Reprinted from "Seniors' Mental Health" issue of Visions Journal, 2002, No. 15, p. 6
Depression occurs commonly in the aging population. The frequency depends on the setting, with estimates rising as high as ten to 12% in inpatient and long-term care settings. Symptoms can persist for up to three years or more if left untreated.
The mortality rates for untreated depression in the elderly are high, attributable to both increased rates of completed suicide as well as increased mortality from cardiovascular and other medical diseases. The rate of completed suicide is twice that of younger people, i.e., 26 as opposed to 12 per 100,000 among 80 to 84 year-olds compared to the general population. A 75% increase in cardiovascular death rate has been documented for depressed compared to non-depressed elderly.
Morbidity, or diminished functioning, from major depression is a significant concern in the elderly, both because of diminished function from the depression itself, as well as from the worsening of other medical symptoms and conditions. Increased use of medical services with a 50% increase in outpatient costs has been noted among elderly depressed patients. Recovery from other medical illnesses is also delayed by co-existing depression. For example, untreated depression following a stroke is associated with prolonged hospital stays and lesser degrees of neurological and functional recovery.
Major depression may present more subtly in the elderly, who frequently do not report low or depressed mood as the primary complaint, even if asked directly; instead, they may complain of feeling unwell in a non-specific way, or they may complain of specific physical symptoms, particularly abdominal pain, indigestion and constipation. Other physical symptoms may include generalized aches and pains, headaches, fatigue, low energy and just feeling “sick.” An overemphasis on the physical complaints may lead physicians to overlook the underlying depression. Predominant somatic complaints, particularly when investigations fail to reveal an organic cause, should be regarded as suspicious for depression.
Stereotypical attitudes towards the elderly may lead to rationalizing away important symptoms such as irritability, which can overshadow low mood as the primary depressive mood equivalent, and reduced activity level. These symptoms can be easily overlooked, particularly among elderly individuals who have significant cognitive or physical limitations. The early stages of depression are often not recognized in seniors. As a result, the depression may only present later and at a more advanced stage, for example, when the person has stopped eating. Older depressed people are also more likely to present with psychotic ideas, typically with nihilistic and negative-based delusions including themes of poverty and poor health. Poor self-esteem and themes of guilt are less common than they are with younger people.
Active and passive suicidal thinking is common among elderly patients and may be difficult to detect. A high index of suspicion for suicide risk is important, especially for recently bereaved, isolated men who are in physical pain and are drinking.
Grief is a common experience among the elderly, as the likelihood of multiple losses — such as relationships, independence, health, comforts, and activities — increases with advancing age. It may be difficult to differentiate bereavement from major depression, and the two may co-exist, but some features make major depression more likely, such as active suicidal thinking, and failure to function on a day-to-day basis.
In the very old, physical symptoms, irritability and decline in function may be the main clues to the presence of a depressive illness. Obtaining collateral information from family members may be essential to recognizing the illness. Risk factors for depression — such as medical illnesses, social factors and losses — are part of the common experience of advancing age. Treatment requires a combination of psychosocial rehabilitation and systematic medical interventions. The elderly are sensitive to medication side effects, but require the same assertive treatment shown to be effective in younger adults. Great caution and patience is required in slowly increasing the antidepressant doses into the therapeutic range for maximal therapeutic benefit. The results of antidepressant treatment, especially combined with psychosocial support, are most rewarding since elderly people respond almost as well as those who are younger.
So remember that depression in the elderly is common, serious and treatable. It is also possible with some experience to recognize, even though the signs and symptoms are not always characteristic of depression as seen in the broader population.