Depression in old age
Introduction
Introduction to senile depression Senile Melancholia is strictly referred to as a mental disorder with a persistent depression as the main clinical manifestation after the first onset of 60 years of age. Mood disorders cannot be attributed to physical illness or brain organic disease. Depression is a negative, unpleasant emotional experience characterized by low emotions, crying, sadness, disappointment, decreased mobility, and slow cognitive function. The general course of disease is long, with a tendency to relieve and relapse, and some patients have poor prognosis and can develop into refractory depression. basic knowledge Sickness ratio: 0.05% Susceptible people: good for people over 60 years old Mode of infection: non-infectious Complications: dementia amenorrhea
Cause
Causes of senile depression
(1) Causes of the disease
The elderly are prone to depression. It is a widespread concern. The cause of the disease is undoubtedly multi-factor. The early-stage depression patients have obvious genetic predisposition. The genetic predisposition of the elderly in the later years is small. In recent years, the research has accumulated a large number of According to biological and psychological data, studies have shown that the cause of senile depression may be related to the aging of the body, especially the degenerative changes of the brain cells, and also related to the frequent mental frustration of the elderly.
1. The changes in central nervous system biochemistry caused by aging. With the increase of age, various biochemical and neuroendocrine changes in neurotransmitters occur in the central nervous system, and these changes play an important role in the onset of senile depression. The role.
(1) Norepinephrine (NE) system: Some research results accumulated over the past 10 years suggest that emotional depression is related to the absolute or relative lack of catecholamines in the brain tissue, especially NE, and studies have reported that the NE system The activity decreases with age. Previous studies have shown that the number of nerve cells in the nucleus of the nucleus is reduced with age. Because this nucleus distributes NE fibers to the central nervous system, it grows with age. The content of NE in the brain tissue is decreased. In addition, the tyrosine hydroxylase necessary for the synthesis of NE, the activity of dopamine decarboxylase is decreased, and the degradation of monoamine oxidase (MAO) activity is also reported. On the contrary, it increases with age, especially in women. After menopause, the secretion of estrogen is reduced, resulting in a decrease in NE concentration in brain tissue, but there are also reports on the contrary.
(2) serotonin (5-HT) system: Recent studies suggest that 5-HT is directly or indirectly involved in the regulation of human mood, 5-HT functional activity is reduced with depressed mood in patients with depression, loss of appetite, insomnia, circadian rhythm disorder , endocrine dysfunction, sexual dysfunction, anxiety, can not cope with stress, activity reduction, etc.; and 5-HT function is related to mania, because the reduction of 5-HT content has an important relationship with the onset of depression, many Scholars are investigating 5-HT changes caused by age-related changes. The results of positron emission tomography (PET) studies of 5-HT receptors indicate that 5-HT2 receptors bind to globus, shells with age. Both the nucleus and the prefrontal cortex are reduced. This result suggests that 5-HT neurons are reduced or 5-HT excess bound to the 5-HT2 receptor, resulting in compensatory changes, Robinson et al (1971) for 55 deaths due to aging. The normal-aged elderly performed autopsy and analyzed the concentration of NE and 5-HT in their hindbrain. It was found that the concentration of the two neurotransmitters decreased with age, but studies have also reported that 5-HT metabolites in human cerebrospinal fluid 5- HIAA (5-oxindole) Acid) increases with age. Therefore, there is no consistent study on the 5-HT system with age. Tryptophan is a precursor for the synthesis of 5-HT. It has been reported that tryptophan in the blood of patients with depression Declined to support the hypothesis that 5-HT is low.
(3) Dopamine (DA) system: The DA content in brain tissue is reduced, which is related to the aging of the body. Previous studies have shown that with the normal aging process, some specific brain regions, especially the nigrostria, have obvious DA content. The decline may be caused by insufficient tyramine hydroxylase and dopamine decarboxylase. Recent studies suggest that the reduction of DA function is one of the causes of depression in the elderly.
(4) Acetylcholine (Ach) system: Tanowry (1972) believes that there is a tension balance between acetylcholine and adrenergic neurons, excessive activity of acetylcholine neurons in the brain can lead to depression, and adrenergic neurons are overactive. Can cause mania, so the anticholinergic effects of antidepressants may play an antidepressant role in this type of depression.
