Presentations of depression in old age
Unexplained chronic physical symptoms
The older person complains of several physical symptoms for which no medical explanation can be given. The complaints will vary and may include insomnia, dizziness, chronic aches and pains, constipation and weight loss. Upon careful questioning, symptoms of depression may become apparent however the older person may deny that it could be the problem. Sometimes, the older person becomes convinced that they are suffering from an incurable illness, and won’t listen to reason. This is commonly found to be the reason that an older person attempts suicide.
Memory loss often accompanies depression in old age. As such, the older person and their family may regard this apparent dementia onset as the significant problem and fail to see the depression. Memory can be improved by treating the underlying depression.
Behavioural changes seen in older people can include agoraphobia in which the older person becomes housebound with fear, refuses to eat, shoplifts, lives in squalor, ‘accidentally’ overdoses, or abuses alcohol. Other behavioural changes may involve situations in which an older person becomes preoccupied with changing their will, gives away personal possessions, talks about death, or takes an unprecedented interest in firearms. Behaviours of this nature should alert friends and family of the possibility of depression and also the risk of suicide.
Types of depression in older people
Non-melancholic depression is the most prevalent type of depression in older age and impacts approximately 10% of older people. It is clear that such depressive states cause considerable disablement and distress and often persists unrecognised for years. Possibly this is because many older people with such depressive disorders also have physical health impairments contributing to the depression. Consequently, symptoms of depression, such as constipation, may be attributed to physical illness, and vice versa.
Causes of depression in older people
A strong relationship exists between physical illness, disability, and depression. For example, physical illness can cause depression through a variety of biological mechanisms. This can occur in an older person where no psychological or social reason for depression is apparent. Cerebrovascular disease is also an important risk factor for late onset depression. Cancer, thyroid disease, vitamin deficiencies and infections are examples of the types of physical illnesses that can trigger depression in old age. That is why it is important for any older person who is experiencing late onset depression to undertake a thorough medical evaluation. Enforced dependency which may result from an older person losing mobility and requiring assistance with self-care may cause a loss of dignity, a sense of being a burden on others and a fear of institutionalisation. Unfortunately, depression is often left untreated in these circumstances, being ‘down’ is seen as a normal response to the situation. Additionally, drugs used to treat high blood pressure, tranquillisers, painkillers and steroids often taken by older age people can cause depression.
Loneliness & social isolation
It is common for people in old age to experience loneliness and social isolation. This may be due to a lack of close family, living alone, reduced connections with their culture or an inability to participate in the local community. When this occurs in combination with physical disablement, demoralisation and depression are common accompaniments. This may result in the overuse of alcohol to quell their depressive symptoms. However alcohol often worsens the depressed mood which the older person does not realise.
Loss in old age
Losses in old age are cumulative and frequent. Symbolic and real losses are the psychological basis of many depressions.
The treatment of depression in old age
Antidepressant medication is usually required in the more severe cases. In order to minimize side-effects, antidepressant medication usually has to be started at a lower dose and increased gradually. Interactions with other medications such as those for the treatment of physical conditions can occur as well. Some antidepressant drugs such as tricyclics, are more likely to have side‐effects, so are used less frequently. Trials of at least 6‐8 weeks may be required in order to see improvement as antidepressant medication may take longer to work in older people.
Electroconvulsive therapy (ECT) is a useful treatment in melancholic and psychotic depression that has failed to respond to medication. Older people tolerate the treatment quite well, however extra precautions should be taken with the anaesthetic.
In the non‐melancholic depressions, the usual range of psychotherapies is applicable, though therapists need to take into account the limitations imposed by poor eyesight, poor hearing, and physical discomfort. Often briefer courses of therapy are required however the treatment response is as good, if not better, than in younger people. Other treatments for depression that are helpful include physical exercise, social activities and music therapy.
The prevention of depression in old age
It is important to implement lifestyle changes in mid life in order to assist in the prevention of depression in old age.
Cerebrovascular disease may cause depression for the first time in old age, so controlling the known risk factors for vascular disease may help prevent depression:
- reduction of high blood pressure.
- moderate alcohol consumption.
- ceasing cigarette smoking.
- reduction of cholesterol and lipid levels.
- a diet rich in fish, grains and greens.
- increased physical exercise.
- weight control.
- Social activities and participation, mental stimulation, control of chronic pain and grief counseling.