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Depression Later In Life
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ACT is a non-profit group, founded in 1999, to support continuing education and research in cognitive therapy. It acts as a resource in cognitive therapy for professionals and the public at large, and works toward identification and certification of clinicians skilled in cognitive therapy. The site includes a section for consumers.
AAGP is a national association which promotes and educates about the mental health and well-being of older people. The site includes a section for patients and caregivers that includes news, facts, tools and expert information for adults coping with mental health issues and aging.
AAS promotes research, training, and public awareness programming, and serves as a national clearinghouse for information about suicide.
AFSP is a not-for-profit organization dedicated to understanding and preventing suicide through research and education, and to reaching out to people with mood disorders and those impacted by suicide.
This is the consumer site for the American Psychological Association. APA is a medical specialty society whose more than 35,000 member physicians around the world work together to ensure humane care and effective treatment for all persons with mental disorders. The site includes information on mental disorders as well as a "Locate a Psychiatrist" section.
SAMHSA helps users of mental health services, their families, the general public, policymakers, and the media by connecting them with appropriate federal, state, and local resources.
DBSA, a non-profit organization, is a patient-directed organization focusing on depression and bipolar disorder. The organization fosters an understanding about the impact and management of these illnesses by providing up-to-date, scientifically based tools and information written in language the general public can understand. The DBSA supports research that promotes timely diagnosis, develops more effective and tolerable treatments, and seeks to discover a cure.
Families for Depression Awareness helps families recognize and cope with depressive disorders to get people well, reduce the stigma associated with depressive disorders, and prevent suicides.
The National Alliance on Mental Illness (NAMI) is a grassroots mental health organization dedicated to improving the lives of individuals and families affected by serious mental illnesses. Founded in 1979, NAMI has 50 state organizations and over 1,100 local affiliates engaged in research, education, support and advocacy.
NIMH is the lead federal government agency for research on mental and behavioral disorders. It is one of 27 components of the National Institutes of Health, the U.S. government's principal biomedical and behavioral research agency.
NIA is one of 27 components of the National Institutes of Health, the U.S. government's principal biomedical and behavioral research agency. Their mission is to lead broad scientific efforts to understand the nature of aging and to extend the healthy, active years of life.
Mental Health America (formerly known as the National Mental Health Association) is a nonprofit organization dedicated to helping people live mentally healthier lives. They work with more than 320 affiliates to promote mental wellness.
The National Suicide Prevention Lifeline offers 24-hour, toll-free suicide prevention services at 1-800-273-TALK (8255). Trained staff route callers to the closest possible local mental health provider.
Other episodes of Second Opinion also explore topics that are relevant to depression in older adults. They include: Depression (Episode 201) Suicide (Episode 406)
Episode number: 
509

Depression in the geriatric population presents different challenges than in younger populations.  Diagnosis and treatment can be difficult, but the management of depression in later life is critical to good physical health.

If you or someone you know is in a crisis and needs help right away, call this toll-free number, available 24 hours a day, every day: 1-800-273-TALK (8255). You'll reach the National Suicide Prevention Lifeline, a service available to anyone.  All calls are confidential.

Betty Davis said it best – "Getting old ain't for sissies."  If you live long enough, here is what will most likely happen.  You'll experience at least one serious illness if not multiple chronic ones.  You will see friends and loved ones get sick and die.  You will be forced to redefine your sense of purpose in life, perhaps more than once.  You will grieve over both physical and personal losses.  If you are lucky, normal feelings of grief and sadness will be temporary but this may not always be the case.  Sometimes, those negative feelings may deepen into a persistent state and interfere with your ability to function.  In fact, stressful life experiences are one of the most common triggers for a serious medical condition called clinical depression.

Depression Statistics

Depression is one of the most common mental disorders experienced by elders.  Of the 35 million Americans age 65 or older, about 2 million suffer from full-blown depression and another 5 million suffer from less severe forms of the illness.1  Of most concern, while people 65 and older account for 12 percent of the population, they represent 16 percent to 25 percent of suicides. 2   

Recognizing Depression in the Elderly

Medical professionals are adamant that depression is not a normal or a necessary part of aging.  They also stress that it is very treatable, no matter what your age. 

