Introduction

Frequent physical symptoms are common complaints among older adults with depression. Vague aches and pains, including chronic joint pain, limb pain, back pain, gastrointestinal problems, fatigue, sleep disturbances, and appetite changes, often point to an underlying psychiatric origin.1 When older adults complaining of these symptoms seek treatment in the primary care setting, providers may interpret symptoms as signs of somatic illness and miss the diagnosis of depression. Pain and depression are believed to share a neurological pathway, which causes patients with imbalanced serotonin and norepinephrine neurotransmitters to experience concomitant physical and depressive symptoms. Therefore, frequent complaints of painful physical symptoms are correlated with greater severity of underlying depression.1

Frequent physical complaints are also characteristic of older adults with generalized anxiety disorder, a condition that frequently coexists with symptoms of depression and affects over a quarter of individuals above age 65.2 Older adults tend to report more frequent worries about their health than their younger counterparts. Health anxiety is especially prevalent among older adults with chronic conditions such as hypertension, urinary incontinence, hearing impairment, and poor sleep habits.2,3 The presentation and experience of anxiety in older adults is due in large part to age-related changes in neurotransmitter levels and responsiveness. Presentation of anxiety may also be complicated by high rates of comorbid medical and psychological conditions and related pharmacologic treatments.3

Anxiety and medical problems often have a reciprocal influence, with psychological problems increasing one’s vulnerability to physical disease. Older adults who have experienced a fall, for example, may develop a fear of falling and begin to self-restrict mobility, resulting in reduced exercise and increased risk for physical complications of immobility. Physical disease can also cause psychological symptoms, in the case of patients with diagnosed cardiovascular disease who fear experiencing palpitations and shortness of breath during physical activity.3 Elderly patients exposed to psychosocial stressors also tend to struggle with anxiety. Negative life events common in old age, such as loss of a spouse, change in employment status, and compromised independence, are likely to worsen symptoms of anxiety if not addressed.2,4

Interprofessional Assessment and Collaborative Interventions

It is important that primary and acute care providers consider the possibility of underlying depression or anxiety in patients complaining of frequent physical symptoms, particularly those with multiple chronic illnesses and comorbid depression.3 Given the high prevalence and coexistence of old age, chronic disease, and depressive symptoms, it is essential that the interprofessional health care team systematically assess for depression and anxiety in this population.1,2 The Geriatric Depression Scale is a well-validated measure often used as part of a comprehensive history and assessment.1,3,4 Primary care physicians and psychiatrists alike may inadvertently ignore physical symptoms in their assessment of depression, assuming these are signs of somatic illness. As such, adequate symptom relief may not be achieved in treatment.

Providers are advised to consult with geriatric psychiatrists and pharmacists regarding the appropriateness of prescribing antidepressants that inhibit reuptake of both serotonin and norepinephrine, such as venlafaxine (Effexor), as first-line treatment for depressed patients who present with physical symptoms.1 It is important that patients receive adequate education from providers and nurses to take these medications properly, as remission of depressive and physical symptoms is dependent upon adherence to treatment. Physical symptoms of depression tend to linger longer than psychological and emotional symptoms, underscoring the importance of continued monitoring and management of these patients by health care providers.1 Beyond pharmacological therapy, psychosocial interventions such as cognitive behavioral therapy will be beneficial for these patients and can be facilitated by psychologists and social workers. Providers should also rule out the possibility that patient is experiencing symptoms of anxiety and depression as side effects of medications. Some medications commonly prescribed for older adults, including antidepressants and antihypertensives, may be partially responsible for symptoms such as insomnia and decreased concentration.3 In all cases, thorough review of patients’ medical history and comprehensive psychiatric and physical assessment is highly recommended for patients with prolonged complaints of physical symptoms.3

Interprofessional contacts for this topic:
Primary care providers
Acute care providers
Geriatric psychiatrists
Pharmacists
Registered nurses
Psychologists
Social workers

Link to the following evidence-based protocols:
Atypical presentation
Depression
Medication
Pain
Sensory changes

References

1Trivedi, M. H. (2004). The link between depression and physical symptoms. Primary Care Companion to the Journal of Clinical Psychiatry, 6(suppl 1), 12.

2Mehta, K. M., Simonsick, E. M., Penninx, B. W., Schulz, R., Rubin, S. M., Satterfield, S., & Yaffe, K. (2003). Prevalence and correlates of anxiety symptoms in well‐functioning older adults: Findings from the health aging and body composition study. Journal of the American Geriatrics Society, 51(4), 499-504.

3Kogan, J. N., Edelstein, B. A., & McKee, D. R. (2000). Assessment of anxiety in older adults: current status. Journal of Anxiety Disorders, 14(2), 109-132.

4Fonda, S. J., & Herzog, A. R. (2001). Patterns and risk factors of change in somatic and mood symptoms among older adults. Annals of Epidemiology, 11(6), 361-368.

5Cahoon, C.G. (2012). Depression in older adults. American Journal of Nursing, 112(11), 22-30.