Depression in Older Adults

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Overview

Depression is a sometimes-debilitating condition that affects more than 6.5 million Americans age 65 and older. (1) Unfortunately, when it occurs in the older population, depression is often undiagnosed or even misdiagnosed.

One reason for this is that many people believe that depressive symptoms are a normal part of aging. The truth is that depression is not part of the natural aging process. Certain events that tend to occur later in life—such as retirement, death of a spouse, or serious illness—can cause depressive periods.

In most cases, older adults ultimately adjust and recover from these events of loss or illness. However, in some cases they aren’t able to adjust on their own and develop depression.

These symptoms of depression are often not recognized by family or care providers. They can be mistaken for signs of physical illness, such as Alzheimer’s disease, dementia, cancer, arthritis, heart disease, stroke, Parkinson’s disease, or thyroid disorders. (2)

Because 80% of older adults have at least one chronic medical problem and 50% have two or more (3), it’s not always easy to identify depressive symptoms.

Another reason that depression in older adults is often missed is that they can have different symptoms than younger people. Older adults are also more likely to be uncomfortable talking about their symptoms. (1)

They can also have issues of disability and dependency that cause fear and distress for both the patient and the caregivers. Many patients and caregivers don’t realize that depression is an illness that can be treated. Others worry that treatment will be too expensive. (2)

Older adults are also likely to have been brought up believing that asking for help is a weakness or something to be ashamed of. Mental illness still has a stigma associated with it, especially with older adults.

Types of Depression (1)

There are three types of depression most likely to affect older adults:

  • Major depression: Episodes of severe symptoms that affect a person’s ability to sleep, work, eat, and enjoy life. These episodes can happen once in a lifetime, or more likely, several times.
  • Persistent depressive disorder: A depressed mood that lasts for two or more years. This can involve periods of major depression along with episodes of less-severe symptoms.
  • Vascular depression: (4) A type of depression that can occur later in life, especially in older adults who have no earlier history of depression. Vascular depression involves restricted blood flow to the brain and other organs. Patients with vascular depression are at high risk for stroke, heart disease, or other vascular illnesses.

Other types of depression that can affect people of any age include seasonal affective disorder, bipolar depression, and psychotic depression.

Causes of Depression (5)

There are many potential causes of depression. It can be brought on by an isolated event such as divorce or trauma. It can be a response to serious medical illness, grief, or the stress of caregiving for a disabled spouse. A person who has had depression earlier in life is more likely to suffer further episodes in their later years.

Depressive episodes can even come on for no apparent reason.

There’s still a lot we don’t know about depression. Physical factors that may play a role include: (5)

  • Biology. We know that depression causes physical changes in the brain. More research is needed to understand what these changes mean.
  • Brain chemistry. You may have heard depression referred to as a chemical imbalance in the brain. These chemicals are neurotransmitters. They occur naturally in the brain, and recent research has shown that changes in these chemicals play a role in mood stability, depression, and treatment.
  • Hormones. Depression can also result from hormone imbalances. There are a number of potential causes for these imbalances, including menopause, thyroid problems, pregnancy and delivery.
  • Inherited traits. There seems to be a genetic component to at least some types of depression. Studies are ongoing to try to isolate a “depression gene.”

Symptoms of Depression in Older Adults (6),(7)

Unlike younger people, older adults with depression don’t present with sadness as their primary symptom. They are more likely to feel tired and irritable. They can develop confusion that can mimic Alzheimer’s disease.

They are also more likely to have medical conditions such as stroke, heart disease, or cancer, which can also cause symptoms of depression. Medication side effects are another potential cause of depressive-type symptoms that can be hard to sort out.

There are many signs of depression, and no two individuals will have the same symptoms.

If you have a number of these symptoms that don’t go away after two weeks, you should see your doctor. You may be depressed.

