Overview

With the aging of the population and with the advent of improved cancer detection and advances in oncologic treatment leading to higher survival rates, greater numbers of older adults are at risk for developing cancer and are also living longer with cancer. Indeed, current

As stated, psychological distress can present at any stage of management, and while it should not necessarily be considered pathological, it should be assessed for and addressed proactively. Manifestations of distress are varied and individualized according to the person’s unique coping style and strengths, among other factors. Symptoms of psychological distress include somatic complaints such as poor sleep, general aches and pains, stomach upset, lower gastrointestinal distress, and muscle tension, and psychological complaints like inability to focus or concentrate, distractibility, irritability, sadness or feeling blue, or worry about the future. The oncologic provider and treatment staff should be aware of these symptoms, as direct and active supportive measures are quite useful in helping patients adjust and successfully cope, and some research suggests, may prevent further behavioral complications. Helpful interventions include active listening, acknowledgment of distress, validation of concerns, explanation of symptoms or care processes, problem-solving, and reassurance. Importantly, many symptoms are time-limited and resolve spontaneously. However, it is critical that psychological distress be screened for and documented since unusually severe or prolonged distress may lead to ineffective coping and poor decision making, and may indicate that the patient is at high risk for an adverse behavioral outcome or development of a psychiatric disorder. The National Cancer Comprehensive Network (NCCN) recommends use of the “Distress Thermometer” as a simple but very effective tool for assessing patients for distress and following symptoms over time and as a way of determining when further evaluation may be needed.

At the same time that the older patient is being queried for psychological distress, it can be useful to inquire about family and social support, trying to determine if it is available and adequate. The lack of extended support has been identified as a risk factor for psychological complications and possibly poorer adherence to treatment. For example, widowhood and social isolation are established risk factors for depression and substance abuse, which then themselves may lead to missed appointments. The older patient often presents with and relies upon close family and friends and may worry that a cancer illness may place an undue burden on them. Specific needs may include transportation to appointments, in-home help or safety evaluations, assistance with simple household chores or meal preparation, or referral to social service agencies. If the older patient’s spouse is also ill, the care burden may fall upon adult children who may be poorly prepared for the additional time commitment required, the financial costs incurred, and the associated schedule disruptions. In addition, for the elderly who are more frail, who are cognitively impaired, or who come from a non-Western or different cultural background, involvement of family and an extended network of friends and caregivers may be instrumental and expected. Coordination of care, identification of key family spokespersons, and family meetings are often essential in the care of the older patient in general, and with a serious illness like cancer, these communications assume greater importance. When family or caregiver dynamics are ineffectual or impaired, a distressed caregiver network or family may inadvertently contribute to the dismay and worry of the older patient. Finally, family and others may have their own concerns or misconceptions concerning cancer and may be unsure of what to expect or how to assist.

In general, depression and anxiety are not normal consequences of aging. In fact, studies of the prevalence of depression in community-dwelling healthy elderly indicate that the prevalence of major depressive disorders is lower in this age group than in the younger adult population. However, as illness burden accumulates, the prevalence of depression or anxiety in older age groups rises dramatically, whether measured by number, severity, or duration of condition(s). In the cancer population, up to 50% of patients report symptoms of psychiatric disturbance. Yet, determination of the exact prevalence of specific psychiatric disorders is difficult and prevalence estimates have varied widely because of multiple variables such as specific cancer type, study design, or demographics. Overall, prevalence of any psychological disturbance, meaning depression, anxiety, or adjustment disorder, has averaged around 30%. As no studies have focused on the epidemiology of depressive or anxiety disorders in older cancer patients, specific data for the elderly are not available. Nonetheless, a few general comments can still be made. There appears to be a strong association between depression and certain cancer types, notably head and neck, lung, and pancreatic cancers, although the exact mechanism of association is undetermined. While breast cancer in younger women may carry a higher depressive risk because of concerns about attractiveness, fertility, or general self-image, for the older female patient, especially at increasing age, the association appears to diminish. Conversely, the availability of a supportive spouse or partner diminishes the risk of developing depression or other psychological disturbances, so that widowed or single women with breast cancer may carry a higher risk of depression. However, effects of antihormone treatment with age may be another factor for which studies have not adequately controlled. Similarly, for men, prostate cancer appears to carry a higher depressive burden, with younger age at onset, degree of sexual impairment, or complications of intervention or antihormone treatment being other cofactors. As before, the availability of a supportive spouse or partner lowers the risk. In contrast, a high level of caregiver distress seems to be a risk factor for the development of psychiatric problems in older medical patients. Finally, other neurobiological factors of aging likely interact with specific cancer processes to mediate the expression and risk for development of psychiatric disturbances. In particular, acute or chronic stress, effects of tumor markers, immune responses in aging, and general systems resiliency may all play a role.

