Depression in the Elderly, Recognizing the Signs and Symptoms

September 26th, 2014

Depression can be a debilitating illness for anyone, regardless of age. Elderly depression often goes unnoticed because many of its signs and symptoms — which include irritability, fatigue, and a lack of interest in activities — are assumed to be normal aspects of aging.

Certainly, the multiple losses that seniors frequently face, such as the deaths of spouses or friends and declining health and function, can make them more prone to depression. But persistent low mood is not an inevitability among seniors, even with these difficult late-life transitions. In truth, that misperception — combined with the fact that seniors are less likely than younger people to receive mental health services — often leads to cases of untreated depression in seniors, despite depression itself being a treatable disease.

Studies suggest that 14 to 20 percent of the elderly experience depressive symptoms, with even higher rates of depression among hospitalized seniors (12 to 45 percent) and those who live in long-term care facilities (about 40 percent). However, the pervasiveness of depressive symptoms among older adults does not mean that they should ever be minimized. On the contrary, any senior experiencing them should receive a thorough medical evaluation. The US Department of Health and Human Services reports that there are several distinct types of depression affecting older adults, ranging from major depression, which is characterized by the presence of five or more depressive symptoms that persist for two weeks, to dysthymia, a low-grade, chronic depressive state that is present for at least two years.

As a healthcare provider, framing depression as a treatable medical condition can go a long way in helping your senior patient understand the disease and have the opportunity to improve his quality of life. As a care professional in a day or long-term care setting, knowing the difference between normal bouts of grief or sadness and clinical depression can help you take the right steps to get seniors the support they need. Here are some common reasons depression in older adults might be overlooked, and some ways you can address barriers to diagnosing and treating depression in seniors.

Depression in Seniors: The Telltale Signs

While a senior may have the usual symptoms of depression that can be found in a person of any age, including social withdrawal, trouble concentrating, and changes in appetite, there are also a number of symptoms that are unique to elderly depression, says Alan Manevitz, MD, family psychiatrist in New York City. Seniors with clinical depression are more apt than younger individuals to exhibit memory problems, vague complaints of pain, difficulty falling asleep or staying asleep, and irritability rather than sadness. In addition, their behaviors might be more demanding or help-seeking, and they might experience delusions or hallucinations.

“If any of these things are going on, as part of the differential diagnosis, you want to think about depression,” says Manevitz. “Seniors can have depression without sadness. They might not claim to feel sad, but they may have aggravated aches and pains or low motivation.”

Manevitz suggests that healthcare professionals and care providers pay attention to whether a senior is neglecting her personal care — for example, forgetting to take her medicines, or not showering or practicing oral hygiene — as this may indicate that she is depressed. Another common way elderly depression presents itself is through anhedonia, an inability to experience joy from activities that she once loved. But because many illnesses and medication side effects could also be the cause of these behaviors, it is critical that a senior receive a thorough screening assessment as soon as possible when depression is suspected. One depression screening per year is free of cost to seniors covered under Medicare.

“Depression and related apathetic behaviors can be mistaken for dementia,” says Heather Smith, PhD, lead psychologist at Milwaukee VA Medical Center. “What’s really important is that a psychologist or neuropsychologist tease out what’s going on by assessing for cognitive impairment and mood symptoms.”

“If you don’t see cognitive impairment but rather issues with attention, that would give you a clue that it’s depression, not dementia,” she adds.

Smith suggests that, when possible, all seniors get established with geriatric-trained primary care providers. Because of their familiarity with issues facing older adults, such professionals may be more equipped to spot depressive signs and symptoms early on and refer the senior to the right mental health specialist.

Challenges to Diagnosing Depression and Risks of Untreated Depression in Seniors

Given that many seniors are dealing with multiple bereavements, clinicians have long struggled with how to distinguish clinical depression from normal bouts of grief and sadness. Historically, before the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was released in 2013, there was a “bereavement exclusion,” which prevented the diagnosis of depression within the first two months following the death of a loved one. Now, it is believed that grief and depression are less entangled than previously thought; unlike in grief, which comes in waves and is mixed with positive feelings about the deceased, in depression, negative moods tend to be severe and prolonged.