Current research suggests that Ach is associated with bipolar disorder, and Dilsaver has reported that discontinuation of an antidepressant with anticholinergic effects can cause a rebound in manic symptoms, suggesting choline-induced choline It can be related to the excessive muscarinic receptors. Recent studies have shown that the cholinergic system is closely related to memory impairment and stress disorder, and choline function is enhanced, which can lead to depressive episodes. Increased cholinergic activity can aggravate depression. State, and can cause some normal controls to have depressive episodes, so some scholars believe that the cholinergic system participates in emotional regulation, and proposes emotional regulation of cholinergic-adrenergic balance theory, both adrenergic enhancement, can cause Excited by humans and animals, acetylcholine can cause depression, which normally restricts each other and maintains normal neurological status. Newhouse suggests that muscarinic neurological dysfunction is closely related to cognitive and emotional changes in senile depression, but The age-induced changes in the Ach system are not yet certain. It can be seen that the aging process of the body significantly affects the monoamine mechanism and may be an important Sense factors.
(5) Adrenocorticotropic hormone (ACTH) system: In the pathogenesis of depression, the obvious abnormality of the neuroendocrine system is an enhancement of the ACTH system, which can be increased from plasma cortisol concentration and in the dexamethasone suppression test (DST). No increase in reactivity to inhibit plasma cortisol concentration was observed. Rosenbaum et al. (1984) performed a dexamethasone suppression test on depressed patients aged 20 to 78 years and found that 18% of elderly people over the age of 65 had plasma cortisol concentrations. Unrestrained response, only 9.1% of young patients are uninhibited, does this reflect the tendency of the elderly to have dysfunction of the hypothalamic-pituitary-adrenal (HPA) system, whether it is due to difficulty in absorption and metabolism of dexamethasone, and In the study, in addition, all neuroendocrine systems, especially the ACTH system, are susceptible to non-specific factors such as sleep-wake rhythm, diet, disease, medical care, stress, etc., and older people are more prone to abnormalities. Recent studies have found that depression Patients with disease not only increase plasma cortisol concentration, but also have a change in the secretion of circadian rhythm. Normal cortisol secretion from the adrenal cortex is typical. The circadian rhythm, that is, the morning begins to rise, the evening and midnight are the lowest, while the depression patients have no spontaneous inhibition of spontaneous cortisol secretion. Most studies believe that cortisol secretion is excessive, not related to stress, but related to depression itself, and The clinical symptoms were relieved and gradually became normal. Secondly, 4.0% of patients with depression were treated with dexamethasone 1 mg at 11 am, and plasma cortisol was higher than 37.95 nmol/L (5 mg/dl) at 4 pm and 11 pm the next day. That is, dexamethasone can not inhibit cortisol secretion. Recent studies have found that the positive rate of DST in elderly patients with depression is high. DST abnormalities are more common in patients with depression, and often return to normal with clinical symptoms. DST abnormalities suggest Drug therapy is needed. DST changes in patients treated with drugs often occur before the clinical symptoms are relieved, DST is persistently positive, suggesting a poor prognosis, and studies have found that corticotropin-releasing hormone (CRH) in cerebrospinal fluid of patients with major depression Increased, and the basis for HPA abnormalities in depression is that CRH is over-secreted.
(6) Growth hormone (GH) system: The amount of GH secretion in patients with depression is increased at 24h, but usually GH decreases with age and the response to gonadotropin-releasing factor (GRF) is also reduced. The GH system in patients with depression is abnormal in the response to clonidine stimulation. By measuring the sensitivity of postsynaptic alpha receptors, it is found that the GH response in patients with depression is lower than that in the normal control group. This abnormality persists after treatment and is considered to be The specificity of depression, although there is evidence that the regulation of GH in patients with depression is not normal, but the mechanism is not clear, immunohistochemical studies show that the size and number of nerve cells secreting GH decrease with age, so some people It is believed that the function of the GH system decreases with age.