Other symptoms of depression include:

  • Feeling irritable or restless, unable to sit still.
  • Appetite changes with weight gain or loss.
  • Fatigue or decreased energy.
  • Feeling worthlessness, guilt, and self-hate.
  • Trouble concentrating.
  • Moving faster or slower than usual.
  • Avoiding activities or no activity at all.
  • Feelings of hopelessness and helplessness.
  • Thoughts of death or suicide, or suicide attempts.
  • Not feeling pleasure in activities you used to enjoy (including sex).
  • Personality changes or decreased memory.
  • Social isolation and disinterest in trying new things.
  • Difficulty making decisions.
  • Insomnia, waking too early, or oversleeping.
  • Headaches, cramps, pain, or stomach problems that don’t seem to have a cause and don’t get better with treatment.
  • Frequent crying.
  • Delusions.
  • Hallucinations.
  • Demanding behavior.
  • Prolonged grief. When older adults have recently lost a loved one, normal grief reaction can lead to depression. Seek help if grief is unusually severe or lasts longer than expected. Your doctor may recommend treatment. (8)

Diagnosis (2)

The first step in diagnosing depression is a complete physical exam. Your provider will want to rule out any underlying health conditions. They will also check your medications to be sure your dosages don’t need adjustment. They may order lab work or imaging studies.

When medical causes for your symptoms are ruled out, the next step is a psychiatric exam. Your provider may also want to speak to your family members to get a better sense of areas where you’re struggling.

Treatment for Depression

Medications (8)

Antidepressants are one of the most common treatments for depression. They can take several weeks to work, and many people will experience side effects. It may take some trial and error to find the right medication for you, but antidepressants have proven to be an effective treatment for a lot of older adults.

Some of the side effects that you may experience include nausea and vomiting, diarrhea, sleepiness, weight gain, sexual problems, and suicidal thoughts. The good news is that most side effects to antidepressants subside over time, but it’s important that you let your provider know. They can adjust dosages or switch you to a different medication.

If you have any thoughts of suicide, let your provider know immediately.

Older adults need to take special precautions when taking antidepressants. They are more likely to be taking medications for physical conditions. This puts them at higher risk of having harmful drug interactions, overdosing, or missing doses.

It is very important that you don’t stop taking antidepressants without your provider’s help. This can lead to withdrawal effects.

Older adults are also more sensitive to some drugs. You may need lower doses than a younger person would. Be sure to tell all of your doctors if you are having trouble with memory, coordination, or alertness. It will guide their decision when choosing an antidepressant that’s right for you.

All of your providers need to know all of the medications that you take. It’s also important that you let them know every time you have a change in a medication.

Psychotherapy (9)

Psychotherapy, either alone or in combination with medication, is another effective treatment for depression. It’s also known as “talk therapy.” It can be helpful both as a tool to manage symptoms and by providing support from a caring professional.

A type of psychotherapy called cognitive behavior therapy (CBT) can teach you new ways to think and solve problems. Research (10) finds that CBT can be an especially useful type of therapy for older adults.

Many adults prefer psychotherapy to taking medication. There are times when a combination of psychotherapy and medication may be the best treatment strategy.

Electroconvulsive Therapy (ECT) (9)

ECT is sometimes used for severe depression that is not responding to other treatment. It is also used for patients who are having delusions (false beliefs) about their illness or who are so depressed that they are not eating.

It involves stimulation of the brain with magnets, electricity, or implants. ECT is often the most effective and fastest way to treat severe symptoms.

ECT has been used to treat severe depression for over 80 years. Many providers and patients have misconceptions about its use, but it is safe and effective for treating severe symptoms in older adults.

As with medications used to treat depression, there are side effects to ECT. These can include memory loss and confusion. These side effects are usually temporary, but sometimes they will last longer.

Complementary Therapies (9)

Complementary therapies are nonmedical forms of treatment. Some examples are exercise, yoga, meditation (11), and dietary supplements.

Many older adults find some complementary therapies helpful, but they should not be used to replace any treatments your doctor might recommend. Be sure to tell your provider about any complementary therapies you are using, especially any herbal supplements. Some supplements recommended for depression should not be used when you’re taking an antidepressant.

For more information about complementary therapies, see the National Center for Complementary and Integrative Health.

Other Forms of Self-help

The National Institute of Mental Health recommends other things you can do to ease your symptoms of depression: (9)

  • Be realistic with your goals.
  • Try not to isolate. Spend time with others and talk with a supportive friend or relative.
  • Let others help.
  • Expect gradual—not immediate—improvement in your symptoms.
  • Don’t make important decisions while you’re depressed. Ask advice from someone you trust first.
  • Learn all you can about depression.

