Depression in the elderly is common

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from Luke’s Journal 2020 | Ageing Gracefully | Vol.25 No.3

Depression is the most common mental illness in old age. Due to the rise in our ageing population, the significance and impact of depression will also increase as a consequence. Depressive disorders in older people are often under-diagnosed and inadequately managed even after a diagnosis has been made. It is also associated with significant morbidity and high mortality rates. As part of the fallen human race, Christians and non-Christians are all vulnerable to depressive illness in ageing. 

Causative and contributory factors for depression in ageing

• Physical ill health is a major risk factor for depression in old age. This is the single most important factor. The risk increases with both an increase in the number of illnesses as well as the severity of the illness.
• Age-related reduction in brain neuroamines (both serotonergic and dopaminergic).
• Genetic – Older people can have new onset depression or they can have a recurrent episode of depression from a pre-existing illness earlier in life. The genetic component plays a more important role in recurrent depression.
• Elevated homocysteine with associated folate deficiency and/or vitamin B-12 deficiency increases the risk of vascular disease and depression.
• Cerebrovascular lesions – atheromatous and ischaemic changes in the white matter of the brain.
• Neurological disorders (eg. CVA’s, Parkinsonism and Motor Neurone Disease) are particularly important as risk factors for depression.
• Disability has been found to be more significant than the acuity of the illness. For example, disability from congestive cardiac failure would contribute more to depression than an acute myocardial infarction. 
• Chronic pain is another important contributory factor.
• Loss of independence and the guilt of being a burden on family and others.
• Alcohol abuse.
• Prescribed medications – Around two dozen different drugs have been implicated and the elderly who have polypharmacy are more vulnerable.
• Psychosocial factors such as the death of a spouse or other recent losses including pets, living alone, loneliness, poor accommodation and financial stress.
• The “scrap heap phenomena” where an individual feels that they have outlived their usefulness and are now a burden on society (including to their family) can be an important factor. Ageism that is prevalent in society does not help this feeling.
• There is a higher incidence of depression in the residential care population.

Main features of depressive disorder

Core symptoms 

• Depressed mood sustained for at least two weeks
• Loss of interest or pleasure in normal activities
• Decreased energy, increased fatigue

Additional symptoms

• Loss of confidence or self esteem
• Inappropriate and excessive guilt
• Recurrent thoughts of death, suicidal thoughts or behaviour
• Diminished evidence of ability to think or concentrate
• Change in psychomotor activity (agitation or retardation)
• Sleep disturbance 
• Appetite change with corresponding weight change (mainly weight loss in older persons)

If the patient has at least five symptoms (including two core ones) from the list, then by definition he or she has a “major depressive” disorder. If the patient has two to four symptoms (including at least one core symptom) then it would be considered as “minor depression”. 

Psalm 38 is an excellent description of someone suffering from depression:

A Psalm of David, for the memorial offering.

O LORD, rebuke me not in your anger, nor discipline me in your wrath!
For your narrows have sunk into me, and your hand has come down on me.
There is no soundness in my flesh because of your indignation; there is no health in my bones because of my sin.
For my iniquities have gone over my head; like a heavy burden, they are too heavy for me.
My wounds stink and fester because of my foolishness,
I am utterly bowed down and prostrate; all the day I go about mourning.
For my sides are filled with burning, and there is no soundness in my flesh.
I am feeble and crushed; I groan because of the tumult of my heart.
O Lord, all my longing is before you; my sighing is not hidden from you.
My heart throbs; my strength fails me, and the light of my eyes – it also has gone from me.
My friends and companions stand aloof from my plague,
and my nearest kin stand far off.
Those who seek my life clay their snares; those who seek my hurt speak of ruin and meditate treachery all day long.
But I am like a deaf man; I do not hear, like a mute man who does not open his mouth.
I have become like a man who does not hear, and in whose mouth are no rebukes.
But for you, O LORD, do I wait; it is you, O Lord my God, who will answer.
For I said, “Only let them not rejoice over me, who boast against me when my foot slips!”
For I am ready to fall, and my pain is ever before me.
I confess my iniquity; I am sorry for my sin.
But my foes are vigorous, they are mighty, and many are those who hate me wrongfully.
Those who render me evil for good accuse me because I follow after good.
Do not forsake me, O LORD! O my God, be not far from me!
Make haste to help me, O Lord, my salvation!

Under-detection of depression in older people

The clinical presentation of depression in older people can often be vague and non-specific. The elderly are less likely to complain of sadness or to identify depressive feelings. They have been brought up to be more “stoic” and are more likely to complain about physical problems rather than emotional problems when seeing a doctor. Their presentation may minimise depressed mood and focus instead on physical complaints, generalised anxiety, nervousness and irritability. Physical co-morbidities and cognitive deficits may also mask depression in older people. Ageism and the thinking that it is “normal to be old and depressed” could be a factor for underdetection. Social stigma about mental illness including depression is another factor. Christians are especially vulnerable due to the view that is wrongly held by many Christians that depression is due to lack of faith or due to a weak faith (Docetism).

“The elderly are less likely to complain of sadness or to identify depressive feelings.”

Depression and Physical Illness

The interaction between physical illness and depression is complex and bidirectional. 