As stated, psychological distress can present at any stage of management, and while it should not necessarily be considered pathological, it should be assessed for and addressed proactively. Manifestations of distress are varied and individualized according to the person’s unique coping style and strengths, among other factors. Symptoms of psychological distress include somatic complaints such as poor sleep, general aches and pains, stomach upset, lower gastrointestinal distress, and muscle tension, and psychological complaints like inability to focus or concentrate, distractibility, irritability, sadness or feeling blue, or worry about the future. The oncologic provider and treatment staff should be aware of these symptoms, as direct and active supportive measures are quite useful in helping patients adjust and successfully cope, and some research suggests, may prevent further behavioral complications. Helpful interventions include active listening, acknowledgment of distress, validation of concerns, explanation of symptoms or care processes, problem-solving, and reassurance. Importantly, many symptoms are time-limited and resolve spontaneously. However, it is critical that psychological distress be screened for and documented since unusually severe or prolonged distress may lead to ineffective coping and poor decision making, and may indicate that the patient is at high risk for an adverse behavioral outcome or development of a psychiatric disorder. The National Cancer Comprehensive Network (NCCN) recommends use of the “Distress Thermometer” as a simple but very effective tool for assessing patients for distress and following symptoms over time and as a way of determining when further evaluation may be needed.

At the same time that the older patient is being queried for psychological distress, it can be useful to inquire about family and social support, trying to determine if it is available and adequate. The lack of extended support has been identified as a risk factor for psychological complications and possibly poorer adherence to treatment. For example, widowhood and social isolation are established risk factors for depression and substance abuse, which then themselves may lead to missed appointments. The older patient often presents with and relies upon close family and friends and may worry that a cancer illness may place an undue burden on them. Specific needs may include transportation to appointments, in-home help or safety evaluations, assistance with simple household chores or meal preparation, or referral to social service agencies. If the older patient’s spouse is also ill, the care burden may fall upon adult children who may be poorly prepared for the additional time commitment required, the financial costs incurred, and the associated schedule disruptions. In addition, for the elderly who are more frail, who are cognitively impaired, or who come from a non-Western or different cultural background, involvement of family and an extended network of friends and caregivers may be instrumental and expected. Coordination of care, identification of key family spokespersons, and family meetings are often essential in the care of the older patient in general, and with a serious illness like cancer, these communications assume greater importance. When family or caregiver dynamics are ineffectual or impaired, a distressed caregiver network or family may inadvertently contribute to the dismay and worry of the older patient. Finally, family and others may have their own concerns or misconceptions concerning cancer and may be unsure of what to expect or how to assist.