(7) Thyroid stimulating hormone (TSH) system: The study found that patients with depression had significantly lower plasma TSH and a significant increase in free T4, and the response of patients to antidepressants may be related to the decline of free T4. Many studies also found that 25% to 70% The TSH of patients with depression is slow to respond to TRH (thyroid stimulating hormone releasing hormone), and the TSH response tends to be normal with the relief of depressive symptoms. Patients with slow TSH response predict that the antidepressant treatment effect is good. It is suggested that the TRH test changes according to the treatment before and after treatment. The change of index (TSH) to predict the possibility of recurrence, and that TSH may help doctors decide when to stop treatment, the pathophysiological significance of TSH response is unknown, some people think that increased secretion of TRH can make pituitary TRH suffer Reduced body sensitivity, resulting in slow TSH response, (8) various amine metabolism and modified amine hypothesis: Some people think that the low 5-HT level in the brain of patients with depression is the genetic basis of genetic determination, but must be accompanied by other biogenic amine systems The dysfunction can lead to the onset of disease, that is, on the basis of low 5-HT, if NE increases, it will lead to mania, and if NE is reduced, it will lead to Yu attack, are also studies that not only the number of onset related biogenic amines, and related to a receptor sensitivity, i.e. when the free amines to reduce the body, reducing the sensitivity before and after the synaptic membrane receptors, leading to episodes of depression.
2. Biological rhythm changes The physiological activity level of organisms has periodic changes corresponding to day and night changes. It is the result of evolution and adaptation of organisms in a constantly changing environment. Human body temperature, sleep-wake, endocrine, digestion, metabolism and Excretion, there are circadian rhythms close to 24h.
3. Brain tissue structure changes Jacoby performed head CT examination on 50 normal elderly people (over 60 years old) and found a tendency to enlarge the ventricles. In 1983, Jacoby performed head CT examination on 41 elderly patients with depression and found that 9 Case (22%) had enlarged ventricles, so it is believed that organic brain damage may have important etiological significance in some elderly patients with depression. After follow-up of these patients, and compared with elderly patients with depression without ventricular enlargement, The 2-year mortality rate of elderly patients with ventricular enlargement was significantly increased. It was also found that in addition to ventricular enlargement, senile depression patients also had sulcal widening, cerebellar sacral atrophy, third ventricle enlargement, brain density reduction, etc. Change, more than half of the patients' symptoms are significantly related to the left frontal lobe lesions. The closer the lesion's leading edge is to the frontal pole, the more serious the condition is. Some scholars believe that patients with late onset senile depression have enlarged ventricles compared with those with early onset. Cortical atrophy is more obvious, so degenerative changes in brain tissue may be more important for the etiology of late onset depression, single-beam emission computed tomography (SPECT) Found (Deng Hong et al 1997), the local cerebral blood flow of the left lower forehead, left anterior humerus and cingulate cortex of the depressed patients decreased significantly, while the right upper frontal, right lower front and medial parietal lobe, the regional cerebral blood flow of the occipital lobe also decreased. There is bilateral asymmetry in the cerebral blood flow of the upper frontal cortex. Magnetic resonance imaging (MRI) found that subcortical white matter in elderly patients with depression showed hypersensitivity to MRI signals, while severe depression showed a reduction in the volume of the nucleus.
4. Genetic factors and APOE gene affective disorder have obvious genetic predisposition. In its etiology, genetic factors are the main internal factors, which have far more influence than environmental factors. In recent years, between APOE gene and Alzheimer's disease (AD) The relationship research is the most, many studies have clearly found that APOE gene is associated with AD susceptibility, although genetic factors seem to be less important in elderly depression patients, but senile depression is closely related to AD, in symptomatic features, pathology, physiology or Anatomically, there may be changes similar to AD, and these features and changes are closely related to the APOE gene. Therefore, the APOE gene may still be a potential cause of senile depression, and the findings on the relationship between senile depression and APOE gene are summarized. Consistent with clinical observation, pathology and neurobiochemical research and CT, MRI, etc., there is a common genetic risk factor for senile depression and AD.
