As people age, they experience many changes to their physical health, lifestyles, and circumstances which affect their ability to function. Most of the changes have been identified as risk factors that make an older adult more vulnerable to depression. We can group the changes into three chief categories: changes in physical health or functioning, changes in mental health, and changes in circumstances or social support.

Changes in physical health or functioning

There is a complex relationship between physical illness, disability, and depression. Many of the physical disorders that are common in older adults place them at risk for developing depression. These include: hip fracture, heart attack, congestive heart failure, chronic obstructive pulmonary disease, cancer, arthritis, diabetes, and macular degeneration. Moreover, untreated depression increases the risk of developing physical disorders (such as heart attacks), and it can complicate recovery from physical disorders (SAMHSA, 2011). Further, depression may be precipitated through health problems such as endocrine disorders (e.g., hypothyroidism), vitamin deficiencies, and neurological conditions such as stroke, Alzheimer’s disease, vascular dementia, and Parkinson’s disease.

Physical disorders are also linked to problems in mobility and functioning that can increase an older person’s risk of depression. One-fifth of older adults have physical problems that limit their ability to perform daily activities, and one-third of this population has mobility limitations (SAMHSA, 2011). There is now evidence that depressive disorders and disability are highly correlated (Baldwin, Chiu, Katona, & Graham, 2002). Restricted mobility and the concomitantly greater need for help with self-care can result in a loss of dignity, a sense of being a burden on others, and fears of institutionalisation, all of which carry elevated risk for depression (Black Dog Institute, 2012).

As an example, the depression rate in older people receiving a high level of support at home is approximately twice as high as less frail community – dwelling older people. For older people in settings where the disability level is uniformly high (such as nursing homes and hospitals), the risk of developing depression is correspondingly higher (Beyondblue, 2009).

Also, sensory and functional impairments affect older adults disproportionately, with one-third of people 65 years and older having hearing problems and one-fifth having vision problems that cannot be corrected by glasses or contact lenses alone. Problems with seeing and hearing often go hand in hand with increased social isolation and decreased ability to engage in cherished activities, such as work, hobbies, social functioning, reading, listening to music, and other pleasurable activities. Thus, losing the opportunity to engage these can be a risk factor for depression (SAMHSA, 2011).

Changes in mental health

One of the biggest risk factors for developing later life depression lies in the factor of mental health changes. The older adults who are most at risk are those who have either experienced a depressive episode before they were 60, or who have an immediate relative with major depression. Too, minor depression and significant depressive symptoms put seniors at risk for developing major depression, and also for physical health problems, such as diabetes.

Further, a comprehensive review of risk factors has shown that:

• There is considerable overlap between the risk profile for anxiety and that of depression;
• Risk factors for having a later-life anxiety disorder include previously having a psychological disorder, having poor coping strategies, stressful life events, and being female; (Vink, Aartsen, & Schoevers, 2008).
• Biological factors (including chronic health conditions, cognitive impairment, and functional limitations) may be more important in predicting depression than anxiety.

In terms of cognitive impairment specifically, we can note that depression frequently co-occurs with Alzheimer’s disease and other types of dementia. And it is common for depression to co-occur in older adults with other mental disorders, such as schizophrenia or anxiety disorders. Those older adults who are struggling with alcohol abuse, misuse of medications, or abuse of illicit substances are particularly at risk for developing depression. Even a moderate amount of alcohol – say, as little as two drinks a night – can place an older person at risk for depression and other poor health outcomes.

Moreover, alcohol creates problems for the drinker in that it interacts with many prescribed medications, especially pain, anxiety, and sleep medications. Side effects of some medications can make some types of depression worse (SAMHSA, 2011). Finally in this category, a community-based study in the Netherlands found that having an external locus of control was the only common risk factor for pure depression and pure anxiety in later life, while family history was associated with concurrent anxiety and depression (Beekman et al, 2000).

Changes in circumstances or social support

Many people confront social isolation and loneliness in older age. This can be as a result of living alone, through a lack of family ties, reduced connection with their culture of origin, or an inability (frequently through lack of transport) to participate in the local community. Too, for many, old age is a period of life in which the losses come thick and heavy. As one woman in her seventies said, she had arrived at the stage of life where there were many funerals, and not so many weddings. Losses of long-term partners, siblings, friends, and pets are incurred, along with loss of independence (including the driver’s licence), health, home, and lifestyle. Some people cope well with these losses, but others go into depression (Black Dog Institute, 2012). We look at the ramifications of both changed financial resources and also social support.

Issues with income or financial resources

Poverty is a risk factor for a number of health conditions in older adults, and one of them is depression. Sadly, although Australia is regarded as an affluent country, a recent report measuring poverty found that the national average of people living below the poverty line (the 60 percent line, which identifies those with less after-tax income than the equivalent of 60 percent of the median family income) is 20 percent. When people 65 years and older were measured, 34.9 percent of all over-65s were living below the poverty line, as were a whopping 55.8 percent of single people over 65 (Davidson, Dorsch, & Gissane, 2012).

Inadequate income may be a lifelong experience, or possibly it may follow the death of a spouse or dwindling income after the loss of a job or retirement. Although retirement is a time to celebrate successes and accomplishments, those who do not have sufficient funds feel anything but celebratory. In order to continue to feel engaged and connected, some older adults choose to keep working (full or part time), which helps prevent both financial insecurity and the tendency to move toward depression. Other elderly adults volunteer, which may help ward off depression, but does not improve financial security.