• Depression is an independent risk factor for numerous medical conditions, including stroke.
• Depressive symptoms add to the disability experienced from physical illness in older people. These symptoms are also associated with physical decline and worsen the prognosis for co-existing physical disorders.
• Elderly people who have a physical disability are three times more likely to develop depression. Disability rather than acuity is the important contributory factor.
• Chronic ill health contributes to a poor prognosis in depressive disorders.
• Sensory impairment (hearing and visual) is associated with depression.
• Depressive symptoms are often masked by physical illness (examples include Parkinsonism, hypothyroidism, chronic pain disorders), resulting in low recognition rates of depression in the elderly. 

Depression and Dementia

There is an interesting but complex relationship between depression and dementia in the elderly.

• Depression can be mistaken for dementia – depression may present as new-onset confusion or increased confusion. It can be difficult for non-psychiatrists to distinguish true dementia from depressive pseudodementia.
• Depression and dementia can co-exist in the same individual.
• Late-onset but recurrent depressive disorder in the elderly could be the precursor to a dementing illness.
• Some of the pharmacological interventions for depression, especially the tricyclic antidepressants, can give rise to cognitive deficits. 

Depression and Psychosis

Sixty percent of women and fifty percent of men with late-onset major depression have psychotic symptoms. Psychotic symptoms are more common in late-onset depressive disorders. Common delusional themes include persecution, guilt, poverty, nihilism and somatic delusions. 

Suicide in the elderly

Elderly people who have depression are a high risk group for suicide. Thirty percent of all suicides in Australia are accounted for by people over the age of 65 years. Risk factors for suicide include elderly men, living alone, social isolation, physical disability, recent bereavement and recent relocation. Symptoms that should cause concern include expressed risk of self-harm, anhedonia, guilty ruminations, weight loss, persistent physical complaints and alcohol abuse. Any deliberate self-harm in the elderly must be treated seriously as they are rarely attention-seeking and there is a high risk of completed suicide or a subsequent completed suicide.

Protective factors

Good physical health and physical fitness are protective factors. Those who are socially active and have well developed coping skills in early life are less vulnerable for depression in older age. Marriage and adequate social supports have also been found to be protective factors. Spirituality and religiosity are also protective factors. As mentioned in the introduction, being a Christian does not make one less vulnerable to depression. However, research has repeatedly shown that the prognosis and recovery from depression is much better in one who has faith. It is spirituality rather than religiosity that is of significance. Having a faith creates hope, which aids recovery. As Christians, we know what, and more importantly Who, we believe in. The importance of taking a spiritual history is pertinent in this regard. In addition, undergoing Saline Process Witness training and being able to sensitively ask about and talk about faith issues would be particularly useful in our clinical work.

“Research has repeatedly shown that the prognosis and recovery from depression is much better in one who has faith.”

Management

Due to the role of multiple factors in late onset depression, the work-up of depression needs an extensive consideration of medical (including medication history), psychological and social issues. As comorbidities play an important role in the elderly, investigations for a first episode of major depression in later life needs to be comprehensive. 

The choice of treatment will be influenced by the type of depression. Major depression (with melancholic and/or psychotic features) requires pharmacological treatment and sometimes Electro-Convulsive Treatment (ECT) with adjunct psychological therapies as the patient begins to recover. Minor depression is often best treated with psychological therapies but there may also be a role for pharmacological interventions. With pharmacological treatments, the dictum with the elderly is to “start low and go slow”. There are no significant differences in speed of onset although older people generally have a longer recovery period. Cognitive Behaviour Therapy (CBT) and Interpersonal Therapy (IPT) have been proven to be useful in the elderly with mild to moderate depression. Other forms of therapy such as brief psychotherapy, problem-solving therapy and life review have also been found to have some benefit.

When to refer to a Specialist Mental Health Service

• When the diagnosis is in doubt
• Severe depression with melancholic/psychotic features
• Depression with suicidal risk
• Medical comorbidities that warrant specialist input
• Failure to respond to first-line therapies

Summary

• Depression is the most common mental health problem in the elderly.
• Depression is often unrecognised and untreated in older people.
• The main risk factor is poor physical health.
• Losses – of loved ones, independence, health, retirement are also important.
• The elderly, especially elderly men, are at high risk group for suicide.
• Depression treatments are effective but require appropriate management strategies to achieve and maintain remission.
• Christians are not immune to depression in ageing.
• Having a faith has been shown to facilitate recovery from depression.

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References:

1. National Ageing Research Institute http://www.nari.net.au/
2. Turner, G et al. Best practice guidelines for the management of frailty: a British Geriatrics Society, Age UK and Royal college of General Practitioners Report. Age and Ageing 2014; 43:744-747. DOI: 10.1093/AGEING/AFU 138
3. Cruz-Jentoft, AJ, et al. Sarcopenia: revised European Consensus on definition and diagnosis. Age and Ageing 2018, 0 :1-16. DOI: 10.1093/ageing/afy 169
4. Malstrom K.M, eta al. SARC-F: A Simple questionnaire to rapidly diagnose sarcopenia. JAMDA 14(2013) 531-532. http://www.jamda.com
5. Exercise in the Age of Evidence Based Medicine: A Clinical Update. Dr Stephen Blair et al http://www.medscape.org/viewarticle/549398 
6. Concannon et al. Exercise in the Older Adult: From the Sedentary Elderly to the Masters Athlete. American Academy of Physical Medicine and Rehabilitation, Vol. 4,833-839, November 2012.
7. https://orthosports.com.au/pdf-download/Exercise-Prescription-(Part-2).pdf