MASKED DEPRESSION IN AN OCTOGENARIAN: CASE REPORT

Authors


An 84-year-old man who experienced several episodes of nocturnal sweating and hypotension without loss of consciousness during the previous 2 months, was admitted to the Department of Gerontology, Geriatrics, and Metabolic Diseases at the Second University of Naples (Naples, Italy). There was no history of seizure, and physical examination did not show pathological signs. Clinical parameters were body weight 76 kg, height 177 cm, blood pressure 120/80 mmHg, and cholesterol 256 mg/dL; serum chemistry and urinary analysis were normal. On admission, the patient received no medication. On Day 2, a 24-hour ambulatory blood pressure measurement (ABPM) was performed and showed a mean blood pressure of 136/77 mmHg and a mean heart rate of 74 bpm. During the ABPM, the patient experienced profuse sweating and hypotension at 11:00 p.m. characterized by blood pressure of 85/55 mmHg and heart rate of 78 bpm lasting for approximately 15 minutes (Figure 1). This episode of nocturnal sweating and hypotension was not associated with prodrome symptoms. Five similar episodes occurred during the following 10 days of hospitalization (mainly at night). Electrocardiogram and 24-hour Holter monitoring did not show any pathological findings. On Day 13, during a cognitive assessment, the 15-item Geriatric Depression Scale evaluation indicated depressive symptoms (score 7/15), and a psychiatric interview revealed the presence of depression and anxiety disorder, probably due to the loss of his wife 3 months before. The patient was then treated with citalopram 10 mg every day. Over the following 3 weeks, an improvement in depression was seen, with complete resolution of nocturnal sweating and hypotensive episodes.

Figure 1.

 Mean 24-hour ambulatory blood pressure, systolic blood pressure (SPB), diastolic blood pressure (DBP), and heart rate (HR). Patient experienced profuse nocturnal sweating and hypotension at 11:00 p.m. (arrow).

DISCUSSION

Late-life depression is one of the main health problems in older adults and is often “masked.”1 Approximately half of patients with depression seen by primary care physicians initially present predominantly with somatic symptoms.2 Patients suffering from “masked depression” may exhibit a variety of somatic complaints or behavioral problems, including nocturnal sweating, dizziness, anxiety, somatization, hypochondriasis, fatigue, weight loss, suicidal ideation, and a preoccupation with death.3,4 An unusual presentation of depressive syndromes with hypotension has recently been reported in an octogenarian.5 Several cross-sectional studies have described “hypotensive syndrome” characterized by somatic complaints of weakness, fainting, and depression.6 Studies have reported the relationship between blood pressure and depression.6 In particular, several studies have proposed the mechanisms that could explain how depression produces somatic symptoms, fatigue, and hypotension. A disorder of central monoamine activity could produce psychological (depression) and physiological (low blood pressure) symptoms.7 In the past 2 decades, numerous studies have suggested that neuropeptide Y, one of the most abundantly expressed neuropeptides, has important functions in these systems and exhibits effects on various domains, such as food intake, blood pressure, and psychological symptoms.8 Regarding the cardiovascular system, neuropeptide Y in the brain seems to suppress sympathetic activity and decrease blood pressure.9 Furthermore, other studies have found that patients with depression may have altered thermoregulation.3 In particular, depressed patients seem to have high nocturnal temperatures, and night sweats have been reported in 30% of geriatric patients.10 Thermogenesis and heat retention (vasoconstriction) could explain the high nocturnal temperatures seen in these patients.3 In older adults, somatic symptoms may be important for diagnosing depression. The present case describes an unusual presentation of “masked depression” in an 84-year-old man otherwise classifiable as a good example of “aging gracefully.” This is the first report in which a case of depression associated with dizziness, hypotension and nocturnal sweating is described. The symptoms of sweating and hypotension disappeared completely with treatment of the depression.

These findings might help to better identify patients with “masked depression” and differentiate them from patients without depression with medical illness.

ACKNOWLEDGMENTS

Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper.

Author Contributions: Mauro Giordano: study concept and design and preparation of letter. Tiziana Ciarambino and Nicoletta Ferrara: design, acquisition of subjects and data, and analysis and interpretation of data.

Sponsor's Role: None.

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