Depression in Older Adults – Causes, Signs and Symptoms

Depression May Have Different Symptoms With Age

Also called: Depression in Elderly

Summary

Depression is a mental health disorder of serious concern in older adults. According to the National Institute of Mental Health (NIMH), an estimated two million of the nearly 35 million Americans over the age of 65 years have some form of diagnosable depression. An additional five million of these individuals have significant symptoms that do not meet the full diagnostic criteria for the disorder.

Depression is frequently undiagnosed and untreated because it is often overlooked or considered normal or inevitable. This is especially true in the face of other medical conditions and life events (e.g., death of loved ones) that frequently affect older adults. However, depression is never a normal part of the aging process.

Many older adults may be particularly susceptible to the numerous complications and other risks of depression. For example, depression appears to be more likely to lead to suicide in older adults than in younger patients. Adults over the age of 65 years make up only 13 percent of the U.S. population, according to NIMH, but they make up 18 percent of all suicide deaths.

The causes of depression are still not fully understood, but a number of advances have been made in identifying potential factors. Most likely, a combination of genetic and environmental factors is involved. Depression tends to run in families and may be triggered by stress (e.g., death of a loved one). Depression is more common in women and people with chronic medical conditions.

The signs and symptoms of depression in older adults may differ from those in younger patients. Among the most common changes of mood in older adults with depression are feelings of nervousness, emptiness, restlessness, irritability or being unloved. Reduced appetite and weight loss, insomnia (not sleeping enough), fatigue, memory problems and confusion are also common in these patients. Older adults may be more likely than younger patients to display vague physical symptoms (e.g., aches and pains).

Depression in older adults is poorly recognized even among physicians. Many individuals, including many physicians, view depression as normal or expected for older adults. This belief is not true and often deters or delays proper diagnosis and treatment. When it is properly recognized, the diagnosis of depression involves a complete medical history, including information about the onset, duration and severity of symptoms.Older patients with mild depression may respond well with psychotherapy alone, whereas those with moderate to severe depression may require antidepressant medication. However, the outcome of treatment is generally best with a combination of psychotherapy and medication. Older adults are often more sensitive than younger patients to medication side effects and are more likely to have other medical conditions. Because of this, selective serotonin reuptake inhibitors (SSRIs) are prescribed more frequently than older antidepressants.

About depression in older adults

Depression is a common medical condition characterized by many physical and psychological symptoms, including profound sadness, loss of interest or pleasure in activities normally enjoyed (anhedonia) and other symptoms that impair a person’s ability to function.

Depression is a growing health issue for older adults. The actual percentage of adults over 65 who meet the diagnostic criteria is low when compared to the population as a whole. However, about 5.8 percent of Americans 65 or older have some form of diagnosable depression (roughly two million out of nearly 34 million), according to the National Institute of Mental Health (NIMH).

The NIMH also estimates that an additional five million have serious symptoms related to depression. Those 65 or older comprise 20 percent of all people who commit suicide. Among white males 85 and older, suicide is nearly six times higher as compared to the national average.

Depression is frequently undiagnosed and untreated in older adults for a number of reasons:

  • Depression is often attributed to other medical conditions, such as heart disease, stroke, Parkinson’s disease and cancer. Patients and their families often share this belief. In addition, a physician’s attention is often focused on treating these physical conditions.
  • Depression may be attributed to the passing of loved ones. Grief and bereavement are natural feelings following the death of a spouse, relatives or close friends. Depression is not.
  • Older patients may be more likely to rely on their primary care physicians, who are not mental health professionals, than younger patients. According to the NIMH, less than 3 percent of people aged 65 and older were treated by mental health professionals.
  • Not all primary care physicians have the training to distinguish between the signs of aging and depression. According to the NIMH, primary care physicians accurately diagnosed less than half of patients who were depressed.

The issue is further complicated by generational attitudes. Many older adults view depression as a character flaw rather than a genuine disorder. These attitudes frequently deter older adults from seeking professional help.

Studies show that older adults in general tend to know less about depression than the general public as a whole. According to the National Mental Health Association (NMHA), about 68 percent of adults over the age of 65 years know little or close to nothing about depression. Around 58 percent of these individuals think that it is normal to get depressed with advancing age, NMHA reports, and only 38 percent of adults in this age group consider depression a genuine health problem.

