may be intractable to medication trials, and electroconvulsive therapy may be a reasonable intervention for some patients. When considering the elderly population, the manifestation of psychotic symptoms may differ in quality and intensity relative to young patients. For example, somatic and visual hallucinations are more commonly encountered in the elderly, especially when the symptoms are secondary to a medical condition such as Parkinson’s disease. The presence of psychosis in dementia is high, with more than 50% of patients with probable Alzheimer’s disease displaying psychotic symptoms at some point during the disease course (Targum, 2001). Often complicating caregiving, persecutory delusions were found in 30% of patients with Alzheimer’s disease and 40% of patients with multi‐infarct dementia (Cummings, Miller, Hill, & Neshkes, 1987). Accurate diagnosis of the underlying cause of the psychosis is of utmost importance, as the identification of the medico‐neurological, psychiatric, or medication causes will ultimately guide treatment and/or behavioural management strategies.
Cognition is viewed as a key to successful ageing by patients and clinicians alike. Recent guidelines for screening of cognitive impairment in older age were published by the International Association of Gerontology and Geriatrics (IAGG) in response to the under‐detection and ‐documenting of an estimated nearly 50% of patients with some degree of cognitive impairment (Morley, et al., 2015). Detection is key, as cognitive impairment may substantially impact the course and nature of clinical care provided and the need for services to ensure health and safety that otherwise may not be considered. This is especially pressing when considering that medical comorbidities increase with age, as does the risk for cognitive decline. An illustration of the importance of understanding the relative degree of cognitive change can be seen in the scenario of older adults with diabetes and comorbid cognitive impairment. Successful management of diabetes requires insight to perform proper self‐care coordination, planning for glucose monitoring, medication and insulin management, and adherence to diet and exercise regimens. Individuals with memory problems may forget medications, insulin injections, glucose monitoring, and follow‐up appointments. Understanding how cognitive impairment may impact successful treatment is essential for developing strategies to improve disease management (e.g. use pillboxes and medication alarms, have pharmacy pack medications for each day) and identifying areas where a caregiver may need to provide aid or oversight. Insel, Morrow, Brewer, and Figueredo (2006) have identified that adherence to and independent management of medication is associated with executive functioning and working memory; when an individual’s abilities in those areas are reduced or impaired, substantial adherence problems may result. Understanding the potential impact of cognitive deficits on medication adherence may require the treating physician to simplify medication regimens and educate caregivers of the need for oversight of medications (Arlt, Lindner, Rösler, & von Renteln‐Kruse, 2008).
Psychological interventions in the elderly
Psychological Interventions are effective in the elderly with behavioural and mental health disorders, and it appears the older adult population prefers psychotherapy to psychiatric medications (Areán, Alvidrez, Barrera, Robinson, & Hicks, 2002). However, in a survey of physicians, only 27% of respondents indicated they would refer depressed older patients to psychotherapy (Alvidrez & Areán, 2002). Tailoring psychotherapeutic intervention for older adults is often beneficial given comorbid medical complexities and the bidirectional relationship of mental health diagnoses with medical burden, disability, and cognitive impairment. In a review of psychotherapy in older adults, Raue and colleagues show there is evidence that cognitive behavioral therapy (CBT), problem‐solving therapy (PST), and interpersonal psychotherapy (IPT) are similarly effective for treating late‐life depression relative to depression in younger adults (Raue, McGovern, Kiosses, & Sirey, 2017). CBT has been utilized with demonstrated effectiveness in treating late‐life depression and anxiety as well as in those with comorbid depression and heart failure (Freedland, Carney, Rich, Steinmeyer, & Rubin, 2015) or Parkinson’s disease (Calleo, et al., 2015). Providing effective and appropriate psychological intervention can improve the primary psychiatric condition and may positively impact the severity of comorbid medical conditions and healthcare utilization. In a randomized controlled trial for the treatment of depression in heart failure, those receiving CBT versus treatment as usual demonstrated lower depression