Change and loss in social support

As noted above, the cumulative and frequent losses of old age normally mean more experiences of grief and bereavement. The loss of family members and friends leaves significant and long-lasting impact on those left behind. The support of caregivers, friends, and family can be helpful at such difficult times, as strong social support networks are solidly related to good physical and mental health. Good social support not only reduces the risk of developing depression, but also means that those who have it are less likely to commit suicide (SAMHSA, 2011).

The challenge for older adults, however, is to maintain the social contacts and activities which will keep the social support networks alive. While it’s natural for activity levels to decrease with age, the total number of people in the social network typically remains steady. As people age, their networks include increasing numbers of younger people and fewer older friends and neighbours, so one challenge might to keep relating to those in the network, even if they are very much younger.

Another challenge for some older adults may be simply getting to the places where social activities are occurring. Loss of transport options, such as the personal car when driving is no longer appropriate, and loss of mobility, especially for those with disabilities, may adversely affect some seniors’ capacity for continuing to engage communally and socially in ways that help to prevent depression. Moreover, those recently widowed may find it hard to re-engage social scenes or activities as a person suddenly without a partner. The resultant sense of awkwardness may keep some at home and unsupported (SAMHSA, 2011).

When older adults experience bereavement, it is natural to have a period of grieving, but for some people, that may lead to a prolonged period of sadness. Such losses may also induce feelings of helplessness or anger. Other losses, such as those of one’s home, financial security, independence, mobility, or other sources of self-esteem, may lead to persistent sorrow, loss of pleasure in life, a sense of emptiness and dwelling on the past, apathy regarding the future, and frustration or irritability (Snowdon, 2001).

Older adults with low levels of social support, especially where there is a history of suicide attempts, should be carefully evaluated for thoughts of suicide, and all precautions taken, even when the person’s depression is deemed mild (SAMHSA, 2011). The prevention of suicide in the older person is, of course, the principal reason to be able to recognise the symptoms of depression and/or suicidality.

Why is it important to treat depression in elderly people?

Because depression in older adults is so widely unrecognised, it can be difficult to comprehend just how forcefully conditions such as deteriorating health, a sense of isolation and hopelessness, and the challenge of adjusting to new life circumstances can create a “perfect storm” pushing an already-depressed person over the edge to suicide. When depression is not treated in elderly white men (in the United States), the suicide rate is six times the national average.

Unbelievably, 75 percent of those men will have been seen by a doctor within several months of their deaths: clearly a doctor who did not truly “see” them! Proper treatment can prevent suicide, but because it so often goes unrecognised, the (U.S.) National Institute of Mental Health considers depression in people age 65 and older to be a major public health problem (Helpguide.org, n.d.).

Moreover, the following facts alert us to the importance of treating depression in elderly people, not only for their sake or that of their families, but for that of the whole community. Here is how depression affects the quality of life for the elderly in ways apart from suicide:

• Depression significantly increases the likelihood of death from physical illnesses
• As noted above, depression can make impairment from a medical disorder worse, and/or impede improvement (while the converse is also true: namely, that psychological treatment can improve the success rate for a number of medical conditions)
• Without treatment for depression, patients are less likely to be able to follow necessary treatment regimens or participate successfully in any rehabilitation program
• Healthcare costs of older adults with depression are about 50 percent higher than those of their non-depressed peers
• The depressed elderly are more likely to rate their health as only fair or poor, to turn up at the emergency department, and to have more doctor visits than non-depressed seniors
• Depression generally lasts longer in seniors
• Treating depression results in better outcomes for anxiety disorders, which commonly co-occur with depression
• Treating depression can help people resolve substance abuse disorders (including here both alcohol and prescription drugs) that have resulted from self-medication for symptoms (Helpguide.org, n.d.)

The same range of treatment methods is available to treat depressed seniors as those that can be used with younger people with depression, but the treatments may be applied differently due to complicating factors in the typical elderly person’s situation.

This article was adapted from the upcoming “Treating Depression in Older Adults” Mental Health Academy CPD course. This course focuses on the needs of those over 65 who are at risk for depression.

References

• Baldwin, R., Chiu, E., Katona, C., & Graham, N. (2002). Guidelines on depression in older people: Practising the evidence. London: Martin Dunitz Ltd.
• 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.
• Black Dog Institute (2012). Depression in older people. Black Dog Institute. Retrieved on 17 June, 2013, from: hyperlink.
• Davidson, P., Dorsch, P., & Gissane, H. Poverty in Australia. (2012). Poverty and Inequality in Australia reports. Australian Council of Social Service. Retrieved on 18 June, 2013, from: hyperlink.
• Helpguide.org. (n.d.). USVH Disease of the Week #2: Depression in older adults. Helpguide.org. Retrieved on 18 June, 2013, from: hyperlink.
• Snowdon, J. (2001). Late-life depression: What can be done? Australian Prescriber, 2001; 24: 65-57. Retrieved on 12 June, 2013, from: hyperlink.
• 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: hyperlink.
• Vink, D., Aartsen, M. J., & Schoevers, R. A. (2008). Risk factors for anxiety and depression in the elderly: A review. Journal of Affective Disorders, 106, 29-44.