Late-life depression is depression occurring in older individuals. Although often associated with the stress and physical problems attendant with advancing age, depression is not a normal part of the aging process.
Depression in the aging and the aged is a major public health problem. Many who suffer from late-life depression go undiagnosed. The insidious nature of depression in the elderly is that its symptoms are often obfuscated in the context of the multiple physical problems of many elderly people. As the body ages, it becomes less able to respond to stress and is at increased risk for disease. The hair grays, the skin wrinkles, and reaction times slow. In addition, disabilities resulting from external factors such as stress, trauma, chronic diseases, lifestyle limitations, financial factors, and isolation may accelerate the process, resulting in the symptoms we think of as defining old age. It would seem little wonder, then, that many seniors are depressed. Depression, however, is not a normal part of aging, nor is it inevitable.
The symptoms of late-life depression can be the same as they are for depressive disorders in younger people, whether they be major depressive disorder , a bipolar disorder , or subsyndromal depression. The individual may experience a profound and persistent feeling of sadness or despair or lose interest in things that were once pleasurable (anhedonia). Late-life depression can also exhibit itself in less obvious ways, including sleep disturbance, change in appetite, or disturbed mental functioning. In extreme cases, late-life depression can lead to suicide. Depression in late life, however, is treatable, not a condition to be suffered in silence.
The percentage of Americans 65 years old and older who have clinical depression is significantly greater than for the general population. Whereas approximately 1% of Americans are clinically depressed, nearly 16% of those 65 years of age and older meet the criteria for clinical depression. Similarly, suicide rates for older adults are disproportionately high, particularly for white males.
A diagnosis of major depressive disorder is more likely in elderly patients who are also medically ill, older than 70 years of age, and are hospitalized or institutionalized. Depression in the elderly is more common when there is a history of depression earlier in life, chronic physical illness, brain disease, alcohol abuse , or stressful life events. Elderly women are more likely to become depressed than are elderly men, and single seniors are more likely to become depressed than are those who are married. It has been estimated that as many as 15% of widowed adults will have a serious depression for a year or more after the death of their spouse.
Subsyndromal depression (depression that is clinically significant but does not meet the criteria for major depressive disorder) is more common than major depressive disorder in elderly adults. It is estimated that 15% to 50% of older adults with subsyndromal depression will develop major depressive disorder within two years. Approximately 30% of nursing home residents have subsyndromal depression. As with major depressive disorder, elders with subsyndromal depression tend to be female.
As opposed to younger individuals, older adults are more likely to have a medical condition in addition to depression. A number of medical conditions have commonly been associated with depression in the elderly. These include:
- Coronary artery disease (high blood pressure, history of heart attack, coronary artery bypass surgery, congestive heart failure)
- Neurologic disorders (stroke, Alzheimer’s disease, Parkinson’s disease, Lou Gehrig’s disease, multiple sclerosis, Binswanger’s disease, senile dementia)
- Metabolic disturbances (diabetes, hypoglycemia, hypothyroidism, hyperthyroidism, hyperparathyroidism, Addison’s disease)
- Cancer (particularly of the pancreas)
- Other medical conditions (chronic obstructive pulmonary disease, rheumatoid arthritis, chronic pain, sexual dysfunction, renal dialysis, chronic constipation, viral pneumonia, hepatitis, influenza)
In addition, a number of medications routinely taken by elderly patients may cause depression. These include:
- Cardiovascular drugs (clonidine, digitalis, guanethidine, hydralazine, methyldopa, procainamide, propranolol, reserpine, thiazide diuretics)
- Chemotherapeutics (6-azauridine, asparaginase, azathioprine, bleomycin, cisplatin, cyclophosphamide, doxorubicin, mithramycin)
- Antiparkinsonian drugs (amantadine, bromocriptine, levodopa)
- Antipsychotic drugs (fluphenazine, haloperidol)
- Sedatives and antianxiety drugs (barbiturates, benzodiazepines, chloral hydrate, ethanol)
- Anticonvulsants (carbamazepine, ethosuximide, phenobarbital, phenytoin, primidone)
- Anti-inflammatory/anti-infective agents (ampicillin, cycloserine, dapsone, ethambutol, griseofulvin, isoniazid, metoclopramide, metronidazole, nalidixic acid, nitrofurantoin, nonsteroidal anti-inflammatory drugs [NSAIDs], penicillin G procaine, streptomycin, sulfonamides, tetracycline)
- Stimulants (amphetamines, caffeine, cocaine, methylphenidate)
- Hormones (adrenocorticotropin, anabolic steroids, glucocorticoids, oral contraceptives)
- Other medications (choline, cimetidine, disulfiram, lecithin, methysergide, phenylephrine, physostigmine, ranitidine, vinblastine, vincristine)
Because of concurrent medical problems and lowered expectations for functionality, elderly patients with depression are often undiagnosed. In addition, elderly patients often are reluctant to speak about psychological symptoms and consider depression to be a normal response to the aging process. Depressed older people may not report being depressed because they have no hope that anyone will intervene. These factors can make diagnosis difficult.
