Geriatric depression

Samar Hafeez

Clinical Psychologist and Counsellor

Bangalore, India

Ageing is natural; feeling depressed as you age is not. Mental health issues in the elderly are not often considered important and the signs of depression in older adults are often chalked up to be the typical signs of getting older, but this is further from truth. 

Depression is more than just being sad or feeling low, rather it’s a persistent and pervasive medical condition which negatively impacts one’s daily functioning. 65 years or older is considered to be a geriatric demographic and this population is specifically at a high risk of under- or mis-diagnosis. The reason being that the elderly usually do not report the symptoms to their primary healthcare provider and most often they consider these to be symptoms or reactions to be caused by other medical conditions. 

Studies show that most older adults feel accomplished and satisfied with their lives in spite of having to deal with age related health decline or disabilities. The normal ageing process includes some highs and lows in one’s mood, chronic physical ailments, progressive physiological and psychosocial changes. All these issues can cause a person to feel anxious or sad. 

Once the adjustment phase is completed, many regain their emotional footing, but others do not and may develop depression. The most common types of depression that occur in the elderly are major depression and dysthymia (chronic persistent depressive disorder that can last for at least 2 years).

Symptoms of depression in the elderly

The imperative feature of a major depressive episode is it lasting over a period of at least 2 weeks, during which there is either depressed mood or loss of interest or pleasure in nearly all activities.

According to the American association for geriatric psychiatry, the most common symptoms of depression in the elderly include:

1.Persistent sadness (lasting 2 weeks or more)

2.Engaging in very few activities or no engagement at all

3.Anhedonia (decreased interest especially in activities they loved doing earlier)

4.Decreased concentration and attention (if one is not suffering from dementia or other degenerative brain disease)

5.Decreased motivation to meet people or to go out

6.Appetite changes (gaining or losing weight) and/or stop eating altogether

7.Frequent tearfulness

8.Feeling of worthlessness or helplessness

9.Pacing, fidgeting and irritability

10. Excessive worrying about health and finances

11. Difficulty falling asleep

12. Somatic complaints (medically unexplained chronic pain or gastrointestinal problems)

13. Withdrawal from social and recreational activities

14. Suicidality (tendency to commit suicide)

Depression in the older population may be difficult to recognise sometimes as they may show different symptoms than the younger population. For many, sadness may not be a main symptom and they may tend to show less obvious symptoms like getting irritable and grumpy very often and very easily.

Depression and dementia

Even though depression and dementia share certain traits, below are symptoms that will help you distinguish between the two.

In depression the mental decline is rapid, there is difficulty in concentration, motor and language skills are slowed down but are still normal, and the sufferer can still state the current time, date, day and year. The orientation of the sufferer also seems to be intact and they worry or get anxious if they notice any memory problems. 

However, in dementia sufferers, the mental decline is gradual, patients struggle with short term memory and the language, writing, executive skills are impaired. Patients become confused and disoriented or wonder where they are and they don’t seem to care or worry about memory problems or confusion.

Depression in the elderly can co-occur with other illnesses like cancer, chronic obstructive pulmonary disease, Parkinson’s disease, diabetes, stroke, cardiovascular diseases, lupus and multiple sclerosis and so on.

Risk factors that can cause geriatric depression

Polypharmacy: The elderly are usually on multiple medications, for example, just to name a few are anti-hypertensives, corticosteroids, chemotherapeutics, medications that treat hepatitis C, anti-inflammatory, anti-infective drugs, all of which can cause depression.

Stroke: Incidents of strokes increase with age and according to a recent population-based study in Europe, damages to different parts of the brain can put patients at a high risk of developing post stroke depression (PSD). 60% of post stroke patients develop depression and the psychological sequelae caused by strokes can be unmanageable.

Chronic illnesses like cancer, diabetes, Parkinson’s disease and multiple sclerosis can lead to the onset of depression in the elderly.

