geriatric depressive disorder
Introduction
Introduction to senile depression Old age depression refers to a mental disorder in the elderly, with a persistent depression as the main clinical phase. Clinical features are characterized by depression, anxiety, delay, and a variety of physical discomfort. Mental disorders cannot be attributed to physical illness or brain organic lesions. The general course of disease is long, with a tendency to relieve and relapse, and some cases have a poor prognosis. basic knowledge The proportion of illness: 0.02% Susceptible people: the elderly Mode of infection: non-infectious Complications: heart failure
Cause
Causes of senile depressive disorder
(1) Causes of the disease
The etiology of affective disorder is still unclear. It may be related to pre-existing personality, genetics, biochemistry and psychosocial factors. The pre-disease personality of elderly patients with depression is characterized by stubbornness, strong dependence, narrow mind and seriousness. Most people have psychosocial predisposing factors before the onset of illness. The most common incentives are often narrowed in social life after retirement. They live in a unit separated from their neighbors and live in a neighbourhood. The environment changes and is restricted by physical conditions. Interpersonal communication is interrupted, people are separated, and there is a sense of loss that has been abandoned by society. Children in the family have grown up to work and study, even after marriage, and the lifestyle is different, while the elderly are The reduction of living time together makes the elderly feel lonely and lonely, away from, after retirement or loss of working ability, the economic source is reduced in the status and role of the family, and at the same time the special age of the elderly, negative life events will continue to emerge, such as Loss of spouse, death of relatives and friends, family conflicts, accidents and many other factors can easily lead to grief for the elderly Emotional, social environmental factors and pre-existing personality, potential factors such as past painful experiences and original health conditions, which cause psychological changes, leading to the occurrence of geriatric depression, although these factors are complex and intertwined, but this Does not affect the diagnosis and treatment of emotional disorders in the elderly by most doctors.
(two) pathogenesis
1. Genetic factors Kay (1959) investigated a group of elderly depressed patients with different ages. Firstly, it was reported that the genetic load of the first onset patients in the old age was significantly lower than that of the early onset, Shen Yucun et al. (1990). It was also found that 14.7% of family members with late onset of affective disorder, and 45.5% of patients with early onset unilateral depression were significantly different. Yu Xin (1996) analyzed 45 patients with affective disorder who were older than 60 years old. There were 11 cases of maddening and bipolar disorder, 34 cases of unipolar depression, and 2 cases of family history of affective disorder, accounting for 4.4% (Yu Xin, 1996). It is speculated that the role of genetic factors in the pathogenesis increases with age. Large and reduced.
2. Psychosocial factors Domestic Chen Yaoyin's survey found that the incidence of major life events in elderly depression was similar to that of young and middle-aged people, but the severity of the incident was serious. The types of incidents were family conflicts and physical illnesses, while the types of young and middle-aged events were individuals. , work, study, and mourning reactions are common. This kind of bad mood can last for one month. If you can maintain normal adaptability, you should be regarded as a normal reaction. Not every disease that suffers from major life events is sick, and it is not necessarily emotional. obstacle.
3. Pre-existing personality characteristics Normal aging process is often accompanied by changes in personality characteristics, such as solitude, passiveness, dependence and stubbornness. Post (1972) and Abrams (1987) found that patients with this disease have obvious personality defects, and normal elderly These features are more prominent than the presence of prominent avoidance and dependence on personality characteristics in the elderly.
4. Biochemical metabolic abnormalities In recent years, studies have found that in patients with unipolar depression, blood (norepinephrine) NE, NE, 3-methoxy-4-hydroxyphenyl glycol (MHPG) and its metabolites in cerebrospinal fluid are not reduced. It is elevated, and monoamine oxidase inhibitor (MAOI) and tricyclic antidepressant (TCA) increase NE, 5-HT action occurs rapidly, and clinical manifestation time is slow, which makes the monoamine theory of affective disorder challenged, Segal (1974) Firstly, the receptor hypothesis is put forward, which is considered to be caused by NE,5-HT receptor hypersensitivity in the brain. Receptor hypersensitivity may be an adaptive response to the reduction of monoamine available in the synaptic parts of depressed patients. Antidepressant Drugs reduce receptor sensitivity to therapeutic effects, but paroxetine does not down-regulate beta receptor sensitivity. 5-HT has been valued in the field of antidepressant and affective diseases, and selective 5-HT depleting agents can reverse TCAs and MAOIs. The antidepressant effect, the 5-HIAA content in the brain of suicides was significantly reduced. It was found that the concentration of 5-HT in cerebrospinal fluid was related to the degree of depression. The lower the concentration, the more severe the depression. In addition, DA and GABA, cholinergic system dysfunction were also Related to affective disorders.
