Depression in the Elderly

Depression impacts older people differently than younger people. In the elderly, depression often occurs with other medical illnesses and disabilities and lasts longer.

Depression in the elderly often increases their risk of cardiac diseases. Depression doubles an elderly person's risk of cardiac diseases and increases their risk of death from illness. At the same time, depression reduces an elderly person's ability to rehabilitate. Studies of nursing home patients with physical illnesses have shown that the presence of depression substantially increases the likelihood of death from those illnesses. Depression also has been associated with increased risk of death following a heart attack. For that reason, making sure that an elderly person you are concerned about is evaluated and treated is important, even if the depression is mild.

Depression also increases the risk of suicide, especially elderly white men. The suicide rate in people ages 80 to 84 is more than twice that of the general population. The National Institute of Mental Health considers depression in people age 65 and older to be a major public health problem.

In addition, advancing age is often accompanied by loss of social support systems due to the death of a spouse or siblings, retirement, or relocation of residence. Because of changes in an elderly person's circumstances and the fact that elderly people are expected to slow down, doctors and family may miss the signs of depression. As a result, effective treatment often gets delayed, forcing many elderly people unnecessarily struggle with depression.

Insomnia is usually a symptom of depression. New studies reveal that insomnia is also a risk factor for depression onset and recurrence -- particularly in the elderly.

To treat insomnia, experts recommend the newer "hypnotic" drugs that are safe and effective in elderly people. If there's no improvement in the sleep disorder and/or depression, a psychiatrist or psychopharmacologist may prescribe medications and/or psychotherapy.

Factors that increase the risk of depression in the elderly include:

• Being female
• Being single, unmarried, divorced, or widowed
• Lack of a supportive social network
• Stressful life events

Physical conditions like stroke, hypertension, atrial fibrillation, diabetes, cancer, dementia, and chronic pain further increase the risk of depression. Additionally, the following risk factors for depression are often seen in the elderly:

• Certain medicines or combination of medicines
• Damage to body image (from amputation, cancer surgery, or heart attack)
• Family history of major depressive disorder
• Fear of death
• Living alone, social isolation
• Other illnesses
• Past suicide attempt(s)
• Presence of chronic or severe pain
• Previous history of depression
• Recent loss of a loved one
• Substance abuse

Brain scans of people who develop their first depression in old age often reveal spots in the brain that may not be receiving adequate blood flow. Chemical changes in these cells may enhance the likelihood of depression separate from any life stress.

There are several treatment options available for depression. They include medicine, psychotherapy or counseling, or electroconvulsive therapy. Sometimes, a combination of these treatments may be used.

Most of the available antidepressants are believed to be equally effective in elderly adults. But the risk of side effects or potential reactions with other medicines must be carefully considered. For example, certain older antidepressants such as amitriptyline and imipramine can be sedating or cause a sudden drop in blood pressure when a person stands up. That can lead to falls and fractures.

Antidepressants may take longer to start working in older people than they do in younger people. Since elderly people are more sensitive to medicines, doctors may prescribe lower doses at first. In general, the length of treatment for depression in the elderly is longer than it is in younger patients.

Most depressed people find that support from family and friends, involvement in self-help and support groups, and psychotherapy are helpful. Psychotherapy is especially beneficial for those who prefer not to take medicine and who have mild to moderate symptoms. It also is helpful for people who cannot take drugs because of side effects, interactions with other medicines, or other medical illnesses.

Psychotherapy in older adults can address a broad range of functional and social consequences of depression. Many doctors recommend the use of psychotherapy in combination with antidepressant medicines.

ECT can play an important role in the treatment of depression in older adults. When older patients are unable to take traditional antidepressant medicines because of side effects or interactions with other medications, or when depression is very severe and interferes with basic daily functioning (such as eating, bathing and grooming), ECT is often a safe and effective treatment alternative.

The stigma attached to mental illness and psychiatric treatment is even more powerful among the elderly than among younger people. This stigma can keep elderly people from acknowledging that they are depressed, even to themselves. Elderly people and their families sometimes also may wrongly misidentify depression symptoms as "normal" reactions to life stresses, losses, or the aging process.

Also, depression may be expressed through physical complaints rather than traditional symptoms. This delays appropriate treatment. In addition, depressed older people may not report their depression because they believe there is no hope for help.

Elderly people may also be unwilling to take their medicines because of side effects or cost. In addition, having certain other illnesses at the same time as depression can interfere with the effectiveness of antidepressant medicines. Alcoholism and abuse of other substances may cause or worsen depression and interfere with effective treatment. And unhappy life events including the death of family or friends, poverty, and isolation may also affect the person's motivation to continue with treatment.

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