Depression - elderly

Answer 1

Definition

Depression is a medical illness in which a person has feelings of sadness, discouragement, and a lack of self-worth.

Causes, incidence, and risk factors

Depression can be caused by:

• Changes within the family
• Chronic pain and illness
• Difficulty getting around
• Frustration with memory loss
• Loss of a spouse or close friend
• Trouble adapting to a life change such as moving from a home to a retirement facility

Depression can also be a sign of a medical problem. It can be a reaction to the illness, or caused by the disease itself. It may be complicated by brain disorders that occur with age, such as Alzheimer's disease. Depression is also a side effect of many drugs commonly prescribed for the elderly.

Depression in the elderly is a widespread problem that is often not diagnosed and frequently undertreated. Many older people will not admit to the signs and symptoms of depression for fear that they will be seen as weak or crazy. Some older people may be aware of their depression, but believe that nothing can be done about it.

Symptoms

Symptoms of depression may not be easy to identify in older adults. Their symptoms are often ignored, or confused with other ailments common in the elderly, such as:

• Alzheimer's disease
• Arthritis
• Cancer
• Dementia
• Heart disease
• Parkinson's disease
• Stroke
• Thyroid disorders

Symptoms of depression include:

• Abnormal thoughts about death
• Abnormal thoughts, excessive or inappropriate guilt
• Aches and pains
• Change in appetite (usually a loss of appetite)
• Change in weight
  • Unintentional weight loss (most common)
  • Weight gain
• Depressed or irritable mood
• Difficulty concentrating
• Fatigue (tiredness or weariness)
• Feelings of worthlessness or sadness
• Irresponsible behavior
• Loss of interest or pleasure in daily activities
• Memory loss
• Plans to commit suicide or actual suicide attempts
• Temper, agitation
• Thoughts about suicide
• Trouble sleeping
  • Daytime sleepiness
  • Difficulty falling asleep (initial insomnia)
  • Waking up many times through the night (middle insomnia)
  • Waking up early in the morning (terminal insomnia)

If you have these symptoms every day for more than 2 weeks, you likely have depression.

Depression in the elderly may be hard to detect because of several factors. Symptoms such as fatigue, appetite loss, and trouble sleeping also can be part of the aging process or a medical condition.

An elderly person may only have a decrease in the ability to perform everyday activities.

Signs and tests

A physical examwill help determine if a medical illness is causing the depression. A psychological evaluation and other tests may be needed.

Blood tests may be done, including:

• Blood differential
• CBC
• Liver or kidney function tests
• Thyroid function tests

Treatment

Sometimes relieving loneliness through group outings, volunteer work, or having regular visitors can help with depression.

Treating the medical conditions that cause depression, or stopping certain medications can relieve the symptoms of depression.

Talking through problems (psychotherapy) with a psychologist, psychiatrist, or other therapist is also an effective treatment. In cases of moderate to severe depression, people may get the best results by combining psychotherapy with antidepressant medications.

Short-term (about 12 weeks) group-based physical exercise programs involving walking or other forms of aerobic exercise can reduce depression in older adults.

Antidepressant drug therapy has been shown to increase the quality of life in depressed elderly people. These medications are carefully monitored for side effects. Doctors usually prescribe lower doses of antidepressants for older people, and increase the dose more slowly than in younger adults.

These medications include:

• Selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), citalopram (Celexa), and escitalopram (Lexapro) are used as first-line treatments.
• Serotonin-norepinephrine reuptake inhibitors (SNRIs), such as venlafaxine (Effexor) and Duloxetine (Cymbalta), as well as mirtazapine (Remeron) may also be tried.
• Tricyclic antidepressants are not used as often because of side effects, particularly for the heart.

Neuroleptic medications can help treat agitation in some people. Electroconvulsive therapy (ECT) can be used in people who are severely depressed if other treatments don't work.

Expectations (prognosis)

Depression can respond to medical treatment. If it is not detected, depression can lead to complications. The outcome is usually worse for people who have limited access to social services, or to family or friends who can help them stay interested in activities.

Complications

Depression can be complicated by Alzheimer's disease or other forms of dementia. It also can complicate other medical conditions in the elderly.

Suicide in the elderly is one of the leading causes of death related to injury. Men account for most of these suicides, and divorced or widowed men are at the highest risk. Families should pay special attention to elderly male relatives who are alone. In addition to finding psychiatric help for them, family members should remove anything from their homes (such as knives) that they could use to harm themselves.

Calling your health care provider

Call your health care provider if you feel worthless or hopeless, or if you cry often. Also call if you are having trouble coping with stresses in your life and want to be referred for counseling.

Go to the nearest emergency room or call your local emergency number (such as 911) if you are thinking about suicide (taking your own life).

If you are caring for an aging family member and think they may have depression, contact their health care provider. Often, older patients will not admit to the signs and symptoms of depression out of pride.

Prevention

Preventing depression depends on the factors involved. Social supports that help people deal with loss, mobility changes, and other depression triggers can be helpful. In many cases, there is no way to prevent depression.

Some older patients may be screened for depression, especially if their condition changes.

