Depression in Older Adults

We all feel sad, moody or down from time to time, it is part of being human, but depression
is more than just a low mood. Depression is a serious illness that affects a persons
emotional, physical and cognitive state and has negative impacts on a persons day-to-day
life. Apart from depressed mood, depressive disorders are characterised by feelings of
worthlessness, guilt, significant weight gain or loss of appetite, problems concentrating or
making decisions, fatigue, insomnia or loss of interest in activities that were once
pleasurable.
Depression in the elderly population may go undetected or untreated because its
presentation can differ from that of younger people and is often incorrectly attributed to old
age, dementia or poor health. Many depressed older people will not claim to feel sad. They
more often complain about low motivation, lack of energy, poor concentration, impaired
memory or physical ailments such as arthritis pain or headaches. Depression in older adults
is associated with significant ill health, including deficits in cognitive functioning, physical
impairment and behavioural changes. Depression in the elderly can be divided into two
types. Early-life onset, which is depression that started earlier in life and reoccurs in old age
and late-life onset which first develops after the age of 60 and is more commonly associated
with physical health problems that accompany ageing.

Prevalence
Among elderly people living in the community the prevalence of clinically significant
depressive symptoms ranges from 8-16% with 1-4% meeting criteria for major depression.
Similar to depression in younger people, elderly women are twice as likely to suffer from
depression than elderly men. Depressive disorders are also more common among elderly
people who live in nursing homes. Of cognitively intact nursing home residents, the
prevalence of depression is 10-20% and for cognitively impaired residents the prevalence
rises to 50-60%. The prevalence of major depression in nursing home residents is around
8%. Similarly, 10-12% of elderly people admitted to hospital meet criteria for major
depression.

Risk Factors
Factors that increase the risk of depression in old age include:

Being female

Being single, unmarried, divorced, or widowed

Lack of social support

Stressful life events

Physical illness such as stroke, diabetes, cancer and chronic pain

Certain medicines or a combination of medicines

Family history of major depressive disorder

Living alone, social isolation

Previous history of depression or suicide attempts

Recent loss of a loved one

Substance abuse

Suicide
Suicide increases with age and is almost twice as frequent in elderly people compared to the
general population. Depressive disorders are the leading risk factor for suicide in older
people. Research suggests that depressive disorders are present in up to 80% of people
aged over 74 who commit suicide. Psychological autopsy studies report depression to be the
most common mental disorder in elderly suicide attempters and victims. A study by Cornwell
(1995) found that 54% of elderly suicide victims had major depression. Similarly Chiu et al.
(2004) reported that among elderly suicide victims in Hong Kong, 53% were diagnosed with
major depression.
Treatment
Depression in elderly people most commonly affects those with chronic illness and cognitive
impairment, causing suffering, family disruption and increased mortality. Depression in the
elderly is treatable but often goes under recognised and undertreated due to an overlap in
symptoms of comorbid physical illnesses as well as elderly peoples tendency to under
report depressed mood and suicidal ideation.

The aims of treatment are to reduce the symptoms of depression, improve cognitive
functioning and prevent suicidal ideation and relapse. Treatment options for elderly people
usually involve:
Antidepressants: play an important role in the treatment of moderate to severe depression
in older adults. Treatment of depression with antidepressants has been found to be as
effective for older adults as it is when given to younger adults. However, onset in older age is
a predictor for a slower recovery and older adults have a higher rate of recurrence compared
to younger adults. Thus, rigorous maintenance is suggested for the older population. As
most antidepressants are equally efficacious for older adults selection should be based on
drug-related factors such as side effects, potential drug interactions and cost combined with
individual client information such as comorbid medical conditions and allergies.
Psychotherapy: interventions such as Cognitive-behavioural therapy (CBT) and
interpersonal therapy (IPT) are the preferred therapies for treatment of depression in the
elderly. In clinical trials they have been found to be just as efficacious as medications for
cognitively intact older adults with mild to moderate depression. CBT and IPT are short term
treatments delivered over a period of two to four months and are as effective in the treatment
of depression in older adults as they are the treatment of younger adults.
Combination: psychotherapy can be beneficial alone or in conjunction with an
antidepressant for geriatric depression. The combination of both has been found to be more
efficacious for moderate to severe depression and for individuals who have late-life major
depression.
Prevention
Depression in older adults is often associated with illness, deficits in functioning, pain and
insomnia. Thus, strategies to manage these underlying issues can often be useful in the
prevention of depression. For example, some illnesses cause chronic pain and restless
sleep. Learning strategies to deal with these symptoms can help prevent them worsening
and contributing to the development of mental illnesses such as depression. Other ways to
reduce the risk of depression include making new friends and getting involved in social
activities. Studies have shown that people with strong social networks are more resilient to
depression and since losing family and friends is part of growing older, it is important for
older people to make an effort to meet new people.
Depressive disorders are one of the most prevalent mental health issues and are associated
with huge losses in quality of life, increased mortality rates and high economic costs.
Focusing on the prevention of such a predominate health issue can reduce the burden of the
illness on the individual, their family and the wider community. Prevention is better than cure.
Authors: Melanie Green and Dr. Rachell Kingsbury