5. Psychosocial factors During the old age, on the one hand, the tolerance to physical illness and mental frustration is declining, on the other hand, there are more and more opportunities for psychological stimulation, unfortunate stress life events, such as The death of his wife, the separation of his children, the change of status, the embarrassment of the economy, the affliction of the disease, the relocation of his place of residence, etc. all give or aggravate the loneliness, loneliness, uselessness, helplessness of the elderly, become the source of depression, depression, and long-term Life recurrence or frustration can also produce or induce depression. In addition, personality inferiority, depression and reversal, excessive introversion, pessimistic cognition and passive passive coping with frustration and misfortune, and lack of social support (very few friends), is also prone to depression, Post (1972) reported that 92 cases of senile depression, 78% of the unfortunate stress life events shortly before the onset, Paykeil (1978) reported that elderly patients with depression, One third of the life events before and after the illness, one in four suffered from physical illness before the illness, and the rest suffered from life such as retirement and economic difficulties. The domestic Lin Qigen (1978) compared the effects of life events before and after the onset of depression in the elderly and young adults. It was found that the incidence of unfortunate life events was quite high within 1 year before the illness, 39.6% for young adults and 83% for the elderly. It can be seen that the pathogenic effect of adverse life events is more prominent and prominent in the elderly. While the elderly are physiologically aging, their mental functions also change, and their psychological defense and psychological adaptability decline. Once they are unfortunate, they are difficult to reconstruct. The stability of the internal environment, if there is a lack of social support, the balance of psychological activities is more difficult to maintain, may lead to depression, aggravation or recurrence, even if it is mild, moderate unfortunate life events may also cause illness, this is in the elderly It is of great significance.
(two) pathogenesis
In recent years, there is a relatively new theory about the pathogenesis of affective disorders, namely the dysfunctional effect of circadian rhythm. The affective disorder has a recurrent course of disease. After each episode, it recovers well. It can be assumed that its seizure is related to biological rhythm. Depression occurs on the basis of normal biochemical and physiological circadian rhythm disorders. The clinical manifestations described by Vogel (1980), especially sleep disorders and diurnal mood changes, reveal the relationship between depression and rhythm synchronization disorders. The disorder of sleep cycle that occurs with age indicates that the problem of day and night may become the cause of depression in old age. It is also reported that the activity of dopamine beta hydroxylase has a circadian rhythm. If the rhythm of the enzyme changes, NE and its precursors can be made. DA is out of sync, NE is sometimes over-extended (manic episodes), sometimes insufficient (depressive episodes), in short, when there are affective disorders, the biological rhythm changes, and this change is related to changes in clinical symptoms, and the mechanism for changes in biological rhythms is currently Little is known, it is generally considered to be closely related to the neuroendocrine function of monoamines and hypothalamus. In animal experiments, Shock can also cause loss of synchronization of circadian rhythm, the biological rhythm of change can not be seen as a stand-alone mode interpret old age depression, it may be the result of various biochemical abnormalities and social environmental factors working together.
In summary, the biochemical, biological rhythm, brain tissue structure, genetic and psychosocial factors, contribute to the occurrence and development of depression in the elderly, through the long-term follow-up observation of depression in the elderly, people found the organic The incidence of dementia is not higher than that in the general social population. Therefore, many scholars speculate that the onset of depression in the elderly may be related to some kind of aging, but it does not reach the obvious degree of lesions like dementia in quality and quantity.
Prevention
Prevention of senile depression
1. Early detection, early diagnosis, early treatment If the early manifestation of depression can be identified early, and the patient's own characteristics, causes, triggering factors, and morbidity characteristics can be comprehensively considered, and effective prevention of recurrence can be formulated. The plan is to "prevent the problem before it happens."
2. Strengthening psychological treatment and social support For patients whose condition tends to recover, they should introduce common sense of health and conduct various forms of psychological treatment, requiring patients to treat themselves correctly, correctly understand diseases, exercise their own character, and establish a correct life. View, face real life, correctly treat and deal with various unfavorable factors, strive for social support, and avoid unnecessary spiritual stimulation.
3. Risk factors and interventions Old age depression is closely related to psychosocial factors. Therefore, it is necessary to prevent risk factors and take interventions. The principle of prevention is to reduce the loneliness and social isolation of the elderly and enhance their self-worth. Specific measures include: encouraging children to live with the elderly, arranging exchanges and group activities among the elderly, improving and coordinating interpersonal relationships, including family members, and striving for support and care from the society, relatives and friends, and neighbors. Encourage the elderly to participate in a limited amount of labor within their capacity, cultivate a variety of hobbies, etc. In addition, because the elderly are not easy to adapt to unfamiliar environments, the relocation of the house should be avoided or reduced as much as possible. Couple therapy is a biological effect, is better than any Drugs have a good effect, so the widowed elderly remarried, maintaining a harmonious relationship, including a moderate and moderate sexual life, can help prevent the occurrence of depression in old age, otherwise, loneliness and depression, and depression Not only does it create a "cardiac illusion", it also makes the body immune Induced depression, dementia, cardiovascular disease and cancer.