Cognitive disorders such as Alzheimer’s disease can mask symptoms of depression. Research indicates that the combination of Alzheimer’s and depression often leads to more advanced cognitive impairment than Alzheimer’s alone. However, depression may be difficult to diagnose in these patients. Alzheimer’s patients often have difficulty describing how they are feeling (e.g., sad, hopeless, helpless, worthless). Because of this, physicians must rely on other signs and nonverbal expressions, including refusal to eat, crying spells, facial expressions, unexplained agitation or hostility and increased confusion.

Depression is closely associated with disability and dependence on caregiver assistance. It causes a great deal of distress for both patients and their caregivers. Depression is also associated with increased healthcare costs. Older patients with symptoms of depression have about 50 percent higher healthcare costs than patients of similar age without such symptoms, according to the NMHA.

Depression versus grief in older adults

Depression in older adults must be differentiated from normal grief or bereavement. This population often faces the loss of loved ones, such as a spouse or life-long friend. Grief following such an event is normal. This grief may include many of the symptoms of depression for a short period of time. However, there are differences between these symptoms in a grieving individual and a depressed patient. Older adults who are grieving tend to focus on the deceased. Their depressive symptoms are usually much more passive and less severe than those of truly depressed individuals. Patients with depression, on the other hand, tend to think more in terms of themselves. They often feel guilt and a reduction in self-esteem.

The pain of bereavement is temporary. Depression tends to last much longer. In general terms, the most intense symptoms of normal grief occur in the weeks following the death. Common symptoms during this period include shock, disbelief, numbness and emptiness. Anxiety, insomnia and physical complaints may also occur.

The first year following the death is a period of adjustment in normal bereavement. People work through and come to accept their loss during this period. After this first year, the grieving individual undergoes recovery. He or she learns to accept life without the lost loved one. The time scale for normal grief is not exact. Some people undergo bereavement more quickly or more slowly than others. However, most older adults who have lost a loved one are at least on their way to feeling better about the loss at the end of the first year. If a patient continues to grieve following this period of time or experiences severe symptoms (e.g., suicidal thoughts, psychosis, severe loss of self-esteem or functionality), it is recommended that they seek medical attention.

Risk factors and causes

The cause of depression at any age cannot be narrowed down to a single factor. However, it appears that brain chemistry plays a major role in the disorder. Chemicals within the brain called neurotransmitters convey messages between the nerves.  Too many or too few neurotransmitters, particularly norepinephrine, serotonin and dopamine, are believed to cause alterations in mood.

Many adults may have had depression for many years, or it may develop later in life. It is important to distinguish between normal sadness due to events, such as the loss of a spouse, and symptoms of depression.

There are many risk factors for depression. For instance, women are nearly twice as likely to develop depression as men. Many mental health professionals believe that hormonal changes related to pregnancy, miscarriage, menstruation, the postpartum period, premenopause and menopause may precipitate depression in women.

It is important to note, however, that depression among men may be underdiagnosed as men may be more hesitant than women to share their feelings with others.

Individuals with a personal or family history of depression are also at greater risk of developing the condition. People who have had one episode of major depression have a 60 percent chance of having another episode. According to the National Alliance on Mental Illness (NAMI), the risk of major depression may be as high as 25 percent in first-degree relatives (e.g., parents, children, siblings) of patients with a history of major depression.

Other risk factors for depression include:

