Despite being the most common mental disorder in older adults, depression is under- recognised. It poses diagnostic difficulties in this population for several reasons; for example, symptomatic and phenomenological differences, age-related biological and psychological factors, and the presence of physical comorbidities.
Full Answer
Despite being the most common mental disorder in older adults, depression is under- recognised. It poses diagnostic difficulties in this population for several reasons; for example, symptomatic and phenomenological differences, age-related biological and psychological factors, and the presence of physical comorbidities.
Depression in older adults can be understood from a lifespan developmental diathesis-stress perspective. Risk and protective factors become more or less prominent in the etiology of depression as they change in frequency or importance over the course of the life span.
Some have found that older adults with late onset depression are more likely to have vascular risk factors (e.g., Hickie et al., 2001) including history of cerebrovascular disease, although this conclusion is not always supported (e.g., Brodaty et al., 2001 ).
However, according to the findings practically observed and supported by research studies, clinical features of depression observed in elderlies may be different than the one seen in early ages. In addition, some features specific to elderlies may make diagnosis and treatment of depression difficult.
Clinical depression in older people is common. That doesn't mean it's normal. Late-life depression affects about 6 million Americans ages 65 and older. But only 10% get treatment. The likely ...
Depression affects more than 19 million Americans every year, regardless of age, race, or gender. While depression is not a normal part of the aging process, there is a strong likelihood of it occurring when other physical health conditions are present. For example, nearly a quarter of the 600,000 people who experience a stroke in a given year will experience clinical depression.[1]
Overview. Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest. Also called major depressive disorder or clinical depression, it affects how you feel, think and behave and can lead to a variety of emotional and physical problems.
The detection of mild disorders is challenging because symptoms do not differ greatly from those seen in healthy but stressed individuals, causing clinicians to underestimate the degree of the patient’s depression.
We found that depression was identified accurately in about half of true cases. Clinicians correctly reassured eight of 10 healthy people but with substantial false alarms. In a typical urban practice (where the prevalence of depression is 20%), the error rate was 25% (10% missed cases and 15% false alarms).
In a second assessment, the patient is more likely to discuss sensitive issues and offer extra information that can aid the diagnosis, and the practitioner has additional time to observe clinical change and employ screening instruments.
Diagnostic accuracy was significantly greater in younger adults than in older adults. Clinicians struggled to recognize depression in older people even after adjusting for differences in prevalence.
Furthermore, in many cases, clinicians recognize symptoms but do not believe psychological issues are clinically significant. Depression can be difficult for any health professional to identify. Few can remember the official diagnostic criteria, and a variety of occupational, financial, and life events ...
Depression is very common in all health-care settings, and primary care is no exception. Recently, our group undertook a meta-analysis in order to better understand the issue of diagnostic error in depression. We identified a surprisingly large number of primary studies—157, across 11 countries—that examined the ability of clinicians to diagnose a mental disorder.
We conclude that depression is common but underdetected and undertreated in primary care. However, accurate diagnosis is difficult based on existing criteria, and primary-care clinicians appear to perform no worse than other medical colleagues.
Since most older adults experience disability, bereavement, or other stressful events in late life, and since most older adults have age-related changes in immune, neurological, and other biological systems , it is of considerable interest to know why most older adults do not experience depression.
Depression in older adults may present somewhat differently than in younger adults. For example, older adults are less likely to endorse cognitive-affective symptoms of depression, including dysphoria and worthlessness/guilt, than are younger adults ( Gallo et al., 1994 ). Sleep disturbance, fatigue, psychomotor retardation, loss of interest in living, and hopelessness about the future may be more prevalent in late-life depression than in depression in younger or middle-aged adults ( Christensen et al., 1999 ). Subjective complaints of poor memory and concentration are also common among depressed older adults. Slower cognitive processing speed and executive dysfunction are frequent findings from objective testing ( Butters et al., 2004 ). Overall there do not appear to be substantial differences by gender or ethnicity. Some evidence suggests that older African Americans are even less likely to report dysphoria than European-Americans and more likely to report thoughts of death ( Gallo, Cooper-Patrick, & Lesikar, 1998 ). With respect to somatic symptoms, depressed older women report more appetite disturbance than men, whereas older men report more agitation ( Kockler & Heun, 2002 ).