4. Community intervention and family intervention strive to conduct social skills training and interpersonal communication skills training in community rehabilitation service centers, improve independent living ability, develop social support networks, and help patients regain their interpersonal skills. Family intervention includes psychological education and Relatives support each other's intervention and survival skills, behavioral skills training-based measures.
Complication
Complications of senile depression Complications dementia amenorrhea
Depressive pseudo-dementia, impotence, women's amenorrhea and so on.
Symptom
Symptoms of depression in the elderly Symptoms Fatigue, fatigue, mental disorder, loss of appetite, suspicion, retreat, depression, depression, old age, personality, isolation, constipation, seasonal depression
1. Characteristics of senile depression
(1) Suspectedness: the symptoms of suspected disease, manifested as physical symptoms with autonomic symptoms. Alarcon (1964) reported that among the elderly with depression over 60 years old, the male patient with suspected symptoms was 65.7%. 62% of female patients, about one-third of the elderly patients with suspected disease as the first symptom of depression, so some scholars have proposed the term of suspected depression, the suspected content often involves digestive symptoms, especially constipation, stomach Intestinal discomfort is one of the most common and early symptoms of such patients. Patients often start with a less serious physical illness, such as a case described by Dr. Shi Hongjun: suffering from keratitis, long-term cure, patients worry about binocular Blindness, although its eyesight is getting better, but depression and anxiety are increasing day by day. Therefore, excessive attention to normal physical function and excessive reaction to mild disease should consider the problem of depression in the elderly.
(2) Agitated: that is, anxiety, Post as early as 1965 clearly pointed out that agitation is most common in the elderly, and subsequent studies have confirmed this, as in 1979, Strian et al pointed out that agitation The average age is 51 years old. In 1984, Avery et al reported that 5% of agitated depression under 40 years old was 47%, 40% was 40% to 40 years old, and 49% was over 60 years old. In 1988, Wesner et al. thought that under 55 years old was 40%. 63% of people over 55 years old, it can be seen that agitation depression increases with age, anxiety is often secondary symptoms of more serious depression, may also become the main symptoms of patients, manifested as anxiety and fear, worry about themselves all day long And the family will suffer unfortunately, the big disaster will come to the fore, the slap in the face, the restlessness, the sorrow, the insomnia at night, or the repeated unsatisfactory things in the past, blaming themselves for doing something wrong, leading to the misfortune of family and others, Sorry for loved ones, they are not interested in everything in the environment. The lighter people are constantly complaining about their experience and "tragic situation", seeking safe people or places, but the heavy ones are necking, electric shock, tearing clothes, rubbing their hair, and turning over , Extreme anxiety, and even suicide attempts.
(3) Occultity: physical symptoms, many elderly patients who deny depression manifest as various physical symptoms, and emotional disorders are easily ignored by family members until the elderly are found to have suicide attempts or behaviors to the psychiatric clinic, Chen Xueshi (1990) longitudinal observation of patients diagnosed with "neurofunction" in general hospitals, without selective treatment with antidepressants, found that 7% of patients achieved remission, 17% significantly improved, the two together accounted for patients 24%, indicating that this part of the patient is not a neurosis, but a depression, because its depressive symptoms are covered by physical symptoms, it is called "occult depression."
(4) Hysteresis: the behavioral block of depression, usually characterized by lack of exercise and slowness of movement, affecting physical and physical activities, and reducing facial expression, speech block, most elderly patients with depression are depressed, Emei No exhibition, unsatisfactory interest, slow thinking, often do not immediately answer questions, and repeatedly asked, in a short and weak speech, the thinking content is poor, the patient is in a state of silence for most of the time, slow behavior, and gaze at both eyes. Emotional apathy, lack of desire, indifferent to the external trend, depression behavioral delay and psychological process has a consistent relationship.
(5) Paranoia: Meyers et al (1984) have reported that late-onset depression has a common paranoia. They studied 50 hospitalized patients with endogenous depression and compared the incidence before and after 60 years of age. The incidence of delusions, found that depression after the onset of 60 years of age has more delusional symptoms than the former, that delusional depression tends to the elderly, two years later Meyers et al reported again, single-phase delusional depression in the elderly The age of onset of the patient is later than that of those who have no delusional depression. In the state of delusion, the most typical of suspected delusions and imaginary delusions are followed by suspicion of suspicion, relationship delusion, poverty delusion, sinful delusion. Mental state is a prerequisite, related to their living environment and attitude towards life.
