What is Late-Life Depression?
Depression in older adults is a serious health issue that’s linked with other health problems, affecting how they function, using more health care resources, and resulting in a higher risk of death, including suicide. This type of depression, which appears for the first time in people aged 65 and older without any previous history, is known as late-life depression. It’s marked by feelings of sadness due to various life events like losing a loved one, not reaching goals, or issues in romantic relationships. Major depression is very similar, but the feelings of sadness are more intense and last longer.
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), major depression is defined by feelings of sadness or a loss of enjoyment in usual activities, along with five or more of these symptoms: changes in appetite or weight (5% of body weight), sleep, energy, concentration, and physical movement, inappropriate feelings of guilt or worthlessness, and recurring thoughts of death or suicide. These symptoms also interfere with social, work, and other areas of life and should have been present for the last two weeks.
Depression later in life often goes undiagnosed and isn’t treated properly. It’s a serious, life-threatening condition that affects 1 in 5 people at some point in their life. When depression happens in older age, it can be hard to tell it apart from dementia, as they can have similar symptoms, especially when depression affects thinking and is described as ‘pseudodementia.’
What Causes Late-Life Depression?
Depression in older age is brought on by a number of factors including, biology, psychology, social conditions, spiritual beliefs, and personality traits.
Biological factors come into play with depression, for example, serotonin, a neurotransmitter is commonly associated with depression. There can also be a misbalance of certain neurohormonal pathways, such as the adrenal gland’s pathway. Other conditions like heart disorders, diabetes, dementia, and other mental disorders can also cause depression to become more common in older people.
The chance of getting depression from inherited genes is less likely in the elderly compared to those with early depression. However, certain genetic markers have been observed in some patients with late-onset depression.
In terms of psychological and social factors, research shows that individuals who experienced neglect or emotional abuse in childhood are more prone to develop depression later in life. Seniors with depression are also more likely to be affected by negative life events due to cognitive distortions. A lack of activity in old age, often due to retirement can also contribute to depression. This lack of activity can also lead to the development of metabolic syndrome, and potentially increase the risk of depression.
With regards to spiritual and personality factors, older individuals who are religious tend to be less likely to develop depression. Certain personality traits can predispose someone for depression early in life. Research shows that individuals with anxious-avoidant and dependent personality disorders are more likely to develop depression later in life, especially when experiencing a significant loss or event.
Risk Factors and Frequency for Late-Life Depression
Depression is not a part of normal aging. It affects between 30% and 45% of older adults. It’s also common in individuals visiting primary care clinics, with about 6% to 9% being affected by Major Depressive Disorder (MDD). However, many older adults with MDD are not diagnosed properly. The rate of depression rises to 10% to 12% among those admitted to acute care settings, and 12% to 14% of nursing home residents meet the criteria for MDD.
- Depression is not a part of normal aging process.
- It’s found in 30% to 45% of older adults.
- In primary care clinic visitors, 6% to 9% suffer from Major Depressive Disorder (MDD).
- Many older adults with MDD are not diagnosed properly.
- The prevalence of depression is 10% to 12% in acute care settings.
- About 12% to 14% of nursing home residents meet the criteria for MDD.
Signs and Symptoms of Late-Life Depression
Diagnosing depression in elderly people, or geriatric depression, can be a challenge. It often starts by collecting a detailed history of the person’s health and feelings. Symptoms are somewhat different from what younger people experience and may include unusual body aches and pains, difficulty sleeping, and decreased thinking abilities. Because of these symptoms, it can be tough to identify geriatric depression.
The next steps involve a comprehensive mental health exam and cognitive tests to determine if dementia could be causing the symptoms. During the mental health exam, the health professional will look for signs like slowed speech and movements. In severe cases, the person may express feelings of guilt or even thoughts of self-harm. It’s crucial to ask about such thoughts, as well as any access to harmful means like firearms. Neuropsychological tests may be necessary for some cases, and a physical exam can help rule out any other medical or neurological issues contributing to the symptoms.