Regardless of whether the drug acts on monoamine uptake or blockade, from the first messenger perspective, Wachtel (1988) proposed a second messenger hypothesis: under normal circumstances, NE transmits information from cAMP, and Ach is composed of phosphatidylinositol system. By transmitting information, the balance between the two sides maintains normal mood, the decline in cAMP system function leads to depression, and the enhancement leads to mania.
5. Neuroendocrine normal neuroendocrine changes in the elderly and depressive disorders are common, sometimes the same patient has both a slow TRH response and abnormal DST, some of which are only one of them, some of them are not, age The factors themselves (men over 60 years old) can cause a slow TRH response, and the pathophysiological significance of neuroendocrine changes is still unclear and needs further clarification.
6. Brain anatomy and pathological changes CT and MRI techniques have been used in the study of affective disorders. The increase in the incidence of structural changes in the subcortical brain of patients over 45 years of age has been confirmed by MRI imaging. These lesions may be related to the elderly. The occurrence of depression is related to prognosis (Krishnan et al, 1988). Wang Jiahua et al (1996) found that the incidence of depression in elderly people with age-related brain changes was higher than that in those without change, and the incidence of anxiety was also high. Whether the morphological changes of the brain in patients with dysfunction are still immature, and further data tracking research is needed.
Prevention
Prevention of senile depression
When the age reaches the old age, there are many changes in the structure and function of the human body. According to the study, if the elderly over 65 years old are compared with the 30-year-old healthy individual, the brain weight of the former is 56% of the latter, cerebral blood. The flow rate is 80%, the maximum working rate is 70%, in addition, there is a significant decline in heart, kidney, respiratory and metabolic functions (Schultz, 1973). It can be seen that as the age is old, the human mental function tends to be slow. And not flexible enough, of course, not all of them. There are many elderly people whose mental function is still very good. The lifestyle of the elderly is becoming more monotonous, more and more lonely, high blood pressure, arteriosclerosis and heart disease. Increasingly, under the influence of many factors such as the aging of the body and the decline of the family status, as well as the economic affluence, the organic or functional mental disorders of the elderly are present in today's world where human life is generally prolonged. Relatively increasing the trend, using multiple stepwise regression analysis, the results show that the most closely related factors of adverse emotional relationship are health status, family relationship, marital status, Franciscan Sources, age and family structure and other factors, therefore, pay attention to mental health in old age, prevent the occurrence of mental illness in old age, it is important for reducing the occurrence and part of this disease.
Some studies have pointed out that after some old people retired, the family became the center of the elderly activities, followed by monotonous life, "empty nest" phenomenon, widowhood, family interpersonal relationship and changes in the family role of the elderly are all facing the elderly. Mental health problems, these problems are handled well, and if they are well-adapted, they will be happy. They can continue to exert their residual heat and contribute to the society. If they are not handled well, they will not be able to adapt, mood depression, emotional depression, and even loss of interest in life. In recent years, the incidence of senile depression in the elderly has increased significantly, which is closely related to the psychosocial factors and environmental factors of the elderly.
The elderly should pay attention to the following points in mental health care:
1 to prevent the occurrence of heart disease in old age: to improve the welfare of retired elderly people, improve their material living standards, coordinate their family life, enrich the content of cultural life, and reduce mental stress, for patients with heart disease Pay full attention to environmental adjustment and psychotherapy.
2 to prevent senile sputum: in the case of congenital diseases, elderly patients are prone to senile convulsions, it is necessary to actively prevent early physical disease, pay attention to the patient's tolerance to any drugs used, when the physical illness or nutrition is relieved After the metabolic disorder, senile convulsions are expected to return to normal.
