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Depression in older adults is associated with functional impairment cognitively, physically and socially 7,12, Such functional impairment is linked to loss of independent function and increased rates of disability Withdrawal from normal social and leisure activities can be marked 7, Social avoidance reduces interaction with others and is often a maintaining factor for depression Self-neglect is a classical feature of depression 7 , with the presence of depressive symptoms in older adults being predictive of it Behavioural disturbances can be a common mode of presentation, especially for older adults living in institutionalised care Behavioural disturbances include incontinence, food refusal, screaming, falling and violence towards others 7.

Depression in older adults has been a condition that has constantly been under-recognised.

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Several issues account for this. Firstly, phenomenological differences are present. Many have argued that phenomenological issues contribute heavily to diagnostic difficulties 28 ; both the DSM and ICD classification systems do not have specific diagnostic criteria for depression in older adults. Potentially invalid diagnostic criteria for depression in older adults could result in fundamental difficulties in understanding, with consequent impact on both clinical practice and research.

Diagnostic difficulties are also encountered because depression in older adults can present with vague symptoms, which do not correspond to the classical triad of low mood, low energy levels and anhedonia, which can all be cardinal symptoms in a younger population. Reports of fatigue, poor sleep and reduced appetite can be attributed to a host of causes other than depression and therefore it is no surprise that a diagnosis of depression is overlooked and goes undetected by healthcare professionals The absence of an affective component i.

Furthermore, symptoms of depression, especially somatic ones, are often attributed to physical illnesses. Depressive somatic symptoms — e. Further complicating diagnostic difficulties and under-recognition is the fact that older adults are less likely to report any symptoms associated with mental health problems and ask for help in the first place 7,10,32 ; explanations for this include older adults being less emotionally open, having a sense of being a burden or nuisance, and believing symptoms are a normal part of ageing or secondary to physical illness 7,10,29, Older adults also have a reluctance to report mental health problems due to their perception of associated stigma; many older adults hold the view the mental health problems are shameful, represents personal failure and leads to a loss of autonomy 7.

There is an overlap between symptoms of depression and symptoms of dementia. It is quite common for older adults with dementia to initially present with depressive symptoms. Depression has a high incidence in those with dementia, especially those with vascular dementia. Depression is particularly difficult to diagnose in dementia due to communication difficulties; diagnosis is often based on observed behaviours 8, In those with pre-existing physical health problems, depression is associated with deterioration, impaired recovery and overall worse outcomes For example, the relative risk of increased morbidity related to coronary heart disease is 3.

Mykletun et al. Several causative routes account for poor physical illness outcomes. Older adults with depression are less likely to report worsening health. Depressive symptomatology indirectly affects physical illness through reduced motivation often secondary to feelings of helplessness and hopelessness and engagement with management. Poor compliance with management advice, notably adherence to medications is observed Feelings of hopelessness, helplessness and negativity will contribute to the failure to seek medical attention in the first place or report worsening health when seen by a healthcare professional.

Depression affects biological pathways directly, which impairs physical recovery. Such biological effects include pro-inflammatory factors, metabolic factors, impact upon the hypothalamic-pituitary axis and autonomic nervous system changes Older adults who are depressed are more likely to have existing physical health conditions and more likely to develop physical health conditions Depression is particularly associated with specific physical illnesses; cardiovascular disease and diabetes mellitus.

A study by Win et al.

Higher incidents of cardiovascular disease and diabetes mellitus are seen in people with depression regardless of age. A study by Brown et al. The hypothalamic-pituitary axis dysfunction found in depression leads to increased levels of cortisol, which in turn, increases visceral fat.

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Increased visceral fat is associated with increased insulin resistance, promoting diabetes mellitus, and increased cardiovascular pathology Depression is a risk factor for the subsequent development of dementia; this is especially so if an older adult has no previous history of depression i. Older adults are less likely to report depressive symptoms to healthcare professionals explaining the under-utilisation of mental health services for depression 32, Despite older adults under-utilising mental health services they over utilise other healthcare services 26, For example, those presenting with non-specific medical complaints or somatisation have been found to have an increase use of healthcare services.

Non-specific medical complaints and somatisation lead to an unnecessary use of resources, such as unnecessary consultations with healthcare professionals and investigations Increase in service utilisation means an increase in the associated economic cost of depression in older adults Healthcare costs of older adults with a comorbid physical illness and depression are far greater than those without depression — findings in diabetes mellitus are a good example The majority of the increased healthcare costs are associated with the chronic physical disease and not the care and treatment of the depression Poor compliance with physical illness management is associated with missed appointments and a greater number of hospital admissions, which both have financial implications.

Studies have found a significant higher rate and severity of white matter hyperintensities on MRI imaging in older adults with depression compared to those without depression 46,48, White matter hyperintensities represent damage to the nerve cells; such damage is a result of hypo-perfusion of the cells secondary to small blood vessel damage White hyperintensities are associated with vascular risk factors e. In older adults with depression, white matter hyperintensities are associated with structural changes to corticostriatal circuits and subsequent executive functional deficits.

Loss of motivation or interest and cognitive impairment in depression are hallmark features of structural brain changes associated with the frontal lobes, which in turn are associated with a vascular pathology A study by Hickie et al. It is not fully understood why vascular depression responds less well to antidepressants; poor response has been linked directly to vascular factors but has also been associated with deficits in executive function Baldwin et al.