In general, depression and anxiety are not normal consequences of aging. In fact, studies of the prevalence of depression in community-dwelling healthy elderly indicate that the prevalence of major depressive disorders is lower in this age group than in the younger adult population. However, as illness burden accumulates, the prevalence of depression or anxiety in older age groups rises dramatically, whether measured by number, severity, or duration of condition(s). In the cancer population, up to 50% of patients report symptoms of psychiatric disturbance. Yet, determination of the exact prevalence of specific psychiatric disorders is difficult and prevalence estimates have varied widely because of multiple variables such as specific cancer type, study design, or demographics. Overall, prevalence of any psychological disturbance, meaning depression, anxiety, or adjustment disorder, has averaged around 30%. As no studies have focused on the epidemiology of depressive or anxiety disorders in older cancer patients, specific data for the elderly are not available. Nonetheless, a few general comments can still be made. There appears to be a strong association between depression and certain cancer types, notably head and neck, lung, and pancreatic cancers, although the exact mechanism of association is undetermined. While breast cancer in younger women may carry a higher depressive risk because of concerns about attractiveness, fertility, or general self-image, for the older female patient, especially at increasing age, the association appears to diminish. Conversely, the availability of a supportive spouse or partner diminishes the risk of developing depression or other psychological disturbances, so that widowed or single women with breast cancer may carry a higher risk of depression. However, effects of antihormone treatment with age may be another factor for which studies have not adequately controlled. Similarly, for men, prostate cancer appears to carry a higher depressive burden, with younger age at onset, degree of sexual impairment, or complications of intervention or antihormone treatment being other cofactors. As before, the availability of a supportive spouse or partner lowers the risk. In contrast, a high level of caregiver distress seems to be a risk factor for the development of psychiatric problems in older medical patients. Finally, other neurobiological factors of aging likely interact with specific cancer processes to mediate the expression and risk for development of psychiatric disturbances. In particular, acute or chronic stress, effects of tumor markers, immune responses in aging, and general systems resiliency may all play a role.

Screening and Diagnosis of Depressive Disorders in Geriatric Oncology

While many patients may endorse some types of depressive symptoms, not all are willing to do so; thus determining who may be clinically depressed, or more precisely, who meets formal criteria for a depressive disorder is not always clear. Clinical depression affects physical, behavioral, psychological, and cognitive domains, each to a varying degree and leading to heterogeneity of presentation. Further complicating assessment are age effects and illness-related factors. However, the current diagnosis of a depressive disorder, using DSM-IV TR criteria, does not take into account this multidimensional nature of depression or recognize particular age-related or illness contributions, resulting in the overdiagnosis, underdiagnosis, and misdiagnosis of depression, especially in the elderly or medically ill populations. Criteria for Major Depressive Disorder, according to DSM-IV TR nomenclature used by psychiatrists and most mental health professionals, are listed in Table 15-1 and are outlined following a simple mnemonic “Sig E Caps.” Note that symptoms must be present most days for at least 2 weeks continuously, and one symptom must include either depressed mood or anhedonia.

As indicated, when assessing an older patient with cancer, age-related factors should be taken into account; these include individual beliefs about mental illness and expectations about what life might be or mean in one’s later years. Some older cohorts of patients view any expression of psychological distress as a sign of personal weakness or character flaw or with shame. Societal and cultural views often relegate older people to the background or discount their value. Sex differences in expression of psychological distress also exist. Women, because of cultural acceptance and social custom, are more open to disclosing their feelings and emotional concerns and are more accepting of psychological assistance. On the other hand, men generally tend to deny inner mental turmoil, and instead, may display distress in a culturally-sanctioned way such as with anger or aggression or may engage in risky behaviors or turn to substance abuse. Table 15-2 lists factors that confound the assessment of depression in an older person. One critical issue not to overlook is the role of therapeutic nihilism, where patient, family, and/or care provider may collude to try to “explain away” depression as a reasonable consequence of grave illness coupled with life circumstances. If this stance becomes accepted, many patients will likely suffer needlessly; depression contributes to disability and lessens quality of life, but once identified, depression is imminently treatable. Finally, patients older than 75 years who are diagnosed with a serious illness for the first time, those with preexisting cognitive impairment, those with lower levels of education, and those with a past history of depression or substance abuse (usually alcohol) also appear at greater risk for developing clinical depression.