Depression in older adults does not necessarily present with the same symptoms as in the general population. Common symptoms in older people that can signify a problem with depression include:
- Unexplained physical complaints: Older adults are often reluctant to discuss psychological symptoms. As a result, symptoms of depression may be expressed in terms of a physical rather than a psychological complaint. For example, depression in older adults is often characterized by physical complaints for which no medical cause can be found or by physical symptoms that are out of proportion to the underlying medical illness.
- Hopelessness or helplessness: In older adults, it is hopelessness rather than sadness that tends to be associated with thoughts of suicide. Statements such as “I wish I were dead already,” “I wish I would fall asleep and not wake up,” or “what’s the use in trying” are cause for immediate concern and should be responded to with psychological assessment rather than platitudes or meaningless assurances that everything is all right. Talk of suicide—even in jest—should always be taken seriously
- Anxiety and worries: Older adults often experience general feelings of worry and tension not associated with specific anxiety or panic disorders. Statements of anxiety and worry in older adults often are signs of depression in addition to or instead of an anxiety disorder. Treatment for an anxiety disorder, however, will not treat any underlying depression.
- Memory complaints: Depressed older adults may complain about memory loss with or without objective signs of cognitive impairment. Particularly when no demonstrable memory problems can be discerned by simple tests, it is important that the patient also be assessed for depression and treated accordingly.
- Loss of feeling of pleasure (anhedonia): A common symptom of depression in older adults is the inability to experience pleasure from life and daily events. Expressions of anhedonia might include no longer deriving enjoyment from being with grandchildren; not wanting to read, listen to music, or participate in hobbies once found enjoyable; or feeling estranged from God or no longer being comforted by religion. Although it might seem that being less active and involved in life is a response to illness or decreased abilities associated with aging, research suggests that depression might in fact contribute to heart disease, diabetes, and arthritis.
- Slowed movement: “Slowing down” is often associated with old age. However, things such as stooped posture, slowed movements, or slowed speech may also be signs of depression. In particular, depression associated with vascular disease is often expressed in such symptoms.
- Irritability: Depression in older adults may also be expressed by excessive or easily provoked anger, annoyance, or impatience. Symptoms of irritability include fussiness, whining, or fretfulness even in the face of comforting. When such a pattern is persistent, assessment for depression should be considered.
- Lack of interest in personal care: Depressed older adults may believe that they are “not worth the trouble” and fail to follow instructions for taking medications or dietary guidelines as a result. Similarly, depressed older adults may display such symptoms as lack of care about personal appearance—including not getting dressed, bathing, or performing other hygiene activities. Individuals displaying such symptoms should be assessed for depression.
- Other symptoms: Sleep disturbance, decreased appetite, weight loss, difficulty concentrating, and fatigue are all common symptoms of late-life depression.
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) of the American Psychiatric Association, there are nine criteria for major depressive disorder:
- Depressed mood
- Sleep disturbance
- Lack of interest or pleasure in activities
- Guilt and feelings of worthlessness
- Lack of energy
- Loss of concentration and difficult making decisions
- Anorexia or weight loss
- Psychomotor agitation or retardation
- Suicidal ideation (thoughts of suicide)
A diagnosis of depression requires at least five of these criteria to be present nearly every day during a two-week period, or a score of 10 or more on the Beck Depression Inventory (BDI) or on the Geriatric Depression Scale.
However, significant depression in older adults does not always meet the criteria for a DSM-IV-TR diagnosis of depression. As a result, although depression occurs more frequently in older adults than in the general population, it often goes undiagnosed in seniors. In addition to or instead of the classic diagnostic symptoms, older adults may exhibit such symptoms as discussed in the previous section, “Causes and symptoms.” Such symptoms should also be considered when diagnosing depression in older adults.
Screening of an elderly patient for depression should include an electrocardiogram (ECG), urinalysis, general blood chemistry screen, complete blood count, and determination of the levels of thyroid-stimulating hormone, vitamin B12, folate, and medication in the blood.
