There are 31 million Americans 65 years or older, and five million of them (just over 16 percent) have depression (Boswell & Stoudemire, 1996). In Australia, one million people currently suffer from depression, and 14 percent will have it at some point in their lives (Australian Bureau of Statistics, 2008). There is some debate as to whether the prevalence of depression increases or decreases with age, with a recent report suggesting that there are fewer diagnoses of depression in older people as the rates are considerably lower than for younger people.

However, when broader measures are used which do not exclude from diagnosing contextual conditions more prevalent in older people – such as bereavement or dementia – the prevalence among community-dwelling elders is reported to be between six and twenty percent of that population: not inconsistent with the American figures. That rises to about 48 percent among the elderly living in hospitals (Bryant, Jackson, & Ames, 2009), and up to 50 percent for older people living in residential aged care (Cummings, 2002).

Percentages around the fifty percent mark are staggering, but there is more bad news. Adults 65 years and older currently make up 12 percent of the population, but by around 2030, they will grow to around 20 percent of the population (U.S. Census Bureau, 2000, in U.S. Department of Health and Human Services (SAMHSA), 2011). Mental health experts estimate that one-third of this group have mental health issues for which professional intervention is needed (Smyer & Qualls, 1999), but the one-third figure does not include normal developmental issues with which seniors may require assistance: challenges such as retirement, grandparenthood, and second careers.

Moreover, Baby-Boomers, many of whom are beginning to retire now, tend to use mental health services more frequently than did previous generations of older adults, and they also tend to be less stigmatised by seeking mental health care. All of these figures point to a clear outcome: the demand for mental health services among older adults is highly likely to increase (SAMHSA, 2011). And it is a set of conditions which will only intensify in coming years as the generational wave of Baby Boomers moves through the system and into extreme old age.

Depression and ageing

What depression is not in older adults is a normal part of ageing. It is, however, commonly unrecognised in elders (Snowdon, 2001; Birrer & Vemuri, 2004). No more than 10 percent of those detected in primary care will be offered anti-depressant treatment and less than 1 percent will be referred to a psychiatrist (Anderson, 2001).

Perhaps doctors fail to see, and thus treat, depression because a majority of people in their seventies and older have at least one physical disability, and depressed elderly patients are likely to focus attention on physical symptoms when they visit their general practitioners, making it easy for the doctor to overlook the depression (Snowdon, 2001).

Yet depressed older people will consult their G.P. two to three times more often than non-depressed elders, offering numerous opportunities to identify and treat depression if it can be picked up. There are differences in the presentation of the depression observed in older adults from that seen in younger people.

More physical complaints, less sadness

While a younger person might present with sadness accompanying their depression, the older person tends to have physical complaints instead. The list of symptoms for which no medical explanation can be found often includes dizziness, constipation, weight loss, fatigue, gastrointestinal problems, and insomnia. Anna, whom you met in the introduction, was ultimately deemed to have depression being somatised as foot pain. Usually a patient’s depression becomes apparent in the course of general practitioner questioning, but the older person may be in denial that depression could be the problem, partly because of shame, lack of understanding of the disorder, or a belief that they should not be talking about it or admitting to not coping (Black Dog Institute, 2012; Beyondblue, 2009).

Mood and movement changes; withdrawal

Some older adults feel like they are slowed down when depressed, yet others may react in seemingly opposite ways: pacing and fidgeting frequently. When a depressed person withdraws from regular social or other activities, they may explain the withdrawal by saying, “It’s too much trouble”, “I don’t feel well enough”, or “I don’t have the energy”. The person may acknowledge feeling worthless or helpless, and may begin to neglect personal appearance. They may be frequently tearful (Geriatric Mental Health Foundation (GMHF), n.d.).

Memory loss, psychosis, and health and finance worries

Depression in older age often comes hand in hand with loss of concentration and memory changes; these become the main focus for intervention rather than the depression. If there is no dementia happening as well, treatment of the underlying depression can usually improve memory (Black Dog Institute, 2012). In addition, psychotic symptoms, melancholia, and hypochondriasis are more likely to occur with older folk with depression than younger ones (Beyondblue, 2009). Some depressed elders will focus on the health of their finances rather than on their personal health (GMHF, n.d.).

Anxiety Disorders

Anxiety disorders frequently co-occur with depression in older adults, and the two types of anxiety which tend to be common among members of this population are phobic disorders and generalised anxiety disorder (GAD). That said, there has also been increasing attention from clinicians to the incidence of PTSD (Post-Traumatic Stress Disorder) in older populations, because the survivors of the World War II and the Holocaust are now very old, and the Vietnam veterans are either already retired or about to retire.

The Vietnam vets, in particular, have well-documented high levels of psychopathology (Owens, Baker, Kasckow, Ciesla, & Mohamed, 2005), with wide-ranging effects on the mental health of family members. While prevalence data on PTSD are very limited, studies of Holocaust survivors have found that up to 46 percent meet criteria for PTSD.