(6) Depressive pseudo-dementia: Depressive pseudo-dementia can be reversed cognitive dysfunction, it has been widely recognized that depression pseudo-dementia is common in the elderly, this cognitive disorder through anti-depression Treatment can be improved, but it must be noted that certain organic, irreversible dementia can also be an early manifestation of depression and needs to be identified.
(7) Suicide tendency: The risk of suicide in old age depression is much greater than that of other age groups. Sainbury reports that 55% of the elderly have committed suicide in depression, and suicide often occurs with physical illness, and The success rate is high. Pankin and other surveys show that the ratio of attempted suicide to success is 20:1 under 40 years old, and 4:1 for those over 60 years old. The risk factors for suicide are mainly loneliness, guilt, suspected symptoms, and agitation. , persistent insomnia, etc., personality and depression awareness is an important additional factor in determining the risk of suicide, such as helpless, hopeless and negative attitudes to life, but there are also opposite findings, Ma Xin et al (1993) on the elderly The study of non-elderly depression showed that the suicidal behavior of the non-elderly group was significantly higher than that of the elderly group. Whether it can reflect the relatively low risk of suicide in the elderly in China is still to be further explored.
(8) Seasonality: Jacobsen et al. (1987) described the characteristics of seasonal affective disorder in the elderly. Dan summarized his diagnostic criteria as follows: 1 The diagnosis of depression meets the criteria of DSM-III-R major depression; Two consecutive winter depressive episodes, spring or summer remission; 3 lack of other severe mental disorders or lack of psychosocial interpretation of seasonal mood changes, this type is difficult to use with ordinary treatment methods.
(9) Others: Post found in a controlled study of "neuropathic" and "psychotic" depression, performance-like behaviors and obsessive-compulsive symptoms common to neurotic depression, also seen in psychotic depression, but There is no such report on depression in young people.
Whitehead describes that elderly depression can be characterized by acute insanity (consciousness disorder), severe agitation, often misdiagnosed as acute insanity, and malnutrition, vitamin deficiency, and dehydration in elderly patients with depression due to loss of appetite can occur The state of acute insanity.
It can be seen that the clinical manifestations of senile depression have obvious specificities, which are caused by psychological and physiological changes in the aging process.
2. Typical symptoms Depression is a state of mind that is characterized by a markedly depressed mood. It is a common state of normal mood, but a serious depression and normality. The mood is different from depression, its state is heavy, it lasts for a long time, and there are some characteristic symptoms (such as sleep disorders).
The most common emotions, behaviors, and typical symptoms of the body are:
(1) Significant depression, morning and light.
(2) Loss of interest or pleasure.
(3) Self-confidence declines or inferiority.
(4) A sense of worthlessness and guilt.
(5) I feel that the future is bleak.
(6) The concept or behavior of self-injury or suicide.
(7) Sleep disorders, early wake up as one of the characteristics.
(8) Eating disorders.
(9) Loss of libido.
(10) The energy is reduced, it is easy to feel fatigue, and the activity is reduced.
(11) Concentration is difficult or declining.
3. The clinical manifestations of atypical symptoms of depression have large individual differences, the following are atypical symptoms:
(1) Mood change: Better or lighter as good things happen.
(2) Atypical symptoms (two or more manifestations):
1 increased appetite or significant weight gain.
2 increased sleep (at least 2 more hours than when not depressed).
3 Feeling heavy or lead-like, sometimes it lasts for hours.
4 Personality enhancements are particularly sensitive when they are rejected from others, so that their social skills are impaired.
Examine
Examination of senile depression
1. Complete blood count, urine routine, rapid plasma antibody determination, chest radiograph, electrocardiogram.
2. T3, T4 and thyrotropin levels were measured to determine thyroid function.
3. If giant cell anemia is suspected, folic acid and vitamin B12 levels should be determined.
When suspected drug poisoning, the plasma concentration of commonly used drugs should be determined; EEG, head CT examination, etc., Yang Quan and other studies have shown that rapid eye movement sleep (REM) latency is shortened, rapid eye movement activity, intensity and density increase are within The unique indicators of electrophysiology of depressive depression provide a biological basis for the diagnosis and differential diagnosis of this disease.