Similarly, illness-related factors can affect each domain separately or in combination, and an identified psychiatric complaint may be due to the cancer illness itself, a complication of the illness, or the effect of a cancer treatment. For example, a brain tumor may affect an area involved with drive or pleasure, pain from cancer may disrupt sleep, or use of steroids may promote irritability. Furthermore, given the prominence of certain symptoms in cancer, to wit, anorexia, fatigue, sleep disturbance, and psychomotor slowing, knowing how and when to attribute a specific symptom to depression or to cancer can be daunting. Thus when approaching any patient with cancer who presents with a psychological or behavioral concern, it is useful to try to undertake an analysis of what may be driving the complaint in order to arrive at the correct diagnosis and best solution. There are clues to help guide when a depressive symptom may be caused by a psychiatric disorder rather than to cancer or a related cancer treatment. One of the most important is the temporal relationship between the psychiatric complaint and physical illness. In most cases, a mood or behavioral change will precede a worsening of any physical component, and to add further support to a diagnosis of a depressive disorder, physical symptoms will co-vary with depressive symptoms in a proportional relationship: as depressive symptoms worsen, so will physical complaints. Table 15-3 lists additional clues to help make the diagnosis of depression when serious medical illness is present and confounds assessment. It is also worth noting that it is the degree of functional impairment resulting from illness that appears to be the greater risk factor for development of depression, especially if the older person loses a fair degree of independence or mobility and if this change occurs abruptly with little time to adjust to or accept this change. How the caregiver or spouse responds to this impairment is another critical factor. Caregivers who become anxious or distressed about the cancer diagnosis or with complications of cancer treatment can often adversely affect the mood and well-being of the patient. Having involved the caregiver at the outset of management may provide an opportunity either to assess the caregiver for treatment or to recommend a separate referral.

While many patients may endorse some types of depressive symptoms, not all are willing to do so; thus determining who may be clinically depressed, or more precisely, who meets formal criteria for a depressive disorder is not always clear. Clinical depression affects physical, behavioral, psychological, and cognitive domains, each to a varying degree and leading to heterogeneity of presentation. Further complicating assessment are age effects and illness-related factors. However, the current diagnosis of a depressive disorder, using DSM-IV TR criteria, does not take into account this multidimensional nature of depression or recognize particular age-related or illness contributions, resulting in the overdiagnosis, underdiagnosis, and misdiagnosis of depression, especially in the elderly or medically ill populations. Criteria for Major Depressive Disorder, according to DSM-IV TR nomenclature used by psychiatrists and most mental health professionals, are listed in Table 15-1 and are outlined following a simple mnemonic “Sig E Caps.” Note that symptoms must be present most days for at least 2 weeks continuously, and one symptom must include either depressed mood or anhedonia.

As indicated, when assessing an older patient with cancer, age-related factors should be taken into account; these include individual beliefs about mental illness and expectations about what life might be or mean in one’s later years. Some older cohorts of patients view any expression of psychological distress as a sign of personal weakness or character flaw or with shame. Societal and cultural views often relegate older people to the background or discount their value. Sex differences in expression of psychological distress also exist. Women, because of cultural acceptance and social custom, are more open to disclosing their feelings and emotional concerns and are more accepting of psychological assistance. On the other hand, men generally tend to deny inner mental turmoil, and instead, may display distress in a culturally-sanctioned way such as with anger or aggression or may engage in risky behaviors or turn to substance abuse. Table 15-2 lists factors that confound the assessment of depression in an older person. One critical issue not to overlook is the role of therapeutic nihilism, where patient, family, and/or care provider may collude to try to “explain away” depression as a reasonable consequence of grave illness coupled with life circumstances. If this stance becomes accepted, many patients will likely suffer needlessly; depression contributes to disability and lessens quality of life, but once identified, depression is imminently treatable. Finally, patients older than 75 years who are diagnosed with a serious illness for the first time, those with preexisting cognitive impairment, those with lower levels of education, and those with a past history of depression or substance abuse (usually alcohol) also appear at greater risk for developing clinical depression.