Older adults who are economically disadvantaged are more likely to experience persistent depressive symptoms ( Mojtabai & Olfson, 2004 ), consistent with the chronic nature of the stressors associated with low income, including financial strain and exposure to unsafe and unstable environments. Practical issues such as these may also complicate treatment for those low income older adults who are depressed ( Areán et al., 2005 ). In addition, socioeconomic disadvantage early in life may increase vulnerability to depression throughout the lifespan through the effects of poor nutrition, reduced opportunities for education, less access to health care, or other mechanisms. The effects of early disadvantage may become even more consequential with age, as economic and health disparities are compounded.
Depression is particularly prevalent in cardiovascular disease. Approximately 20-25% of heart disease patients experience major depression, and another 20-25% report symptoms of depression that do not meet criteria for major depressive disorder (Carney & Freedland, 2003).
DIABETES . Prevalence estimates for depression in patients with Type II diabetes are as high as 15% for major depression and approximately 20% for elevated depressive symptoms (Li, Ford, Strine, & Mokdad, 2008).
Much attention has been paid to neuroanatomical and chemical changes in the central nervous system as risk factors for depression and as predictors of poor response to treatment. Frontal, basal ganglia, and subcortical white matter lesions may be responsible for the phenomenon of depression-executive dysfunction syndrome ( Alexopoulos, 2005; Krishnan, 2002 ). Structural abnormalities in various brain regions have been observed in depressed older adults ( Alexopoulos, 2005; Blazer 2003 ). Functionally, depression is associated with hypoactivity in cortical structures and hyperactivity in limbic structures, and hypometabolism of the anterior cingulate is associated with treatment resistance ( Alexopoulos, 2005 ). Reduced connectivity between the amygdala and structures in the thalamus and frontal cortex that regulate emotional processing may contribute to the maintenance of late-life depression ( Alexopoulos, 2005 ). Studies have found a reduction in glial cells and neuronal abnormalities associated with late life depression, suggesting possible mechanisms for this decreased connectivity.
The search for specific genes associated with depression in older adults has encompassed both genes studied in the non-geriatric population and genes that might relate to distinctive aspects of late life depression. Genetic studies in the non-geriatric population have for the most part focused on the short variant of an insertion/deletion polymorphism located in the promoter region of the serotonin transporter gene (5-HTTLPR). In one of the few extensions of this work to older adults, Jansson and colleagues (2003) found a significant effect for the A/A genotype of the 5-HTR2A gene promoter polymorphism and depressed mood for older males but not for older females. In this study, the 5-HTT serotonin transporter gene was not associated with depressed mood.
Depression may sometimes be undiagnosed or misdiagnosed in some older adults because sadness is not their main symptom. They may have other, less obvious symptoms of depression or they may not be willing to talk about their feelings. It is important to know the signs and seek help if you are concerned.
If you have been experiencing several of the following symptoms for at least two weeks, you may be suffering from depression: Persistent sad, anxious, or “empty” mood. Loss of interest or pleasure in hobbies and activities. Feelings of hopelessness, pessimism. Feelings of guilt, worthlessness, helplessness.
The primary treatment options for depression include medication and psychotherapy . It is important to remember that as doctors and therapists develop a personalized treatment plan for each individual, different treatments or treatment combinations sometimes might be tried until you find one that works for you.
If other factors can be ruled out, the doctor may refer you to a mental health professional, such as a psychologist, counselor , social worker, or psychiatrist. Some providers are specially trained to treat depression and other emotional problems in older adults.
The good news is that, in most cases, depression is treatable in older adults. The right treatment may help improve your overall health and quality of life. With the right treatment, you may begin to see improvements as early as two weeks from the start of your therapy. Some symptoms may start to improve within a week or two, but it may be several weeks before you feel the full effect.