Risk Factors for Depression (6)

There are a number of things that can put people at risk of developing depression. That list includes:

  • Personality traits such as low self-esteem or being overly dependent on others, pessimistic, or self-critical.
  • Trauma or stress such as abuse, loss of a loved one, relationship or financial problems.
  • Family history of depression, suicide, bipolar disorder, or alcoholism.
  • Being gay, lesbian, bisexual or transgender, or intersex (having reproductive organs that aren’t obviously male or female) without support.
  • Other mental health disorders such as posttraumatic stress disorder, anxiety disorder, or eating disorder.
  • Alcohol or other drug abuse.
  • Chronic or serious illness such as heart disease, cancer, stroke, or chronic pain.
  • Certain medications, including sleeping pills or some blood pressure medications.

Prevention of Depression or Worsening Depression

There is no sure-fire way to prevent depression, but there are some strategies that may be helpful: (6)

  • Control your stress so you’re better able to handle problems and maintain your self-esteem.
  • Talk to supportive family and friends in times of trouble or unusual stress.
  • Get help right away if you or loved ones notice symptoms.
  • Talk to your doctor about long-term treatment to prevent a relapse.

You might also consider participating in a behavioral health program. See the National Council on Aging for a directory of programs designed for older adults.

If you are not comfortable with the idea of seeking treatment, reach out to a friend, supportive family member, or clergy as soon as you notice symptoms.

If you are having thoughts of hurting yourself, call 911 immediately.

If you are having suicidal thoughts, call a suicide hotline. In the US, call the National Suicide Prevention Lifeline at 1-800-273-TALK (1-800-273-8255). If you’re a veteran, pressing 1 will connect you to the Veterans Crisis Line.

Conclusion

Depression can be hard to diagnose in older adults for a variety of reasons. However, it is common in this age group. Educating yourself about the risk factors and symptoms of depression can help you to cope when you’re feeling down and can’t identify why.

It is critically important to avoid social isolation. Depression and loneliness feed off each other in a cycle that’s hard to break on your own.

You don’t have to live with depression. Ask for help right away if you are experiencing any symptoms.

References

1) “Depression in Older Adults.” National Institute on Aging. https://www.nia.nih.gov/health/depression-and-older-adults. Updated May 1, 2017. Accessed June 6, 2019.

2) “Depression in Older Persons.” National Alliance on Mental Illness. https://namimn.org/wp-content/uploads/sites/188/2018/05/DepressionInOlderPersons_Illnesses_Adult_2018.pdf. Updated March 2017. Accessed June 6, 2019.

3) “Depression is Not a Normal Part of Growing Older.” Centers for Disease Control and Prevention. https://www.cdc.gov/aging/mentalhealth/depression.htm. Updated January 31, 2017. Accessed June 6, 2019.

4) “Vascular Dementia.” Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/vascular-dementia/symptoms-causes/syc-20378793. Accessed June 6, 2019.

5) “Dealing with Depression.” Southwestern Indiana Regional Council on Aging (SWIRCA & More), University of Southern Indiana. http://resources.swirca.org/en/dealing-depression/. Accessed June 6, 2019.

6) “Depression (Major Depressive Disorder).” Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/depression/symptoms-causes/syc-20356007. Accessed June 6, 2019.

7) “Depression.” MedlinePlus. https://medlineplus.gov/ency/article/003213.htm. Updated May 8, 2019. Accessed June 5, 2019.

8) “Older Adults and Depression.” National Institute of Mental Health, https://www.nimh.nih.gov/health/publications/older-adults-and-depression/index.shtml, NIH Publication No. QF 16-7697. Accessed June 6, 2019.

9) “Depression.” National Institute of Mental Health. https://www.nimh.nih.gov/health/topics/depression/index.shtml. Updated February 2018. Accessed June 5, 2019.

10) Cuijpers, Pim et al. “Managing depression in older age: psychological interventions.” Maturitas vol. 79,2 (2014): 160-9. doi:10.1016/j.maturitas.2014.05.027

11) A Simple, Fast Way to Reduce Stress, Mayo Clinic. https://www.mayoclinic.org/tests-procedures/meditation/in-depth/meditation/art-20045858. Updated October 17, 2017. Accessed June 5, 2019.