Similarly, illness-related factors can affect each domain separately or in combination, and an identified psychiatric complaint may be due to the cancer illness itself, a complication of the illness, or the effect of a cancer treatment. For example, a brain tumor may affect an area involved with drive or pleasure, pain from cancer may disrupt sleep, or use of steroids may promote irritability. Furthermore, given the prominence of certain symptoms in cancer, to wit, anorexia, fatigue, sleep disturbance, and psychomotor slowing, knowing how and when to attribute a specific symptom to depression or to cancer can be daunting. Thus when approaching any patient with cancer who presents with a psychological or behavioral concern, it is useful to try to undertake an analysis of what may be driving the complaint in order to arrive at the correct diagnosis and best solution. There are clues to help guide when a depressive symptom may be caused by a psychiatric disorder rather than to cancer or a related cancer treatment. One of the most important is the temporal relationship between the psychiatric complaint and physical illness. In most cases, a mood or behavioral change will precede a worsening of any physical component, and to add further support to a diagnosis of a depressive disorder, physical symptoms will co-vary with depressive symptoms in a proportional relationship: as depressive symptoms worsen, so will physical complaints. Table 15-3 lists additional clues to help make the diagnosis of depression when serious medical illness is present and confounds assessment. It is also worth noting that it is the degree of functional impairment resulting from illness that appears to be the greater risk factor for development of depression, especially if the older person loses a fair degree of independence or mobility and if this change occurs abruptly with little time to adjust to or accept this change. How the caregiver or spouse responds to this impairment is another critical factor. Caregivers who become anxious or distressed about the cancer diagnosis or with complications of cancer treatment can often adversely affect the mood and well-being of the patient. Having involved the caregiver at the outset of management may provide an opportunity either to assess the caregiver for treatment or to recommend a separate referral.

Differential Diagnosis of Depression in the Older Patient with Cancer

While the previous discussion has focused on the diagnosis of major depression, it is important not to overlook what is involved, generally speaking, in the differential diagnosis. Included here are other medical illnesses and effects of medications or treatments, other depressive and psychiatric disorders, and life circumstances. Table 15-4 lists some considerations.

When a medical problem is found to be etiologically related or causal to the mood disorder, a diagnosis of Mood Disorder due to General Medical Condition is made. Treating the underlying medical problem may address the mood components, although frequently additional psychotropic or psychological management will be needed. However, another main point is that while major depression can present with physical complaints, many medical conditions also present with depressive symptoms, that is, depressive symptoms are not pathognomonic, and thus a careful history is critical to determining which problem is primary. For the older patient, while much of the focus will necessarily be on the management of cancer, new medical conditions can arise and exacerbations of preexisting problems may occur. Furthermore, depression can coexist with cancer, or any other medical problem, and often does. In the older patient, particular mention must be made of dementia and delirium, both of which occur more commonly with age and with increasing medical stressors or use of multiple medications. Since dementia prevalence rises with age and given that a longer life span also exposes people to a greater risk of cancer and to living with cancer, it is reasonable to expect that more patients will be afflicted with both dementia and cancer. How each condition might affect the other in terms of assessment or management is poorly understood. What is known is that the presence of dementia may influence the expression of depression, obscure its detection, or may confuse assessment. Alzheimer disease (AD), the most common type of dementia in later life, is often accompanied by a depressive complication, and indeed, up to 40% of AD patients by some estimates will experience depression over their course of illness. Importantly, studies show that depression in dementia is treatable with medications and with behavioral or psychological approaches, although the extent of improvement and durability of response varies, as would be expected in a neurodegenerative process. With regard to delirium, the main risk is in overlooking this important diagnosis. Untreated delirium carries a high mortality risk and may be a poor prognostic sign in a frail older patient, especially if it does not clear and becomes chronic. From a psychiatric perspective, the concern for delirium is highest in medically ill patients with an abrupt onset of depressive symptoms, the presence of psychosis or acute suicidal ideation, or a history of substance abuse or polypharmacy. In addition, delirium should be considered in the differential diagnosis of patients who are hospitalized, who present to the emergency room, or whose cognitive profile appears at odds with their baseline.