If you think you have depression, the first step is to talk to your doctor or health care provider. Your doctor will review your medical history and do a physical exam to rule out other conditions that may be causing or contributing to your depression symptoms.
If you are an older adult, you may be at a higher risk if you: are female. have a chronic medical illness, such as cancer, diabetes or heart disease. have a disability. sleep poorly. are lonely or socially isolated. You may also be at a higher risk if you: have a personal or family history of depression.
Recent bereavements. The death of friends, family members, and pets, or the loss of a spouse or partner are common causes of depression in older adults.
And the symptoms of elderly depression can affect every aspect of your life, impacting your energy, appetite, sleep, and interest in work, hobbies, and relationships. Unfortunately, all too many depressed older adults fail to recognize the symptoms of depression, or don’t take the steps to get the help they need.
But small steps can make a big difference to how you feel. Taking a short walk, for example, is something you can do right now—and it can boost your mood for the next two hours. By taking small steps day by day, your depression symptoms will ease and you’ll find yourself feeling more energetic and hopeful again.
Recognizing depression in the elderly starts with knowing the signs and symptoms. Depression red flags include: Sadness or feelings of despair. Unexplained or aggravated aches and pains. Loss of interest in socializing or hobbies.
As we grow older, we often face significant life changes that can increase the risk for depression. These can include: Health problems. Illness and disability, chronic or severe pain, cognitive decline, damage to your body image due to surgery or sickness can all be contributors to depression. Loneliness and isolation.
Aim for somewhere between 7 to 9 hours of sleep each night. You can help yourself get better quality sleep by avoiding alcohol and caffeine, keeping a regular sleep-wake schedule, and making sure your bedroom is dark, quiet, and cool.
And you don’t have to suffer through a rigorous workout to reap the benefits. Take a short walk now and see how much better you feel. Anything that gets you up and moving helps. Look for small ways to add more movement to your day: park farther from the store, take the stairs, do light housework or gardening. It all adds up.
Psychosocial: 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 advers e life events . Stressors include lack of social support, social isolation, loneliness and financial hardship.
Depression in older adults is an important clinical topic because outcomes are worse in comparison to younger adults. It is also associated with higher rates of morbidity and mortality, increased healthcare utilisation and economic costs.
Cognitive deficits are characteristic of depression in older adults 7,11 and are described as ‘substantial and disabling’ 12. Such deficits mainly concern executive function 13-14. Pseudodementia is a phenomenon seen in older adults 15. The term refers to cognitive impairment secondary to a psychiatric condition, most commonly depression 16. Pseudodementia has become synonymous with depression. Pseudodementia can be mistaken for an organic dementia and so older adults who are depressed can present primarily to mental health services with memory problems. Pseudodementia is classically associated with ‘don’t know’ answers, whereas older adults with a true dementia will often respond with incorrect answers 17.
In those with pre-existing physical health problems, depression is associated with deterioration, impaired recovery and overall worse outcomes 34. For example, the relative risk of increased morbidity related to coronary heart disease is 3.3 in comparison to individuals without depression 35. Mykletun et al. established that a diagnosis of depression in older adults increased mortality by 70% 36. 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 37. 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.
The International Classification of Diseases (ICD) diagnostic classification systems describe three core symptoms of depression; low mood, anhedonia and reduced energy levels 1. Other symptoms include impaired concentration, loss of confidence, suicidal ideation, disturbances in sleep and changes in appetite. Symptoms must have been present for at least a period of two weeks for a diagnosis of depression to be made. Major depression refers to the presence of all three core symptoms and, in accordance with ICD criteria, at least the presence of a further five other symptoms 1. See Table 1 for severity criteria of a depressive episode according to ICD criteria.