  • Stressful events or life situations. Individuals who have experienced major stresses, such as the death of a loved one, discrimination, abuse or trauma have an increased risk of depression. Unrealistic or unreachable expectations or life goals or major obstacles (real or perceived) to life goals and expectations may also increase the risk of depression. Retirement, moving out of a family home or moving into a community for older adults are a few examples of stressful events and situations that may affect older adults.
  • Chronic physical medical conditions. The rate of depression among patients hospitalized for general medical illnesses is between 10 and 14 percent, according to the National Mental Health Association (NMHA). The more severe the condition, the greater the risk of major depression. Medical conditions of particular concern include:
    • Heart disease. According to the NMHA, about 18 to 20 percent of patients with coronary disease who have not had a heart attack may be depressed and as many as 40 to 65 percent of heart attack survivors may have major depression.
    • Stroke. The NMHA reports that nearly 25 percent of patients who have a stroke in any given year will also develop major depression.
    • Diabetes. The risk of major depression in patients with adult onset diabetes is as high as 25 percent, according to the NMHA. In addition, as many as 70 percent of patients with diabetic complications, such as kidney failure, may be depressed.
    • Cancer. An estimated one in four people with cancer are depressed, according to the NMHA.
    • Other medical conditions that are associated with depression include the eye disorder macular degeneration, Parkinson’s disease, arthritis and chronic lung disease. Patients who have undergone certain medical procedures (e.g., bypass surgery) are also at an increased risk.
  • Medication use. Numerous medications can produce side effects that include symptoms of depression. In older adults who must often take many medications, these effects may be particularly significant.
  • Other mental health conditions. People with other mental health conditions, including some anxiety disorders and cognitive disorders (e.g., Alzheimer’s disease), are more likely to experience depression.
  • Substance abuse. People who abuse alcohol, drugs or other substances have an increased risk of depression.
  • Marital status, quality of marriage and lack of social supports. Single people have an increased risk for depression. This is particularly true for individuals who have been widowed. According to the NMHA, a third of people who lose a spouse develop depression in the first month after their spouse’s death. About half of these remain depressed after one year. Individuals who feel rejected or depreciated by a loved one, or who have few or no friends, are also at an increased risk for depression.

Signs and symptoms in older adults

The signs and symptoms of depression may vary greatly among patients. Symptoms in older adults may differ from those in younger patients and tend to last longer and be more persistent. Generally, there are nine primary symptoms of depression, which include:

  • Altered mood. Among the most common changes of mood in older adults with depression are feelings of nervousness, emptiness, restlessness, irritability or being unloved. The patient may also experience profound sadness, anxiety, anger or apathy (lack of emotion). They may be pessimistic or discouraged and may experience crying spells or excessive emotional sensitivity.
  • Anhedonia. Reduction or loss of interest in activities the patient formerly found pleasurable, such as eating, sex, work, friends, hobbies and entertainment.
  • Significant change in appetite or weight. The patient may experience reduced or increased appetite or significant weight loss or gain. In older adults, reduced appetite and weight loss are more common than increased appetite and weight gain.
  • Changes in sleep patterns. The patient may sleep too much (hypersomnia) or not enough (insomnia). In older adults, insomnia is much more common than hypersomnia.
  • Self-worth. The patient may have feelings of worthlessness, self-reproach or excessive or inappropriate guilt.
  • Fatigue and loss of energy.
  • Concentration. The patient may exhibit a diminished ability to think or concentrate. Memory problems and confusion are common in older adults with depression.
  • Death thoughts. The patient may have recurrent thoughts of death and death wishes. They may think about committing suicide (suicidal ideation) or engage in suicidal actions. The patient may even attempt or complete suicide. This is a serious concern for older adults with depression.
  • Physical or verbal activity. Patients may be agitated and anxious. They may wring their hands, pace or not be able to sit still. Conversely, patients may have sluggish movements or speech. There may be a pause before answering questions or starting actions. They may speak quietly or not be able to be heard. They may not speak except in response to a direct question or may become completely mute (not talking at all).

Older people who have depression may not initially seek treatment for their mood, but may instead see their primary physician to treat what they believe is a physical disorder. Fatigue, headache and stomach pains that do not respond to medication are often reported. Older adults may be more likely than younger patients to display these vague physical symptoms. In some cases, hallucinations or delusions may also occur. These may be mistaken for signs of dementia.

Diagnosis methods for depression

According to the National Mental Health Association (NMHA), only 42 percent of older adults seek help for depression. Of these, the NMHA reports, more than 55 percent are treated by primary care physicians. Less than 3 percent of patients with depression over the age of 65 years see a mental health professional, according to the NMHA.

This poses a problem because depression in older adults is poorly recognized even among physicians. According to the NMHA, primary care physicians accurately recognize less than 50 percent of depression patients. Many common symptoms of this condition in older adults (e.g., loss of energy, poor appetite, insomnia) are attributed to other medical problems. Other symptoms (e.g., confusion) may be mistaken for dementia.

Many individuals, including many physicians, view depression as normal or expected for older adults. This is particularly a problem in the face of the serious medical illnesses and social circumstances (e.g., death of a loved one) that affect many older adults. This belief is not true and often deters or delays proper diagnosis and treatment.