When a medication or substance is thought to explain the mood disturbance, a diagnosis of Substance-Induced Mood Disorder is made, and removing the offending agent may result in improvement of the underlying behavioral problem. However, separating specific agents to see which is related to particular mood symptoms is often daunting if not impossible. With regard to the older patient, age-related changes in pharmacokinetics and pharmacodynamics are also relevant but remain understudied where cancer is concerned. The best clue again derives from history and determining whether the drug, when given, was temporally associated with induction of the observed mood or behavioral change. When a medication that seems to promote depressive feelings must be used to treat an underlying medical problem or manage a symptom, it is worth trying to find a drug with the desired effect but a different side-effect profile, from a different class or with a different mechanism of action. Similarly, other iatrogenic causes of depression cannot be overlooked; these situations usually involve polypharmacy, where drug-drug interactions are most likely a result of the sheer number of medications prescribed, and where drug monitoring is often inadequate and is more challenging the more providers are involved in a given patient’s care. In management of an older patient, it may be unusually challenging to separate out the effects of narcotics on mood, cognition, and behavior, especially in the presence of pain, which, if inadequately treated, is itself a risk factor for depression. Here clinical judgment must be used and careful attention placed on the goals of pain management. Determining if and when pain control has been achieved and has led to the desired outcomes can be a helpful guide. Encouraging the use of alternative and complementary forms of pain management may be another option for the older patient with cancer. Importantly, narcotics should never be withheld for fear of promoting addiction or dependency in a patient with cancer, especially in the terminal phase of illness. Finally, it is critical not to overlook that untreated depression can amplify the perception of pain or other distressing physical symptoms, so that effectively treating any underlying depressive disorder may also result in improvement in pain.

The previous list does not include specific concerns about chemotherapeutic agents. These are listed in Table 15-5 . However, much controversy surrounds this association and the causal links have yet to be definitively proven. Nonetheless, caution should be followed when a cancer patient on one of these medications develops depressive symptoms for the first time after commencement. Further study is needed.

Other depressive disorders are possible in the older cancer patient and should be considered when symptoms are either of short duration or inadequate in number to meet DSM-IV-TR criteria for major depression. Importantly, while falling short of the full syndrome, these symptoms remain clinically meaningful and can adversely affect health outcomes, increase cost of care, and lower quality of life. If unresolved, these disorders also place patients at increased risk of developing major depression over the next year. Included in this category are the DSM-IV-TR diagnoses Subsyndromal Depression, which encompasses Minor Depression, Non-Dysphoric Depression, and Brief Reactive Depression; Dysthymia, which is diagnosed when symptoms of low-grade depression last for 2 years or longer; and Adjustment Disorder with depressed, anxious, or mixed mood. With regard to the last, adjustment disorder is an abnormal excessive reaction to a life stressor such as a new serious illness like cancer, getting divorced, or death of a loved one, and usually begins within 3 months of onset of the stressor. Once the stressor or its consequences has terminated, symptoms resolve and should not persist beyond 6 months. Closer surveillance of these patients is suggested. Treatment of adjustment disorder is supportive and usually psychosocial and behavioral in nature rather than pharmacological.

It can be very difficult to separate out an anxiety disorder from clinical depression, given the overlap of symptoms between the two conditions. Indeed, anxiety can be a component of depression in some patients, and a certain subtype called Mixed Anxiety Depression or Anxious Depression may be more common in the elderly. Furthermore, a person can have both an anxiety disorder and a depressive disorder. Anxiety may also be a normal reaction to the diagnosis of cancer and may be part of a normal stress response. However, anxiety is not a disorder of mood, so depressed and sad feelings are absent, and anxiety does not affect interests or ability to derive pleasure. The section that follows more fully discusses assessment and management of anxiety disorders in older patients with cancer.