There are also specific assessment tools used for older adults. One of the commonly used scales is the Patient Health Questionnaire 2 (PHQ-2). Another is the Geriatric Depression Scale, a self-administered 30-item questionnaire that asks about mood, energy level, loss of interest in fun activities, feelings of guilt, hopelessness, worthlessness, and thoughts of self-harm. Each question is scored as 0 or 1 point. The total points are added up, determining if the person’s feelings fall in the normal (0 to 9 points), mild depression (10 to 19 points), or severe depression (20 to 30 points) range.
Testing for Late-Life Depression
Depression is a complex illness that is increasingly causing sickness and death. Before thinking about how to handle depression, it’s important to look for specific causes that can be treated or reversed. To do this, you’ll need to undergo some lab tests before being diagnosed with major depressive disorder.
These tests usually include routine checks like a complete blood count (CBC) and comprehensive metabolic panel (CMP), a urine drug test, and checks for levels of vitamin B12, folate, and thyroid-stimulating hormone (TSH). Depending on your symptoms and medical history, you might also be tested for syphilis and HIV. You may also need imaging studies like a CT scan or MRI scan of your brain.
Treatment Options for Late-Life Depression
Elderly people suffering from depression alongside dementia or other cognitive disorders can face challenges in their treatment. This is because these conditions can affect their ability to make informed consent for treatments. Therefore, it’s crucial to thoroughly evaluate their capacity to make decisions before starting any treatment.
Depression in older adults can be treated in several ways. Mild depression is often treated with psychotherapy, including cognitive behavior therapy and interpersonal therapy. For more severe cases, medication is typically used. Chronic depression often requires a combination of medication and psychotherapy for effective treatment.
Medication, or pharmacotherapy, is used to manage the malfunctioning brain systems often present in major depression. One such system that’s usually targeted is the serotonergic, or serotonin, system. Due to changes in metabolism, medicine absorption, and medicine distribution that occur with age, starting with low doses and increasing slowly is usually recommended for elderly patients. However, the effectiveness of using medication for depression ranges and can sometimes be challenging in elderly patients.
Different categories of medication have shown promising results in treating depression:
1) Selective Serotonin Reuptake Inhibitors (SSRIs):
These are often the first choice of medication due to their safety and ease of use in elderly patients. It’s important to note that it may take 4-6 weeks for SSRIs to take full effect. Some side effects to watch out for include low sodium levels, restlessness, loss of appetite, and slow heart rate.
2) Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs):
These medications are usually the second choice and can be potentially useful for patients with accompanying pain. However, they can cause high blood pressure and serotonin syndrome (a serious condition that can occur with high levels of serotonin).
3) Atypical Antidepressants:
This category includes bupropion and mirtazapine. Mirtazapine can be particularly useful in patients with insomnia, loss of appetite, and restlessness. Bupropion can help with symptoms of lethargy or fatigue but can lower the seizure threshold.
4) Tricyclic Antidepressants (TCAs):
Although TCAs are effective, they come with many side effects due to their interaction with various receptors. They are more typically used when other treatments have failed.
5) Monoamine Oxidase Inhibitors (MAOIs):
These are less commonly used because they need specific dietary restrictions to prevent serious side effects, although they have shown benefits in atypical depression cases.
Aside from medication, electroconvulsive therapy (ECT) can be used for depression that hasn’t responded to psychotherapy or pharmacotherapy. Other brain stimulation techniques like repetitive transcranial magnetic stimulation (rTMS), deep brain stimulation (DBS), and vagus nerve stimulation (VNS) can also be utilized, but more research is needed in the elderly population.
Lastly, healthy lifestyle habits like a balanced diet, regular exercise, and meditation can help with the prevention and treatment of mild depression in older adults. A diet rich in omega-3 fatty acids and fish oil has been found to improve depression symptoms.
What else can Late-Life Depression be?
When an older adult presents with symptoms that suggest cognitive decline, it can sometimes be difficult to determine if these are signs of dementia or late-onset depression. Mental evaluations and cognitive tests are necessary to make the correct diagnosis.
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) outlines other potential diagnoses that share some symptoms with depression:
- Manic episodes characterized by mixed feelings or irritability – sometimes when a person seems extremely angry or irritable, it might seem like a manic episode rather than depression.