References
Aguiar, W. M & Dunningham, W. (1993). Geriatric depression: Clinical and therapeutic
aspects. Brazilian Medical Files, 67(4), 291-310.
Alexopoulos, G. S. (2005). Depression in the elderly. Lancet, 365, 1961-1970.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders: DSM-5. Washington, D.C: American Psychiatric Association.
Bartels, S. J., Dums, A. R., & Oxman, T. E., et al. (2003). Evidence-based practices in
geriatric mental health care: An overview of systematic reviews and meta-analyses.
Psychiatric Clinics of North America, 26, 971-990.
Berkman, L., Berkman, C., & Kasl, S. et al. (1986). Depressive symptoms in relation to
physical health and functioning in the elderly. American Journal of Epidemiology, 124, 372
388.
Blazer, D. G. (2003). Depression in late life: Review and commentary. Journal of
Gerontology: Medical Sciences, 58(3), 249265.
Blazer, D. G. & Williams, C. D. (1980). The epidemiology of dysphoria and depression in an
elderly population. American Journal of Psychiatry, 13,439-44.
Blazer, D., Burchett, B., Service, C., & George, L. (1991). The association of age and
depression among the elderly: An epidemiologic exploration. The Journal of Gerontology,
46(6), M210-M215.
Chiu, H. F. K., Yip, P. S. F., & Chi, I., et al. (2004). Elderly suicide in Hong Kong a casecontrolled psychological autopsy study. Acta Psychiatrica Scandinavica, 109, 299-305.
Conwell, Y., & Brent., D. Suicide and aging: patterns of psychiatric diagnosis. In: Tam, C. W.
C., & Chiu, H. F. K. (2011). Depression and Suicide in the Elderly. Medical Bulletin, 16(9),
13-16.
Conwell, Y., Duberstein, P. R., Herrmann, J. H., & Caine, E. D. (1996). Relationship of age
and axis I diagnoses in victims of completed suicide: A psychological autopsy study.
American Journal of Psychiatry, 153(8): 1001-1008.
Koder, D. A., Brodaty, H., & Anstey, K. J. (1996). Cognitive therapy for depression in the
elderly. International Journal of Geriatric Psychiatry,11: 97-107.

Lenze, E. J, Dew, M. A., & Mazumdar, S. et al. (2002). Combined pharmacotherapy and
psychotherapy as maintenance treatment for late-life depression: effects on social
adjustment. American Journal of Psychiatry, 159, 466-468.
McDougall, F. A., Matthews, F. E., Kvaal, K., Dewey, M. E., & Brayne, C. (2007). Prevalence
and symptomatology of depression in older people living in institutions in England and
Wales. Age and Ageing, 36(5), 562-568.
Minino, A. M., Arias, E., Kochanek, K. D., Murphy, S. L., & Smith, B. L.(2002). Deaths: final
data for 2000. National Vital Statistics Reports, 50(15), 1-119.
Mueller, T. I., Kohn, R., & Leventhal, N., et al. (2004). The course of depression in elderly
patients.American Journal of Geriatric Psychiatry, 12(1), 22-29.
Mulsant, B. H., & Ganguli, M. (1999). Epidemiology and diagnosis of depression in late life.
Journal of Clinical Psychiatry, 60(20), 915.
Murrell, S., Himmelfarb, S., & Wright, K. (1983). Prevalence of depression and its correlates
in older adults. American Journal of Epidemiology, 117:173185.
Reynolds, C. F., Frank, E., & Perel, J. M., et al. (1999). Nortriptyline and interpersonal
psychotherapy as maintenance therapies for recurrent major depression: A randomized
controlled trial in patients older than 59 years. Journal of the American Medical Association,
281:39-45.
Salzman, C., Wong, E., & Wright, C. B. (2002). Drugs and ECT treatment of depression in
the elderly, 19962001: A literature review. Biological Psychiatry, 52, 265-285.
Tam, C. W. C., & Chiu, H. F. K. (2011). Depression and Suicide in the Elderly. Medical
Bulletin, 16(9), 13-16.
Volkers, A. C., Nuyen, J., Verhaak, P. F. M., & Schellevis, F.G. (2004). The problem of
diagnosing major depression in elderly primary care patients. Journal of Affective Disorders,
82, 259-263.
Wiese, B. S. (2011). Geriatric depression: The use of antidepressants in the elderly. British
Columbia Medical Journal, 53(7), 341-347.