Depression is not an inevitable part of growing older, but there are factors that come with aging that can increase the risk of developing depression, even for a person who does not have a history of depression. These include retiring and losing one’s professional identity, increased medical problems, losing loved ones, and increased isolation. It is important for primary care providers to be aware of the risk of depression in older patients, to be able to assess for and make treatment recommendations appropriately.
The symptoms of depression can be the same for older patients as younger adults. However, older patients with depression can often deny feeling sad or depressed. Here are some clues to indicate that an older patient might have depression.
- unexplained or aggravated aches and pains
- feelings of hopelessness or helplessness
- anxiety and worries
- concentration problems
- lack of motivation and energy
- slowed movement and speech
- loss of interest in socializing and hobbies
- neglecting personal care
It can be easy to think of a patient’s presenting symptoms as a normal part of aging, for example it is common for people to experience trouble with concentration and difficulty maintaining sleep as they get older. Even feelings of guilt and worthlessness can appear to be a reaction to losing a loved one or retiring, respectively. One important factor is looking at the level of impairment to help determine if a more serious process is occurring.
Depression can occur co-morbidly with dementia and the two disorders each increase the risk of the other, but the cognitive concerns that occur with each are different. Persons with depression commonly report trouble concentrating and being motivated. Persons with dementia present with short-term memory loss and word finding difficulties, and may not be aware of the cognitive challenges. The cognitive decline seen in dementia is mostly a slow process whereas the cognitive decline seen in depression is more rapid. Here is a helpful chart to distinguish between depression and dementia.
|Mental decline is relatively rapid||Mental decline happens slowly|
|Oriented||Confused and disoriented|
|Difficulty concentrating||Difficulty with short-term memory|
|Language and motor skills are slow, but normal||Writing, speaking and motor skills are impaired|
|Notices or worries about memory problems||Doesn’t notice memory problems or seem to care|
One very important thing to be aware of is that the suicide risk is high among older patients with depression, particularly in Caucasian males. Research shows that 75% of people who commit suicide have visited their PCPs in the previous month but their symptoms of depression were either not disclosed or not assessed for. This is a serious and potentially preventable problem, and starts with improving psycho-education and awareness of depression in older patients.
It is also important to be aware that medical problems and medications can cause depressive symptoms in older adults. Medical problems that can cause depressive symptoms, either directly or as a psychological reaction to the illness, include Parkinson’s disease, stroke, heart disease, cancer, diabetes, thyroid disorders, vitamin B12 deficiency, dementia, lupus and multiple sclerosis. Medications that can cause of worsen depression include: beta-blockers, sleeping medications, benzodiazepines, calcium-channel blockers, ulcer medications, steroids, cholesterol medications, and pain medications. While the mood-related side effects of prescription medication can affect anyone, older adults are more sensitive because of less efficient metabolism of medication.
Treatment for depression should include treating underlying medical factors, increasing social engagement and therapy. Medication (primarily the SSRIs) can be an important part of the treatment as well, but it is important to utilize the lowest effective dose and monitor closely for side effects, which can include bone loss and increased risk for falls and fractures in elderly patients. Measures to reduce the risk of bone loss, like exercise and calcium and vitamin D supplementation, are important to consider adjunctively.
As mentioned previously, it is important to improve awareness of and assessment for depression in older patients, It not only can be a debilitating condition on its own, but it can also complicate the presentation of other medical problems and limit effectiveness of treatment for those other medical problems.