“Roughly speaking, if someone meets all criteria of depression, the fact that they’ve lost a loved one shouldn’t cancel that out,” says Bob Knight, PhD, professor of gerontology and psychology at the USC Davis School of Gerontology/Andrus Gerontology Center.

But it’s not just the loss of a loved one that could lead a senior to have depressed feelings. He might have lost the ability to drive or live independently, or he may be aware that is he experiencing memory loss or cannot focus the way he used to. The older a senior becomes, the more likely it is that he will have experienced many of these difficult losses.

“If someone knows they used to be able to rattle off the names of all the presidents and now they can’t, that can be very hard on someone emotionally,” says Barbara Distler, licensed clinical psychologist with a private practice in New York City. “When you’re aware that you’re not as cognitively competent as you used to be or you have to be more dependent on others, it can lead to depressed feelings or intensify ones that are already there.”

Nevertheless, seniors with evidence of mental disorders are less likely to receive mental health services, according to the American Psychological Association. And in the instances where they do, they are less likely to receive specialized care from a mental health professional. If an older adult downplays, ignores, or hides her feelings, or blames herself for feeling blue, a healthcare provider will face additional barriers to diagnosing her depression and coordinating the appropriate medical care. Unfortunately, depression still carries a social stigma that other medical conditions don’t, which can contribute to seniors’ misunderstandings about the disease and the often devastating effects of not treating it.

“The elderly frequently think that being depressed is a personal failure or personality flaw,” says Cathy Wilson, LCSW, program coordinator and clinical social worker for the Geriatric Psychiatry Outreach Program at Wake Forest Baptist Medical Center. “The lack of education and awareness of depression among the elderly can be a barrier to treatment.”

Untreated elderly depression can be very costly. It has been proven to increase older adults’ risk of cognitive decline, worsen their physical health, and prevent them from adhering to medication regimens required to manage chronic conditions. Of course, seniors also face the same dangers as younger people with the disease, including feelings of helplessness and hopelessness and thoughts of suicide. Older adults with depression have higher mortality rates, whether due to a worsening of physical health or suicide.

Furthermore, early, aggressive treatment of elderly depression has been emphasized by mental health professionals in recent years because of its known association with dementia. In a 2013 study published in the British Journal of Psychiatry, depressed older adults were significantly more likely to develop vascular dementia (caused by conditions that block bloodflow to the brain) and Alzheimer’s disease than non-depressed seniors.

Treatments and Outcomes

There is a considerable body of research that shows that seniors with depression often respond favorably to psychological interventions. Psychotherapy services and antidepressant medications, either used individually or in conjunction depending on the severity and duration of the depression, can be effective in reducing their depressive symptoms and in improving their functioning.

Since the beginning of 2014, mental health services have been a covered benefit under Medicare in the same way that other medical services are. Eighty percent of the Medicare-approved amount for mental health visits is paid by Medicare, and a senior will be responsible for the other 20 percent, unless she has a co-insurance that can pick up the rest.

Once a senior is treated, a number of other factors will influence how well she copes with the disease. These include:

  • Premorbid resilience, or how effectively she coped throughout her life before the onset of depression;
  • Effective pain management for any physical medical conditions;
  • Her degree of cognitive impairment (with dementia, there is a point at which cognitive-behavioral therapy is no longer effective); and
  • Her level of social support and engagement in social activities, which has been shown to relieve depressive symptoms in the elderly.

From a behavioral perspective, maintaining connections with other people is crucial to ameliorating the isolation that depressed seniors experience. Manevitz tells his patients to try to find five people in their lives whom they can rely on, which makes them less vulnerable to losses, and volunteer if they are physically able. They might also join a book or movie club. Some lifestyle changes that can help lift the cloud of depression are avoiding alcohol, making sure to get enough sleep, and exercising regularly, Manevitz says.

Reluctance on the part of an older adult’s healthcare providers, caregivers, or family members to talk to her about depression can sometimes delay diagnosis and treatment. As such, her care team should be prepared to bring the subject up more than once. “You don’t want to get into a position of arguing with [older adults], but help them understand that pessimism and not wanting help is part of the depression,” says Knight. “My impression has been that if depression is explained and the treatments are explained in jargon-free language, older adults are no more reluctant to receive help than younger people.”