Diagnosis
Diagnosis and diagnosis of senile depression
Diagnostic criteria
1. The patient is first ill in old age, generally slow onset, and can be induced by physical illness and/or other mental factors.
2. Clinical symptoms have psychological and physiological characteristics in old age, and the mood of depression is long-lasting, but the emotional experience is often not as clear as that of young adults, anxiety or psychomotor inhibition is more obvious, and the symptoms of physical discomfort are numerous. The somatization tendency of depressive symptoms should be emphasized.
3. The diagnostic reference value of biochemical and neuroendocrine abnormalities and positive findings such as EEG is not significant.
4. Exclude depressive syndrome associated with brain organic diseases and physical diseases that directly cause depression by biological factors.
Differential diagnosis
1. Identification of secondary depression is prone to brain organic diseases and physical diseases in the elderly, and often taking related drugs, these conditions are likely to cause secondary depression syndrome, such as cancer (especially pancreatic cancer), virus Infection (such as influenza, hepatitis), endocrine diseases, anemia, vitamin B6, or folic acid deficiency, cerebrovascular disease, Parkinson's disease, multiple sclerosis, etc., drugs that cause secondary depression are methyldopa, Lisheping, corticosteroids, etc., the diagnosis of secondary depression syndrome is mainly based on medical history, physical examination, neurological examination and laboratory tests to find the specific organic factors associated with the cause of depression.
2. Identification of depressive pseudo-dementia and senile dementia in the elderly In the elderly depression, some patients may have both depressive symptoms, memory, and mental retardation, because their dementia is reversible. Therefore, some people call it depressive pseudo-dementia. In the case of senile dementia with brain organic damage, depression and anxiety may occur in the early stage of the disease. At this time, the mental disorder has not been clarified. In addition, some symptoms such as Personal habits, mental retardation, emotional instability, loss of libido, loss of appetite, constipation, weight loss, etc., can be common symptoms of depression and organic dementia, therefore, it is necessary to distinguish whether it is pseudo-dementia or True dementia (elderly dementia) is often difficult, and the points listed can be used as a reference for identifying both (Table 4).
3. Identification with anxiety disorders Because depression is often accompanied by anxiety, it is difficult to describe the dividing line between depression and anxiety.
1 Emotional Disorder: Fear, excitement, lack of attention in the face of a major disaster.
2 physical disorders: manifested as palpitations, difficulty breathing, tremors, sweating, dizziness and gastrointestinal dysfunction.
3 Social behavioral disorders: manifested as people or places seeking security, responding to aversion to safe people or places, Murphy (1986) suggested that if depression and anxiety coexist, the general rule is that the diagnosis of depression takes precedence over anxiety. If depression is associated with anxiety and has biological symptoms, first diagnose depression. In clinical practice, depression often occurs as a new event in people with lifelong anxiety or chronic anxiety. In the first years of depression in the later years, once the symptoms of depression are eliminated, persistent anxiety symptoms may become the only residual symptoms.
The Hamilton anxiety scale (HAMA) was compiled by Hamilton in 1959. It is mainly used to assess the severity of anxiety symptoms in patients. It is one of the commonly used clinical scales for psychiatry. All HAMA projects use 0 to 4 points. Level 5, 0 is asymptomatic, 1 point is light, 2 points is medium, 3 points is heavy, 4 points is extremely heavy, and this scale includes 14 items:
(1) Anxiety: Worry, worry, feel that the worst things are going to happen, and it is easy to get angry.
(2) Tension: tension, fatigue, not relaxation, emotional reaction, easy to cry, trembling, feeling uneasy.
(3) Fear: fear of darkness, strangers, alone, animals, rides or brigades.
(4) Insomnia: It is difficult to fall asleep, easy to wake up, not sleep deeply, dreams, nightmares, night terrors, and feeling tired after waking up.
(5) Cognitive function: or memory, attention disorder, inattention, poor memory.
(6) Depressive mood: Loss of interest, lack of pleasure in past hobbies, depression, early awakening, and heavy night light.
(7) Muscle system symptoms: muscle soreness, inflexible activity, muscle twitching, limb twitching, teeth fighting, and trembling voice.
(8) Sensory system symptoms: blurred vision, cold and fever, weakness, weakness and stinging.
(9) Cardiovascular symptoms: tachycardia, palpitations, chest pain, vascular motility, fainting, and heartbeat leakage.