A study in the Netherlands found that 47.5 percent of older people with major depressive disorders also met criteria for anxiety disorders (Beekman, de Beurs, van Balkom, Deeg, Van Dyck, & Van Tilburg, 2000), Debate continues as to whether the presentation of PTSD is similar in older people to younger ones, and more research is needed (Beyondblue, 2009).

Behavioural changes

Older adults’ behaviours can vary widely, but signs that a depressive illness is occurring include: refusal to eat, avoiding leaving home, hoarding, alcohol abuse, and shoplifting. Also, when older people begin to be preoccupied with changing their will, giving away personal possessions, talking about death, or taking a sudden interest in firearms, there may be not only depression, but also the risk of suicide (Black Dog Institute, 2012).

Differentiating between depression and dementia

In diagnosing depression in older-age adults, it is not only necessary to recognise the different presentation from that of depression in a younger person; it is also important to distinguish elder depression from dementia. Here are some of the characteristic differences.

Dementia:

• Onset: Gradual onset; people are not sure when it began
• Duration of symptoms: Usually long
• Mood, behaviour, emotions: Behaviour seems impaired, with inconsistent mood and emotions fluctuating
• Cognitive functioning: Consistent, stable, or worsening
• Neurologic defects: Often present
• Disabilities: Concealed by patient
• Depressive symptoms: Present
• Memory impairment: Doesn’t remember recent events; often unaware of memory loss. Memory loss precedes mood change
• Psychiatric history: None
• Answers to questions: Near answers
• Performance: Tries hard, but is unconcerned about losses
• Associations: Unsociability, uncooperativeness, hostility, emotional instability, reduced alertness, confusion, disorientation

Depression:

• Onset: Relatively rapid onset, associated with mood changes
• Duration of symptoms: Usually short
• Mood, behaviour, emotions: Behaviour is intact, mood and emotions vary between night and day, complaints are worse than what tests show
• Cognitive functioning: Inconsistent: sometimes better, sometimes worse
• Neurologic defects: Absent
• Disabilities: Highlighted by patient
• Depressive symptoms: Present
• Memory impairment: Concentration poor. Patient complains of memory loss of recent and remote events; this follows onset of depressed mood
• Psychiatric history: Often, history of depression
• Answers to questions: “Don’t know” answers
• Performance: Does not try hard, but is more distressed by losses
• Associations: Appetite and sleep disturbances, suicidal thoughts

(Birrer & Vemuri, 2004)

This article was adapted from the upcoming Mental Health Academy CPD course “Treating Depression in Older Adults”. For more information, visit www.mentalhealthacademy.com.au.

References

• Anderson, D. (2001). Treating depression in old age: The reasons to be positive. Age and Ageing, 2001; 30: 13-17.
• Australian Bureau of Statistics. (2008). National Survey of Mental Health and Wellbeing: Summary of results (No. ABS Catalogue No. 4326.0). Canberra: ABS.
• Beekman, A. T. F., de Beurs, E., van Balkom, A. J. L., Deeg, D. J. H., van Dyck, R., & Van Tilburg, W. 2000). Anxiety and Depression in Later Life: Co-Occurrence and Communality of Risk Factors. American Journal of Psychiatry, 157, 89-95.
• Beyondblue. (2009). Depression in older age: A scoping study. Final Report – National ageing Research Institute, September, 2009.
• Birrer, R. B. & Vemuri, S. P. (2004). Depression in later life: A diagnostic and therapeutic challenge. American Family Physician, 15:69(10): 2375-2382. Retrieved on 12 June, 2013, from: http://bit.ly/13UYRML.
• Black Dog Institute (2012). Depression in older people. Black Dog Institute. Retrieved on 17 June, 2013, from: http://bit.ly/1bDl1c5.
• Boswell, E.B. & Stoudemire, A. (1996). Major depression in the primary care setting. American Journal of Medicine. 101, 3S–9S.
• Bryant, C., Jackson, H., & Ames, D. (2009). Depression and anxiety in medically unwell older adults: prevalence and short-term course. International Psychogeriatrics.
• Cummings, S. M. (2002). Predictors of psychological well-being among assisted living residents. Health & Social Work, 27, 293-302.
• Geriatric Mental Health Foundation (GMHF). (n.d.). Depression in late life: Not a natural part of aging. Geriatric Mental Health Foundation. Retrieved on 12 June, 2013, from: http://bit.ly/17crDGu.
• Owens, G. P., Baker, D. G., Kasckow, J., Ciesla, J. A., & Mohamed, S. (2005). Review of assessment and treatment of PTSD among elderly American armed forces veterans. International Journal of Geriatric Psychiatry, 20, 1118-1130.
• Smyer, M.A. & Qualls, S. H. (1999). Aging and mental health. Malden, Massachusetts: Blackwell.
• Snowdon, J. (2001). Late-life depression: What can be done? Australian Prescriber, 2001; 24: 65-57. Retrieved on 12 June, 2013, from: http://bit.ly/19tFWwC.
• U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration (SAMSHA). (2011). Depression and Older Adults: Key Issues. The treatment of depression in older adults. HHS Publication No. SMA-11-4631. Retrieved on 17 June, 2013, from: http://1.usa.gov/1ci4LuU.