Another major obstacle to diagnosis is the attitude of the patients themselves. Some people believe there is a stigma attached to seeking help for any potential mental health condition. Older adults in particular may be reluctant to acknowledge any mental health problems. They are more likely than younger patients to try to deal with the condition themselves.

Before depression can be diagnosed, a physician will typically perform a physical examination to rule out other conditions that may be causing symptoms. Many people who are eventually diagnosed with depression visit their primary care physician first because they suspect there is a physical problem. However, a mental health professional is usually more capable of diagnosing depression.

Once the patient seeks the attention of a physician or non-physician mental health professional, diagnosis is possible. Diagnosis of depression typically begins with a complete medical history, including information about the onset, duration and severity of symptoms.

The diagnosis of depression in older patients may include the use of the geriatric depression scale. This is a screening tool designed specifically for older adults who may have depression. It is a short form made up of 15 simple yes or no questions. The physician or mental health professional will also ask whether the patient has experienced these symptoms before and, if so, whether and how they were treated. The patient will also be asked about alcohol and drug use, whether they have thought about death or suicide and whether other family members have had a depressive illness.

If there is a family history of depression, the practitioner will ask how it was treated and whether treatment was effective. A diagnostic evaluation should also be performed. This examination of the patient’s mental status determines if memory, speech or thought patterns have been affected.

Treatment and prevention of depression

According to the National Institute of Mental Health (NIMH), more than 80 percent of people with depression can be treated successfully with medication, psychotherapy or a combination of both. The treatment options available for depression are quite varied and individualized. However, results often take time and as many as half the patients undergoing treatment for depression do not respond immediately.

Medications for depression offer relief of symptoms over a period of time. The primary medications for this disorder are antidepressants. There are several different kinds of antidepressants, including selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs).

SSRIs and SNRIs are usually associated with milder side effects than older antidepressants such as the TCAs and MAOIs. Because older adults are more sensitive to side effects, SSRIs are prescribed more frequently for older adults, according to the National Institutes of Health. A physician may prescribe a lower dose to minimize side effect risks.

The U.S. Food and Drug Administration (FDA) has advised that antidepressants may increase the risk of suicidal thinking in some patients and all people being treated with them should be monitored closely for unusual changes in behavior.

Other medications may be used in combination with antidepressants in some cases. However, many physicians prefer to keep the number of medications taken by older adults to a minimum to reduce side effects and the risk of medication interactions. However, if the patient displays psychotic features (e.g., hallucinations, delusions), antipsychotics may be prescribed.

One form of psychotherapy that may be helpful for older adults focuses on family stress, grief and the changing nature of family roles (e.g., children making decisions for parents). Called interpersonal therapy(IPT), this form has been used for both depressive disorders and patients going through normal bereavement.

In rare cases, electroconvulsive therapy (ECT) may be recommended by some physicians to treat severe depression in patients who cannot take or do not respond to medications. ECT is a treatment in which electrical current is used to cause a brief convulsion in the patient.

A healthy lifestyle that includes a balanced diet and exercise and strong social and interpersonal connections may help some older adults minimize the risk of developing depression. Those who have experienced major depression and recognize the return of their symptoms can seek help immediately to minimize their effect.

Ongoing research regarding depression

Researchers and scientists are continually trying to understand more about how depression occurs in and affects older adults. The National Institute of Mental Health (NIMH) is funding studies into the effectiveness of depression education in primary care clinics. This is for the purpose of increasing the diagnosis and treatment numbers of older patients with depression, particularly those with suicidal symptoms.


Research is also ongoing in the evaluation of hormonal factors in depression in older adults, including the possibility of using hormone replacement therapy in its treatment. There is also ongoing research to further understand the causes of depression, including the changes in the brain that occur when it is present.

Questions for your doctor about depression

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions related to depression in older adults:

  1. How much experience do you have in treating depression, especially in older adults?
  2. Do you suspect that I have depression?
  3. What treatment options are right for me?
  4. How often will I need to attend therapy?
  5. Should my family be involved in my therapy?
  6. Will the treatment of my depression include antidepressants?
  7. How may my antidepressants affect my other medical conditions?
  8. Could my antidepressants interact with any of my other medications?
  9. How long will I have to take antidepressants?
  10. How long may it take for my treatment to begin to work?
  11. What should I do if I miss a dose of my antidepressant?
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