Younger and older adults share a number of fundamental risk factors for depression; such as female gender, personal history and family history 7. Older adults have additional risk factors related to ageing, which are not just physiological in nature.

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Age related changes occurring in the endocrine, cardiovascular, neurological, inflammatory and immune systems have been directly linked to depression in older adults 3. The normal ageing process sees changes to sleep architecture and circadian rhythms with resultant changes to sleep patterns Thus sleep disturbances are common in older adults and positively correlated to advancing age 52 ; over a quarter of adults over the age of 80 years report insomnia, and research has well-established that this is a risk factor for depression A meta-analysis by Cole et al.

Sensory impairments, whether secondary to the ageing or a disease process, are risk factors 53, Research has found that hearing and vision impairments are linked to depression A sensory impairment can lead to social isolation and withdrawal, which, in turn, are further risk factors for depression. Physical illness, regardless of age, is a risk factor for depression. Older adults are more likely to have physical illnesses and so in turn are more at risk of depression.

See Table 2. Physical illness is associated with sensory impairments, reduced mobility, impairment in activities of daily living and impaired social function, all of which can lead to depression. Physical illnesses associated with chronicity, pain and disability pose the greatest risk for the subsequent development of depression 7,53, Physical illness affecting particular systems of the body, such as the cardiovascular, cerebrovascular and neurological, are more likely to cause depression 3.

Essentially, however, any serious or chronic illness can lead to the development of depression. It should be noted that a large proportion of older adults have physical illness but do not experience depression symptoms, therefore other factors must be at play 5, Treatments of physical illness are directly linked to aetiology in depression, for example, certain medications are known to cause depression; cardiovascular drugs e.

Propranolol, thiazide diuretics , anti-Parkinson drugs e. NSAIDs , antibiotics e. Penicillin, Nitrofurantoin , stimulants e. Haloperidol , anti-anxiolytics e. Phenytoin, Carbamazepine 7, Polypharmacy is present in many older adults further increasing the risk of depression. Pharmacokinetic and pharmacodynamic age related changes also contribute to an increased risk of medication induced depression in older adults. Dementia is common in old age and those with dementia are at higher risk of developing depression compared to those who do not have it Depression is a risk factor for the subsequent onset of dementia.

When compared to younger adults, older adults are at a greater risk of developing depression due to the increased likelihood of experiencing particular psychosocial stressors, in particular adverse life events. Stressors include lack of social support, social isolation, loneliness and financial hardship. Financial hardship and functional impairment often sees older adults downsizing in property. Deteriorating physical health often sees older adults no longer being able to manage living independently at home necessitating a move into institutional living.

Bereavement, especially spousal, and the associated role change that follows this are risk factors for depression 3. The prevalence of depression in older adults in England and Wales was found to be 8. A meta-analysis by Luppa et al. Sub-threshold depression is times more prevalent than major depression in older adults 26, These depressive symptoms are often clinically relevant 26, Incidence and prevalence are greater in women; Older women are more likely to experience recurrent episodes of depression compared to older men The gender gap in incidence and prevalence becomes narrower with increasing age 3.

It should be acknowledged however that women are more likely to present to healthcare services and seek help in comparison to men The prevalence of major depression in older adults varies by setting Highest rates are seen in long-term institutional care and inpatient hospital settings Table 3 summaries prevalence rates of major depression by setting. Depression in older adults is associated with a slower rate of recovery 9 , worse clinical outcomes compared to younger adults 3 and is associated with higher relapse rates Worse prognosis in older adults correlates with advancing age, physical comorbidities and functional impairment The structural brain changes associated with depression in older adults are linked, as discussed, to poorer treatment response.

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Morbidity and mortality associated with depression can be described as primary or secondary; primary morbidity and mortality arises directly from the depressive illness; whereas secondary morbidity and mortality arises from physical health problems, which are secondary to depression. Outcomes from sub-threshold depression are on par with those of major depression; however sub-threshold depression which develops into major depression is associated with worse outcomes 2.

Proportionally more people over the age of 65 years commit suicide compared to younger people This further supports and suggests the fact the depression is under-detected. Unlike younger adults, older adults are less likely to report suicidal ideation and can experience suicidal ideation without feeling low in mood 3,7. Older adults have few suicide attempts, compared to younger adults, because their suicide methods are more lethal Hypertensive emergencies involve a series of clinical presentations where uncontrolled blood pressure BP leads to progressive end-organ dysfunction affecting the neurological, cardiovascular, renal, or other organ systems.

In these situations, the BP should be controlled over minutes to hours.

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Many causes are involved in severe elevation of blood pressure; inadequate treatment of hypertension, renal diseases, head trauma and pre-eclampsia. Intraoperative hypertension is also common and has many causes. It is usually successfully controlled by anaesthetists. However, there is a lack of agreement concerning treatment plans and appropriate therapeutic goals, making common management protocols difficult. A wide range of pharmacological alternatives are available to control blood pressure and reduce the risk of complications in these patients. This article reviews the perioperative hypertensive crisis and the common strategies used in management.

Perioperative hypertension commonly occurs in patients undergoing surgery.