An often overlooked consideration in the older patient is substance abuse or dependence, either from a common substance such as alcohol or from prescription medications. When cancer enters into consideration, assessment can be confusing and management can quickly become problematic. A patient who is actively abusing cannot be reliably assessed, and every effort should be made to have the patient abstain for a sufficient period to allow for a more accurate accounting of symptoms. However, this area is controversial and not sufficiently studied in the older population or, specifically, in the situation of older cancer patients. Importantly, older patients with a past history of substance abuse or dependence appear to be at higher risk for developing depression in the context of serious illness.

Finally, life circumstances themselves may be demoralizing and discouraging, and separating out appropriate responses to these types of challenges can be daunting but should not be overlooked, minimized, or deemed pathological. Personal losses begin to accumulate and grief and bereavement, which are unavoidable, should be recognized first as normal reactions. Financial difficulties may mount, especially when faced with expensive medical treatment on a fixed income. After children and despite the availability of Medicare and Social Security, the elderly have the highest poverty rates, with older single women being most at risk for impoverishment due to a catastrophic illness. To help defray the cost of care, an older person may be forced to move from a longtime home or into a new living arrangement. With aging, a person may undertake a life review and think of past deeds, of lost opportunities, or of poor choices made and look back with regret or sadness. Finally, with age, awareness of mortality and of limited time remaining enters into consciousness, which may precipitate an existential or spiritual crisis with anxiety, panic, and despair as prominent symptoms. Thoughts of death begin to appear and enter into usual discussion, not as a symptom of suicidal ideation, but as recognition of this final stage of life. If resolved successfully, distressing symptoms subside to be replaced with peace, gratitude, and calmness.

Screening and Assessment Tools

For all the issues discussed previously, depression can be challenging to detect and diagnose in older patients with cancer. While the “Distress Thermometer” provides a simple and systematic way of identifying patients who may require heightened surveillance for psychological distress, it has yet to be effectively compared to other “gold standard” self-report or clinician-administered depression screening or diagnostic instruments that are often recommended for use in older patient samples. However, a further question is whether these latter instruments, while validated in groups of older medically ill patients, have been specifically studied in older patients with cancer. The short answer is no. Notwithstanding the lack of studies, given the importance and prevalence of depression, it remains reasonable to suggest use of screening measures and other diagnostic tools in this population until data become available. These instruments and some psychometric properties are listed in Table 15-6 .

Applying the one- or two-item Patient Health Questionnaire (PHQ) screens, along with the Distress Thermometer, can be an efficient strategy to identify the patient at risk for depression. The one-item question is, “Do you often feel sad or depressed?” and can be easily asked by staff at check-in or during a routine visit. The PHQ-2 screen asks, “Over the past 2 weeks, how often have you been bothered by: (1) a lack of interest; or (2) feeling sad or depressed?” These questions are rated on a scale of 0 to 3 (range from 0 to 6) with a positive score being 3 or greater. However, if the patient screens positive on one of these questions, further assessment should follow with a diagnostic instrument such as the Center for Epidemiological Studies-Depression Scale (CES-D), Geriatric Depression Scale (GDS, various forms available), Patient Health Questionnaire-9 (PHQ-9), or, if the patient is cognitively impaired, with the Cornell Scale for Depression in Dementia (CSDD). Most of these scales can be administered in about 3 to 10 minutes. A unique feature of the CSDD is the incorporation of observer or caregiver feedback on the patient. Lastly, except for the one- or two-item screeners, most can be used both to gauge severity of depression and to follow change from treatment, so that systematic use of the tools over time, e.g., weekly or monthly, can help guide the effectiveness of interventions or the need for additional specialist mental health referral. However, it is critical to keep in mind that a number of scale attributes should be considered when using these in a geriatric cancer setting. These include the time period assessed (past week or 2 weeks, for example), completion time and item length, variable assessment of multiple mood symptoms, impact of concomitant cognitive impairment, and phrasing of individual items such as hopelessness, which may have contextual importance and differing meaning depending on the patient’s age or stage of illness. Except for the PHQ-9, which queries for all depressive symptom domains according to current DSM-IV-TR criteria, the advantage of the other identified tools is the reliance primarily on the psychological symptoms of depression.