3 pay attention to improve brain function, prevent mental disorders caused by some ischemic brain diseases, prevent the development of cerebral arteriosclerosis, strengthen cerebral blood circulation, and if necessary, preventive treatment measures, such as taking blood lipids, reducing blood vessel fragility, and promoting Small arterial expansion drugs, etc.
4 Carry out publicity and consultation on mental health for the elderly, popularize common sense of medical and health, enhance the adaptability of the elderly, and find out early, timely diagnosis and treatment, and reduce mental disorders and mental illness of the elderly.
In women, the body changes in menopause are more significant. When women are 45 to 50 years old, the ovaries stop ovulation, menstruation stops, and the decline of gonadal activity is more prominent. The resulting endocrine system and related metabolism have changed. The autonomic nervous system also has obvious disorders, and therefore also affects the high-level neural activity of the cerebral cortex. Women in menopause often have weak and weak dysfunction, lack of energy and anxiety, anxiety, plus the appearance of aging and autonomic function. Unstable, many people show menopausal symptoms to varying degrees. A few people, under the trigger of certain trauma, have a menopausal state of depression or paranoia. In the youth, they have emotional psychosis and are in menopause. It is also easy to be ill, clinically mostly with anxiety and depression as the main disease. Women in the menopause stage should strengthen physical exercise, ensure adequate sleep and pay attention to physical and mental health, pay attention to prevent trauma and physical illness, and have symptoms of menopause. Groups should use endocrine and other treatments in a timely manner. Often, doubtful people should be diagnosed and treated early.
Complication
Complications of senile depressive disorder Complications heart failure
The general course of disease is long, with a tendency to relieve and relapse, and some cases have a poor prognosis.
Symptom
Symptoms of senile depressive disorder Common symptoms Loss of appetite, fatigue, back pain, mental disorder, dizziness, dementia, cognitive dysfunction, anxiety, insomnia
There is no qualitative difference between the clinical manifestations of senile depression and young adults. There is no consensus. At least the disease is still affected by the psychological and physiological changes of the aging process (Ma Xin, 1994).
1. Mixed state of anxiety, depression and agitation In elderly patients, the feelings of sadness are often not well expressed. They often use no meaning, uncomfortable in heart or express indifference to external things, often denying or disguising their bad mood, and even forcing smiles. Their relatives and acquaintances may also be unaware of the serious emotional illness, but only think that they are "uncomfortable" of the body. When they see the doctor, they keep their hands on the body and complain about physical discomfort. Sometimes the body anxiety completely covers the depression. The unreasonable complaints of people are not good for him, so that people are at a loss.
2. Interested in the fact that patients can not experience fun is a more common feature, patients not only have the enthusiasm and fun of past life decline, more and more reluctant to participate in normal activities, such as social, entertainment, and even live alone, alienation of relatives and friends, and some patients I can say that I can laugh and entertain, but I can't experience "happiness." Some patients experience "happy" when they get out of tears when they meet with their families.
3. The energy is reduced, subjectively feels lack of energy, fatigue and weakness, and the heavy person needs to be supported in bedtime all the time. Older patients are often mistaken for serious physical illness and sent to general hospital for expensive medical examination, which leads to delay in treatment. .
4. Self-evaluation Low patients have low evaluation of their own status and think that they are useless and blame themselves.
5. Suicidal conception and behavior The elderly often do not express clearly. If it is possible to say "play a shot to let me die", but deny that there is suicidal thought, the elderly depression has a chronic tendency, and there is also a torture that can not bear the pain, suicide The thoughts are getting stronger and stronger, and the problem is solved by death.
6. The mood circadian rhythm changes the mood of the patient's mood and the lightness of the rhythm is often used as one of the indications for the diagnosis of endogenous depression. Especially when accompanied by early waking, the elderly who are milder feel relaxed before going to sleep. Can come over" or can experience the mood after the night lights are turned on.
7. Physical or biological symptoms (Bridges KW, 1985) Emotional reactions are not only manifested in the state of mind, but are always accompanied by certain changes in the organism. The body complaints of the patients are mainly concentrated in the following categories.