Such psychological symptoms include feelings of guilt, poor motivation, low interest levels, anxiety related symptoms and suicidal ideation. The presence of irritability and agitation are key features as well 7. Hallucinations and delusions are also more common in older adults, particularly nihilistic delusions (i.e. a person believing their body is dead or a part of their body is not working properly or rotting).
The Kings Fund has estimated that by 2032 the proportion of older adults aged 65-84 years old will have increased by 39% whereas the proportion over the age of 85 years will have increased by 106% 4. This increase in population will consequently see the incidence and prevalence of depression rise. By 2020 it is estimated that depression will be the second leading cause of disability in the world regardless of age 5. Recognising, and so diagnosing, depression in older adults will become more important because of a greater demand on existing healthcare services and provisions, due to physical health consequences, impact upon healthcare utilisation and greater economic healthcare costs.
The symptoms prominent in vascular depression are apathy, psychomotor retardation and disability. In these patients complete remission rates are low and typically there are residual depressive symptoms. An important property of vascular depression is the existence of dysfunction in executive functions. In fact, this kind of depression is called as depression-executive dysfunction syndrome. In elder ages, depression appears with vascular diseases, degenerative brain diseases or their cumulative effect in most of the patients [46]. Risk factors for late life depression are summarized in Table 1.
The main symptoms of major depressive disorder are depressive mood and loss of interest/desire and/or difficulty in enjoying life (an hedonia). In addition to these main symptoms, detecting three more symptoms listed below and continuation of these symptoms for 15 days is assumed as sufficient to diagnose major depression. These symptoms can be summarized as insignificancy and excessive or unsuitable feeling of guilt; retardation in emotions or thoughts (psychomotor retardation) or agitation; tiredness, fatigue, loss of energy; suicide thoughts and attempts; decrease in attention and concentration, instability; change in appetite and sleep disorders [9]. In addition, pessimism, hopelessness, anxiety, absence of sexual desire and somatic symptoms such as head and back aches can be found in depressive disorder [10]. According to DSM-IV major depressive disorder can be seen in single-episode or be repetitive [9]. Moreover, according to ICD-10 fatigue and low energy symptoms are also among main symptoms and other symptoms are coincide with DSM-IV diagnosis criteria [11].
The conditions in which depressive disorder continues for two weeks but it meets lower than 5 diagnosis criteria are called as minor depressive disorder [9]. In elderlies depressive symptoms called as minor, subsyndromal or sub-threshold, which do not exactly meet the major depressive disorder diagnosis criteria are frequently seen and can cause loss of functionality [3].
Depression is one of the most common mental diseases seen during elderliness. The frequencies of depression and subsyndromal depressive indications are reported between 1 and 4% (approximately 3%) and 10 and 15%, respectively [2, 3]. As the depression seen in elderliness might be a part of a unipolar depressive disorder it can appear for ...
The most common thought disorders are delusions of persecution and the delusion of considering to be caught by an illness whose treatment is impossible. Feeling of guilt is seen relatively less in this age group and the existence of guilt feelings indicate that there might have been a depressive episode in younger ages. Nihilistic delusions are those that accompany depression in older age. There are fewer hallucinations than delusions [14]. On the other hand, there are also studies reporting that there is no difference in late-period depression in terms of atypical appearance and psychotic symptom existence as well as in terms of intensity of depression and loss of functionality [4].
As physical diseases can directly cause depressive symptoms, limitation of person’s physical activity, reduction in life quality and requiring another person’s support can also trigger depression. Medicines such as antihypertensive and corticosteroids which block, increase their emissions, cause up/down regulation, and modify catecholamin or indoleamin systems can cause depression [29, 42]. Increase in the frequency of physical diseases and accordingly the use of medicines with the age enhances the depression risk. A detailed investigation is needed in this perspective as an evaluation of depression in elderlies.