- A mood disorder due to another health problem – depression may be ruled out if it’s clear that the mood changes are directly caused by a specific health condition such as multiple sclerosis, stroke, or hypothyroidism.
Furthermore, the cause of the depressive symptoms can sometimes be traced back to the use of certain medications or substances. Once these are discontinued, the symptoms usually go away. Time of sadness that doesn’t meet the full criteria for depression; these are normal human experiences and should not be confused with depression unless they’re severe and persistent.
What to expect with Late-Life Depression
Depression was once thought to be a temporary condition that patients could completely recover from. People were cared for just when they felt depressed, and there was no long-term treatment plan. However, we now know that without treatment, depression often becomes a long-lasting and recurring illness that can severely impact a person’s ability to function daily. It’s worth noting that neither diabetes, asthma, heart disease, nor arthritis impact a person’s overall health as much as depression does.
Simultaneously, having depression in addition to another chronic illness can further worsen a person’s health status. If depression goes untreated, it commonly recurs, which makes proper treatment extremely important.
Current guidelines advise that antidepressant medications should be continued for 4 to 6 months after a patient starts feeling better to avoid a relapse. Unfortunately, even then, about half of patients experience a relapse within one year and most within two years. It’s also reported that 50 to 85% of those who’ve experienced one episode of depression will have a second episode. Those who’ve had a second episode are 80 to 90% likely to have a third. Nearly all individuals with severe depression are likely to experience a recurrence.
Reports suggest that chronic depression tends to run in families and is harder to treat than sporadic episodes of major depression. It also affects daily functioning more significantly. Factors associated with a poorer prognosis can be divided into patient factors and illness factors.
Let’s look at the patient factors:
1. A family history of mood disorders
2. Pre-existing mild chronic depression
3. Concurrent anxiety disorder
4. Concurrent substance abuse
5. Low levels of the hormone, T3
Now, let’s review the illness factors:
1. History of a previous depressive episode
2. A longer and more severe initial episode of depression
3. Remaining mildly depressed after an episode
4. Having the first episode after the age of 60
5. Depression that follows a seasonal pattern
Possible Complications When Diagnosed with Late-Life Depression
Depression is a serious condition that can cause real struggles in a person’s life. It gets even more complicated when depression occurs with another mental health disorder, known as co-morbidity. This dual disorder often results in longer, more severe episodes of depression, an increased risk of the depression becoming chronic, disruption to normal life and activities, hospitalization, and suicidal attempts. Co-morbidity also affects the progress of the depressive disorder and plays an essential role in assessing and treating a person with depression.
Some common mental health disorders that often accompany depression include phobias, anxiety disorders, post-traumatic stress disorder, agoraphobia, panic disorder, substance-use disorders, alcohol dependence, and other drug dependencies. Another significant challenge that comes with depression is the potential for thoughts of suicide. This risk becomes especially high in elderly individuals, with 25% of all suicides occurring among the elderly. The risk further increases among elderly white males and those who are isolated.
Predictors of suicide risk include:
- Old age
- Being male and separated, widowed, isolated or divorced
- Having a debilitating illness
- Substance abuse
In addition to the mental health implications, depression raises the risk of medical complications in elderly individuals. These complications often manifest as:
- Cardiovascular disorders
- Diabetes
- Dementia
- Stroke
- Stress ulcers
- Potential development of cancer
Preventing Late-Life Depression
As the population of older adults increases, so too does the occurrence of mental health issues in later life. These conditions, including dementia, delirium, and depression in old age, not only disable those affected by them, but they also decrease their quality of life. This has a knock-on effect, placing more stress on family members and those tasked with their care. Two conditions in particular, dementia and major depression, are responsible for a significant proportion of all disability-related ‘life years’ experienced by older individuals.
As such, the world’s aging population presents important considerations for societal, economic, and health policies. Depression is often connected to many physical illnesses, influencing their development and how they progress. Therefore, it’s crucial that patients and their caregivers are aware of the symptoms and signals of depression. Early awareness and treatment can prevent these conditions from worsening and endangering the lives of those affected.