(1) Cardiovascular system: Many complaints of symptoms such as palpitation, shortness of breath, nausea, vomiting, chest tightness, pain in the anterior region, and back pain, etc., can be sent to the emergency center several times for elderly patients.
(2) Digestive system: loss of appetite is the most common, self-reported abdominal fullness, bad appetite, acid reflux, abdominal pain, constipation, diarrhea, and more symptoms of gastrointestinal disorders such as weight loss, dry mouth, Constipation is also a common symptom. Individual patients also have hunger or gluttony. They have encountered a 70-year-old woman who has hunger and gradually worsens. Finally, she also takes food such as steamed buns, snacks, etc. when she sees a doctor. Continue to eat, after checking the body without abnormal signs, and then slowly appear anxiety and depression, after the treatment of anti-anxiety and depression treatment.
(3) Sleep Disorder: It is the main reason why many patients go to specialist hospitals. About 80% of patients have sleep disorders, mainly middle and late sleep. They often claim that they have difficulty falling asleep and nightmares, and can't sleep all night. I feel that taking a variety of sleeping pills does not work. I feel very painful. I urgently ask the doctor to provide treatment. The familys situation is not as serious as the patient said. He is not sleeping, but sleeping. More, that is, when you wake him up from sleep, he will not admit that he is asleep. It is typical to wake up early. After waking up two or three in the morning, he will fall into the painful desperation of how to live today, because the patient is not sleepy enough. Reflecting its enemy of anxiety about insomnia.
(4) autonomic nervous system: Some patients complain of autonomic nervous disorder, such as headache, dizziness, palpitations, chest tightness, shortness of breath, numbness of the limbs, and abnormal feelings, such as burning of the skin, sweating, and anger on the body. Strings, etc.
In addition, cognitive dysfunction is also a common symptom of senile depression. About 80% of patients have complaints of memory loss, and there are obvious cognitive impairments similar to dementia, accounting for 10% to 15%, such as computational power, memory, understanding and Decreased judgment, the simple mental state checklist (MMSE) screening can be false positive, other intelligence tests can also find mild to moderate abnormalities, foreign authors call this depression depression dementia, some of them will have irreversible dementia Alexopoulo (1993) conducted a 3-year follow-up study of 57 patients who met the DSM-III-R criteria for major depressive disorder and found a rate of dementia with dementia on follow-up. %) was significantly higher than simple depression (12%) (Alexopoulos G, 1993).
Examine
Examination of senile depression
There are no central nervous system symptoms in elderly patients with depression, and no positive findings in brain CT examination.
Diagnosis
Diagnosis and diagnosis of senile depression
diagnosis
Old age depression is easy to miss diagnosis, depression is often concealed by other physical symptoms of the body. At present, there is no classification of diseases of senile functional disability in the international and domestic, and the diagnosis of various functional mental disorders for the first time in old age. Still referring to the current international and domestic classification and diagnostic criteria, WHO (1970) classification of functional mental disorders in the elderly is too simple, domestic and foreign authors also try to classify the first-phase depression in the elderly, but these opinions are not widely Recognition.
Psychologists propose a self-assessment method, according to which self-assessment can be performed. New Zealand doctors summarize 10 of the most sensitive factors based on clinical observations, and design 10 conversational questions, each with 4 alternatives. The answer is for selection. According to my situation, choose the most appropriate answer among them. The judgment method is to divide the total score (the scores of all the answers) by 40 and multiply by 100 to calculate the depression index. The index is greater than 70 points. Can be judged as depression.
Scoring method: The formula for calculating the dialogue detection method is: total score ×40×100
Judgment: If the index is greater than 70 points, it can be judged as depression.