References

Institute for Clinical Systems Improvement. Health Care Guideline: Major Depression in Adults in Primary Care. 11th ed. 2008.

Unutzer J. Clinical practice: late-life depression. N Engl J Med. 2007;357:2269-2276.

Answer 2

Definition

Depression is a medical illness in which a person has persistent feelings of sadness,often with discouragement and a lack of self-worth.

Depression in the elderly is a widespread problem, but is often not recognized or treated.

Causes, incidence, and risk factors

See: Depression - major for more information about the causes of depression.

In the elderly, a number of life changes can increase the risk for depression, or make existing depression worse. Some of these changes are:

• Adapting to a move from home to an apartment or retirement facility
• Chronicpain
• Feelings of isolation or loneliness as children move away and their spouse and close friends die
• Loss of independence (problems getting around, caring for themselves, or driving)
• Multiple illnesses
• Struggles with memory loss and problems thinking clearly

Elderly people often use alcohol to self-treat depression, but this may make symptoms worse.

Depression can be a sign of a physical illness. It can be a psychological reaction to the illness, or directly caused by the physical illness.

• Physical illnesses that increase the risk for depression include: thyroid disorders, Parkinson's disease, Heart disease, cancer, and stroke.
• Symptoms of depression may occur as part of dementia ( Alzheimer's disease).
• Symptoms of depression are also a side effect of many drugs commonly prescribed for the elderly.

Many older people will not admit to feeling depressed, for fear that they will be seen as "weak" or "crazy." Some older people will not report their depression because they believe that feeling sad is "normal," or that nothing can be done about it.

Symptoms

Many of the usual symptoms of depression may be present in the elderly. See: Depression - major for more details.

Depression in the elderly may be hard to detect. Common symptoms such as fatigue, appetite loss, and trouble sleeping can be part of the aging process or a physical illness. As a result, early depression may be ignored, or confused with other conditions that are common in the elderly.

Clues to depression in the elderly may include:

• Being more confused or forgetful.
• Eating less. The refrigerator may be empty or contain spoiled food.
• Not bathing or shaving as often. Visitors may notice smells of urine or stool. Clothes may be dirty and wrinkled.
• Not taking care of the home.
• Stopping medicines or not taking them correctly.
• Withdrawing from others. Not talking as much, and not answering the phone or returning phone calls.

Signs and tests

A discussion of your symptoms, physical exam, and blood and urine tests will help determine if a physical illness is causing the depression.

Sometimes your primary care doctor will send you to an expert in depression, such as a psychiatrist, to help with diagnosis and treatment. This may be especially useful for telling the difference between depression and normal grieving, which occurs more often in this age group.

Treatment

See: Depression - major for more information about medications and other therapies used to treat depression.

The first step is to address any physical illnesses and stop taking any medications that may be making your symptoms worse.

If these steps do not relieve the depression, antidepressant medications and talking through problems (psychotherapy) with a psychologist, psychiatrist, or other therapist is usually helpful.

Antidepressant drug therapy should be carefully monitored for side effects, which can be more common in the elderly. Doctors usually prescribe lower doses of antidepressants for older people, and increase the dose more slowly than in younger adults.

To better manage depression at home, elderly people should:

• Exercise regularly, seek out pleasurable activities, and maintain good sleep habits.
• Learn to watch for the early signs of depression, and know how to react if it gets worse.
• Minimize alcohol use and avoid illegal drugs. These substances can make depression worse over time, and they may also impair judgment about suicide.
• Surround themselves with people who are caring and positive.
• Talk about their feelings to someone they trust.
• Take medications correctly and learn how to manage side effects.

Expectations (prognosis)

Depression usually responds to treatment. If it is not detected, depression can lead to complications. The outcome is usually better for people who have access to social services, family, and friends who can help them stay active and engaged.

Complications

The most worrisome complication of depression is suicide. Depression and older age are both risk factors for suicide. Men account for most suicides among the elderly, and divorced or widowed men are at the highest risk. Families should pay special attention to elderly relatives who live alone.

Other complications include reduced functioning at work and in social relationships.

Calling your health care provider

Call your health care provider if you feel persistently sad, worthless, or hopeless, or if you cry often. Also call if you are having trouble coping with stresses in your life and want to be referred for talk therapy.

Go to the nearest emergency room or call your local emergency number (such as 911) if you are thinking about suicide (taking your own life).

If you are caring for an aging family member and think they may have depression, contact their health care provider.

Prevention

Staying physically, mentally, and socially active may help reduce the risk of depression in older age.

References

Cassano P, Fava M. Mood disorders: major depressive disorder and dysthymic disorder. In: Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL, eds. Massachusetts General Hospital Comprehensive Clinical Psychiatry. 1st ed. Philadelphia, Pa: Mosby Elsevier;2008:chap 29.

Unutzer J. Clinical practice: late-life depression. N Engl J Med. 2007;357:2269-2276.

Reviewed By

Review Date: 08/15/2010

David B. Merrill, MD, Assistant Clinical Professor of Psychiatry, Department of Psychiatry, Columbia Unviersity Medical Center, New York, NY. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.