(10) Respiratory symptoms: chest tightness, suffocation, sigh, difficulty breathing.
(11) Gastrointestinal symptoms: difficulty swallowing, hernia, indigestion (fighting abdominal pain, burning stomach, bloating, nausea, stomach fullness), intestinal motility, bowel, diarrhea, weight loss, constipation.
(12) genitourinary system symptoms: frequency of urinary urination, urgency, menopause, cold, premature ejaculation, impotence.
(13) autonomic nervous system symptoms: dry mouth, flushing, pale, easy to sweat, from "goose bump", tension headache, hair erect.
(14) Behavior during the talks:
1 general performance: nervous, can not relax, restless, biting fingers, clenched fists, playing with handkerchiefs, facial muscles twitching, restless feet, hands shaking, frowning, stiff expression, high muscle tension, sigh-like breathing, pale.
2 Physiological manifestations: swallowing, snoring, fast heart rate, fast breathing (>20 times / min), sputum reflexes, tremors, pupil dilation, eyelid beating, easy to sweat, eyeballs prominent.
(15) Assessment notes:
1 The two doctors who have been trained should conduct a joint examination of the patients by means of conversation and observation. After the examination, the two assessors are independently scored, and it takes 10 to 15 minutes for one assessment.
2 is mainly used to assess the severity of anxiety symptoms in neurosis and other patients.
In the 3HAMA, in addition to the 14th item to be combined with observation, all items are scored according to the patient's oral narrative, with special emphasis on the subjective experience of the subject, which is also the medical point of view of the HAMA compiler, because the patient is only subjective in the disease. When you feel the time to see a doctor and receive treatment, it can be used as a criterion for progress.
4HAMA has no work rating, but generally can be scored like this: 1 mild symptoms. 2 There are certain symptoms, but it does not affect life and activities. 3 The symptoms are heavy, need to be treated, or have affected life activities. 4 The symptoms are extremely serious and seriously affect their lives.
(16) Analysis of results:
1 total score: can better reflect the severity of the disease, the scale cooperation group has compared the total HAMA score of 230 patients with different subtypes of neurosis, the total score of neurasthenia is 21.00, the anxiety disorder is 29.25, depressive nerve The syndrome is 23.87. It can be seen that anxiety symptoms are prominent manifestations of patients with anxiety disorders.
2 factor analysis: HAMA is divided into two major types of factor structures: physical and mental.
Somatic anxiety: by (7) somatic anxiety: the muscular system. (8) Somatic anxiety: sensory system. (9) Cardiovascular symptoms. (10) Respiratory symptoms. (11) Gastrointestinal symptoms. (12) genitourinary symptoms. (13) 7 components including autonomic nervous system symptoms.
Factor analysis can not only reflect the psychopathological characteristics of patients, but also reflect the treatment results of target symptom groups.
3 According to the information provided by the National Scale Cooperation Group, the total score is more than 29 points, which may be severe anxiety, more than 21 points, there must be obvious anxiety, more than 14 points, there must be anxiety, more than 7 points, there may be anxiety, such as less than 6 The patient has no symptoms of anxiety. It is generally considered that the HAMA 14 has a demarcation value of 14 points.
4. Distinguishing from excessive sorrow is the biggest grief in life. In old age, it is easy to encounter widowed, lost or lost serious life events, so the grief during bereavement is very common. The mourning can not be regarded as a mood disorder. Its sadness, loss of loved ones is a normal emotional experience, lack of energy, loss of interest, frequent crying, sleep problems, inattention is common, not the extra symptoms after losing loved ones. Self-blame can be manifested in the elderly, but not as common as in depression. The typical grief response improves within 6 months. The grief response is the first in addition to the life events related to grief or the loss of loved ones. The commemorative day is generally not seizure, but depression is a seizure, periodic course, grief reaction - does not lead to a decline in work ability and social adaptability, can continue to maintain their lives, carry out their normal daily activities, In the early stage of depression, the symptoms of interpersonal communication decline and work ability decline, and the grief response generally has no circadian rhythm. Depression, which is characterized by morning and late light rhythm, grief response without psychomotor retardation, few real negative attitudes and suicide attempts, the risk of suicide only occurs in the low-cultural group of grief-responsive people. It must be noted that in individuals who are susceptible to depression, mourning can be a sudden cause of illness, especially for those with a history of vulnerability and depression.