Differential diagnosis
Old people are often accompanied by various physical diseases and cerebrovascular diseases. Many acute and chronic diseases, such as heart and lung diseases, endocrine diseases, anemia, vitamin deficiency, etc. can cause depressive symptoms. Some drugs taken due to physical diseases, such as Lishe Ping (reserpine), guanethidine, -methyldopa, propranolol (propranolol), steroids and anti-tumor drugs can also induce depression, in the differential diagnosis should be detailed in the history and medication history, as much as possible Conduct a comprehensive laboratory examination, carefully analyze the relationship between emotional symptoms and physical illness and medication, and determine whether the emotional symptoms are parallel to the severity of the physical illness and fluctuate accordingly. Can the reduction or disappearance of the symptoms be alleviated or disappeared? It is helpful to identify the diagnosis. It is worth noting that some elderly patients with depression have various physical discomforts such as chest tightness, shortness of breath, fatigue, weakness, digestive dysfunction, nausea and vomiting, and weight loss. The patient's depression is often the body. The symptoms are covered up, the patient blames his discomfort on medical diseases, and repeatedly goes to the general hospital for examination. Symptomatic treatment often has poor efficacy and is often misdiagnosed as Neurosis or physical illness and delay in treatment, this is "occult depression", detailed mental examination, with or without emotional stagnation and weight loss can help to confirm the diagnosis.
In elderly patients, there is a complex relationship between depression and cognitive impairment. A certain proportion of patients with depression have reversible cognitive impairment, namely pseudo-dementia (Well CF, 1979). Some of them have irreversible dementia. Alzheimer's disease and other degenerative brain disorders, especially in the early stages of the disease, resemble depressive disorders. These diseases start very slowly. Memory and disorientation are progressive and progressively worse before the onset of depressive symptoms. Most The patient has no complaints and painful experience of cognitive impairment. Patients with intellectual examination often give approximate answers and language function disorders. CT and MRI examinations can show obvious brain atrophy and ventricular enlargement. In the diagnosis of dementia, there are about 20% with depressive symptoms (Reifler et al, 1982), the use of antidepressants to treat mood and behavior can be improved, but basic cognitive impairment will not improve, the difference between depressive pseudo-dementia and dementia can be found in Table 2.
other:
1. Alzheimer's disease and other degenerative brain diseases
According to reports, 7% to 40% of Alzheimer's disease and 30% to 60% of patients with Parkinson's disease can have depressive symptoms, especially in the early stage of the disease, clinical manifestations resemble depressive disorders, but this type of degenerative brain disease begins Very slow, there are memory and disorientation disorders before the onset of depressive symptoms, cognitive impairment is progressively aggravated, most patients have no complaints of cognitive impairment, and no painful experience, mental examination patients often give approximate answers, language There are also obstacles in function. CT and MRI can be found in patients with obvious diffuse brain atrophy and ventricle enlargement. Patients also have corresponding neurological symptoms and signs and characteristic neuropathological changes, and antidepressant drugs are ineffective.
2. Mental disorders associated with cerebrovascular diseases
In some brain regions, especially in the frontal cortex and subcortical vascular lesions, the symptoms of depressive symptoms are as high as 505. Clinically, it is similar to depressive disorder. Cerebrovascular diseases are generally acute onset, the condition is fluctuating, and depressive symptoms are also fluctuating. Patients often have a history of hypertension and cerebral arteriosclerosis, or have multiple episodes of stroke, usually with limited neurological symptoms, comprehensive neurological examination, CT and MRI to help identify.
3. Mental disorders associated with physical illness and drug-induced depression
Many acute, chronic physical diseases such as obstructive emphysema, heart failure, pancreatic head cancer, endocrine diseases (hyperthyroidism, hypothyroidism, adrenal insufficiency), anemia and vitamin deficiency can cause depressive symptoms, due to physical illness Certain drugs, such as reserpine, guanethidine, alpha-methyldopa, quinidine, propranolol, steroids and anti-tumor drugs, are also common causes of depression. When identifying, first understand the physical illness of elderly patients. History and history of medication, careful analysis and evaluation of the biological direct cause of physical illness and the cause of the drug, to determine whether the symptoms of depression are parallel with the severity of physical illness and fluctuate accordingly, whether reducing or stopping the drug can reduce the symptoms of depression Or disappeared to help identify, in addition, blood, urine routine, erythrocyte sedimentation rate, electrolytes, liver function, blood sugar, folic acid, vitamin B12, thyroid function, chest and electrocardiogram can be used as routine laboratory tests for elderly patients.