Similarly, it is reported that executive functions and cognitive functions such as memory and attention are distorted in late life depression [18–22]. It was determined that mainly processing speed is affected in late life depression and that accordingly impairments in executive functions, working memory, memory and language are encountered. Factors such as age, depression intensity, race, vascular factors and education were found to be related to cognitive dysfunction in late life depression [23]. It was determined that neuropsychological test performances of the patients over the age of 60 with unipolar depressive disorder are lower than those of the healthy persons in the same age groups. More than half of the patients showed explicit dysfunction in information processing, visuo-spatial functions and executive functions. It was emphasized that retardation in information processing is a characteristic feature for late life depression [24]. It is reported that there is a relationship among dysfunction in executive functions, relapse, recurrence and subsyndromal depressive symptoms [19]. Indeed, retardation in processing speed and dysfunction of executive functions seems to be peculiar to elderly period though the losses in cognitive functions in late life depression resemble those observed in younger ages.
In its report, the IOM found that depression, whether recurring or late onset, was the most common mental illness seen in the elderly. 2. “Someone who has heart failure and arthritis and has suffered various losses may start developing depression,” says Bruce Leff, a Johns Hopkins geriatrician.
In 1999 a consensus conference convened by the University of California, San Diego, and led by Dilip V. Jeste , a geriatric psychiatrist there, predicted “an upcoming crisis” in geriatric mental health.
Prescribing treatments for geriatric patients with mental illness is another challenge for health care providers. As patients age, the body’s ability to metabolize and excrete medications declines, so drugs can accumulate and cause more intense effects and side effects, Jeste says.
Despite signs of innovation in geriatric mental health, there remain barriers to spreading even the most promising models widely. One of the barriers, says Unützer, is the stigma felt by many older adults toward mental illness—even their own.
By now, warnings about the impact of an aging population on the nation’s health care system have become familiar: rising numbers of seniors with diabetes, heart disease, and other chronic illnesses; increased costs; and a strained geriatric workforce that is insufficient to meet even today’s needs. But despite well-publicized alarm over Alzheimer’s disease, whose victims are expected to triple by 2050, 1 scant attention has been paid to non-dementia-related mental illnesses such as depression and anxiety.
In his IMPACT (Improving Mood-Promoting Access to Collaborative Treatment) model of care, a patient’s primary care provider works with a care manager—a nurse, psychologist, or social worker—to develop a treatment plan. A staff psychiatrist consults on new cases and on difficult ones in which patients haven’t improved with treatment . When patients don’t respond to a second line of therapy, the treatment team reviews the case again and considers steps such as medication changes, psychotherapy, or hospitalization.
Many also regard the symptoms, both physical and emotional, as inevitable features of aging, not features of an underlying mental disorder.
Depression in older adults may be difficult to recognize because older people may have different symptoms than younger people. For some older adults with depression, sadness is not their main symptom. They could instead be feeling more of a numbness or a lack of interest in activities.
Depressive Disorder Due to A Medical Condition – depression related to a separate illness, like heart disease or multiple sclerosis. Other forms of depression include psychotic depression, postmenopausal depression, and seasonal affective disorder.
Signs and symptoms of depression can look different depending on the person and their cultural background. People from different cultures may express emotions, moods, and mood disorders — including depression — in different ways. In some cultures, depression may be displayed as physical symptoms, such as aches or pains, headaches, cramps, or digestive problems.
Still, because people experience depression differently, there may be symptoms that are not on this list. Persistent sad, anxious, or "empty" mood. Feelings of hopelessness, guilt, worthlessness, or helplessness. Irritability, restlessness, or having trouble sitting still.
Thoughts of death or suicide, or suicide attempts. If you have several of these signs and symptoms and they last for more than two weeks, talk with your doctor. These could be signs of depression or another health condition. Don’t ignore the warning signs.
As you get older, body changes can affect the way medicines are absorbed and used. Because of these changes, there can be a larger risk of drug interactions among older adults. Share information about all medications and supplements you’re taking with your doctor or pharmacist.
Difficulty concentrating, remembering, or making decisions. Difficulty sleeping, waking up too early in the morning, or oversleeping. Eating more or less than usual, usually with unplanned weight gain or loss. Thoughts of death or suicide, or suicide attempts.