History of depression, alcoholism and other substance abuse can also play a factor in major depression.

Psycho-socio factors: Loss of a spouse or a loved one, loss of peers, thoughts associated with one’s own death, retirement, changes in social roles, neighbourhood changes, loneliness, empty nest syndrome (wherein grown children leave the house for education, to get married or move out) and social isolation or neglect.

Diagnosis

Diagnosing and screening this population is incredibly important. Early intervention leads to a quicker recovery and prevents symptoms from worsening.

Research shows that if the elderly are treated for geriatric depression, they are less likely to develop dementia. It’s shown to be a protecting factor for memory and cognition.

According to the British Medical Journal, a geriatric research group was followed for 8 years to study the mortality rate of elderly who were on treatment for depression. The concluding report showed that those that were treated for depression had a 24% decreased mortality rate than those that were depressed and not treated. Geriatric depression, if treated at early stages, can lead to a longer, healthier, productive and more cognitively intact life.

To ensure the right diagnosis and avoid misdiagnosis, talk with your primary care doctors about the symptoms, medications and medical conditions can cause depression like symptoms, your primary health care doctors will help rule out these possibilities by doing a physical examination or lab tests. Also look for geriatric psychiatrist or specifically trained psychologist who are specialists in psychological evaluation and treatment. 

The best option is to try to get hold of a collaborative care unit which consists of primary care doctors, geriatric psychiatrists, psychologist and mental health nurses/psychiatric nurses. Such teams can provide total medical care for elderly patients with depression.

Effective treatment options

Antidepressants are prescribed to manage depression in severe cases. A psychiatrist may prescribe selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs) or any of the newer types of antidepressants like mirtazapin, venlafaxine and duloxetine. These medications are often administered at low doses and may take up to 2-4 weeks to show effects.

Non-pharmacological therapies include psychotherapy and especially cognitive- behavioural therapy alone which may help elderly patients with mild to moderate depression. This ongoing therapy has excellent tools to change the negative thinking pattern and help elderly function better in their day to day chores. Combining psychotherapy and medications can be very helpful in severe cases.

Interpersonal psychotherapy (IPT) helps in recognising and coping with potential or actual recurring conflicts. Participants will show significant reduction in suicidal ideation, death ideation and significant improvement in the perceived meaning of life and social adjustment.

Support groups can help you connect to like-minded individuals with similar passions. This interaction with others will help strengthen compliance with treatments and help you understand that you are not alone; thereby increasing one’s sense of social support. These groups can help alleviate depression and improve self-worth in the elderly.

Increase in elderly dependency, limited mobility and need for long term care, make the elderly population more vulnerable to maltreatment and insufficient care. In such context, the caregivers or supporters have a tremendous role to play.

Key supporters’ strategies

Family members should actively intervene and increase their positive support for elderly members. They should help coordinate with health care providers and accompany the person to the doctor and provide important information.

Most depressed elderly patients may resist help, but they must be assured in a non-acquiring way that an evaluation will get them the best possible treatment which will help improve their functioning and overall wellbeing.

The caregivers can keep a track of activity or a mood log and this tool makes it easy to track moods of a depressed person through the day. Keeping a track of their medication regularly and indicating improvements on a weekly basis helps. A caregiver should be careful about getting burned out, they should get a medical check done once every 6 months and it is crucial that the caregiver’s mental and emotional valence is stable.

There is always a risk of suicide in the elderly population. It is more common in this group than in any other age group, but remember, depression is a highly treatable medical problem; more than 75% of all people treated with depression can be successfully treated. 

Elderly people fly under the radar as they usually do not report their symptoms to the doctor. They must be encouraged to share with others if they feel anything that is overly uncomfortable. Getting help to improve mental health is not a weakness or character flaw; it is just like seeking help for any other physical ailment or problem.

(Please see your GP and a geriatric psychiatrist or a specifically trained psychologist if you feel you have symptoms mentioned in this article)