Treatment for depression in elderly patients may be done with medication and/or psychotherapy (including talk therapy and behavior therapy). Further, research has shown that a combination of the two treatment options is more effective than the use of medication or therapy alone. Although improvement may be seen as early as two weeks, the full effect of therapy may not be observable for several months. If the patient is having a major depressive episode, recovery may take from 6 to 12 months. This means that therapy for older adults is typically needed for longer periods of time than for the general population.
Medication for depression is generally well tolerated in older adults. Drugs used in treating depression in older adults include selective serotonin reuptake inhibitors (SSRIs) (sertraline, fluoxetine, paroxetine, fluvoxamine, citalopram, escitalopram) , secondary tricyclic antidepressants (nortriptyline, protriptyline, desipramine, amoxapine ), tertiary tricyclic antidepressants (amitriptyline, imipramine, doxepin, trimipramine, clomipramine ), monoamine oxidase inhibitors (MAOIs) (phenelzine, tranylcypromine ), and other antidepressants (maprotiline, bupropion, trazodone, venlafaxine, nefazodone, mirtazapine ). As with any medication, the patient should be monitored closely to determine how
Bipolar disorders —A group of mood disorders characterized by both depressive and manic or hypomanic episodes.
Major depressive disorder —Mental illness characterized by a profound and persistent feeling of sadness or despair and/or a loss of interest in things that were once pleasurable.
Seasonal affective disorder —A mood disorder in which major depressive episodes and/or manic episodes occur at predictable times of the year, with depressive episodes typically occurring during the fall and winter months. Seasonal affective disorder may be associated with a bipolar disorder, major depressive disorder, or subsyndromal depression.
Subsyndromal depression —Depressive episodes that do not meet the severity levels necessary for classification as major depressive episodes.
well he or she is reacting to the medication. If adverse reactions occur, another medication can be tried.
The general prognosis for recovery from depression in older adults is good, although recovery may take longer for older adults than for the general population.
Increasingly, the literature is recognizing that although it is imperative to diagnose and treat depression in late life, it is equally important to prevent late-life depression in the first place. Researchers are currently investigating several models of prevention. These focus on individuals at high risk for depression in late life, including those with diseases that often occur with depression.
There are a number of steps that can be taken to help prevent depression. Eating a balanced diet and keeping regular meal times is important, particularly if one has problems with insulin or blood sugar levels. Getting regular exercise also helps stave off depression. If one’s depression has a seasonal component, taking walks in the morning sunshine or using a light box can also help. Maintaining a regular sleep pattern is also helpful, as is avoiding drugs and alcohol. Those seniors living alone should also make an effort to widen their social support network. Research has found that making friends at a senior center is an excellent way to do this. Additional steps that can be taken by those who have been diagnosed and are being treated for depression are to continue to take any antidepressant medications as prescribed until directed to stop by one’s physician and to continue with therapy even after the medications have been stopped.
Researchers are continuing to investigate depression prevention for older adults in the hope that this too common and undiagnosed disorder can be not only successfully treated, but also prevented from occurring in the first place.
See alsoSeasonal affective disorder.
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American Association for Geriatric Psychiatry (AAGP), 7910 Woodmont Avenue, Suite 1050, Bethesda, MD 20814-3004. (301) 654-7850. <http://www.AAGPonline.org>.
American Psychiatric Association, 1000 Wilson Boulevard, Suite 1825, Arlington, VA 22209-3901. (703) 907-7300. <http://www.psych.org>.
American Psychological Association, 750 First Street NE, Washington, D.C. 20002-4242. (800) 374-2721. TDD/TTY: (202) 336-6123. <http://www.apa.org>.
Depression and Bipolar Support Alliance (DBSA), 730 North Franklin Street, Suite 501, Chicago, IL 60610-7224. (800) 826-3632. <http://www.dbsalliance.org>.
Fuqua Center for Late-Life Depression, Wesley Woods Health Center, 4th Floor, 1841 Clifton Road NE, Atlanta, GA 30329. (404) 728-6302. <http://www.emoryhealthcare.org/departments/fuqua>.
Geriatric Mental Health Foundation, 7910 Woodmont Avenue, Suite 1050, Bethesda, MD 20814. (301) 654-7850. <http://www.gmhfonline.org/gmhf/consumer/depression.html>.
National Alliance on Mental Illness, Colonial Place Three, 2107 Wilson Boulevard, Suite 300, Arlington, VA 22201-3042. (703) 524-7600, (800) 950-6264. TDD: (703) 516-7227 <http://www.nami.org>.
Older Adult Consumer Mental Health Alliance (OACMHA), Bazelon Center for Mental Health Law, 1101 15th Street, NW, Suite 1202, Washington, DC 20005. (202) 467-5730 Ext. 140. <http://www.oacmha.com>.
Ruth A. Wienclaw, PhD