The snag is that depression is often harder to recognize in the elderly than in their younger counterparts:

  • Doctors and patients may both subscribe to a policy of "Don't ask.  Don't tell."  Older patients may mistakenly believe that depression is a sign of personal weakness or that they can will it away.   If their insurance plan doesn't cover mental illnesses to the same extent that it covers other illnesses, they may avoid the discussion because of cost.  For their part, doctors may be so focused on solving the patient's long list of physical ailments that they miss depression.  
  • Despite evidence to the contrary, patients, caregivers and even health professionals may assume that persistent depression is an acceptable response to the challenges of aging with its illnesses and social and financial hardships.  Quite simply, their functional expectations may be set too low.3  
  • Cognitive deterioration from other causes may mask the signs of depression.   For instance, research has shown that dementia and depression often co-exist but dementia patients can not describe how they feel.  Other common medical conditions that can cause cognitive impairment include endocrine disorders, obstructive sleep apnea, and vitamin B12 deficiency.4
  • Symptoms in older adults may be atypical.  While they may exhibit classic symptoms like sadness, hopelessness, loss of interest in normally pleasurable activities, or extremely prolonged grief after a loss, they're just as likely to become irritable and agitated.  They may become confused, have memory problems, or develop exaggerated fears and fixations with physical ailments.
  • Elderly adults who live alone may have little social interation with people who know them well enough to notice changes in their personalities.  

If left untreated, depression can last months or even years.  Not only does this consign the individual to unnecessary psychic misery, but it makes all other medical problems more difficult to treat.  Depression doubles their risk of developing cardiac disease, reduces their ability to rehabilitate, and increases their risk of death from illness. Studies of nursing home patients with physical illnesses have confirmed that the presence of depression substantially increased the likelihood of death from those illnesses. Depression also has been associated with increased risk of death following a heart attack.5

Causes of Depression in Later Life

Researchers are still investigating the whys of depression.  What they all agree on is there is no single cause.  It can be related to one or a combination of factors: 

  • A neurochemical disorder, which can be mild or severe, is often responsible for most severe cases of depression, usually marked by major changes in personality and detachment from reality.  Neurochemical imbalance might be especially suspect when the person's circumstances do not seem to warrant sadness or anxiety.
  • Depression often co-exists with other illnesses.  Such illnesses may precede the depression, cause it, and/or be a consequence of it.6
    • Some medical conditions, like Parkinson's disease, endocrine disorders and vascular disease, can directly affect the body's chemical systems and parts of the brain that govern mood. 
    • Being diagnosed with a life-threatening disease or living with the limitations of a chronic condition or chronic pain can put you at increased risk for serious depression.
    • People with anxiety disorders (such as post-traumatic stress disorder, obsessive-compulsive disorder and panic disorder) and cognitive disorders (such as dementia) are more likely to experience depression. 
    • Certain medical procedures (such as bypass surgery) may trigger depression.
    • Certain medications can trigger or intensify depression.
  • Some types of depression tend to run in families. However, depression can occur in people without family histories of depression as well.7  Genetics research indicates that risk for depression results from the influence of multiple genes acting together with environmental or other factors.8
     
  • Events such as the death of a loved one, divorce, financial strains, history of trauma, moving to a new location or significant loss can contribute to the onset of clinical depression.
  • Stressful life experiences are a common trigger.  These include:
    • A recent bereavement (including the loss of a pet)
    • Leaving the workforce
    • Moving out of a family home
    • Living alone
    • A dwindling social life
    • Conflicts with family or friends
    • Financial problem
  • Excess use of alcohol may contribute to depression or be a symptom of it.
  • Low self-esteem, feeling out of control and fear of death or dying predispose people to depression.   

1 National Institutes of Health.
2 Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.
3 Meyers BS. Geriatric Psychotic Depression, Clin Ger 1997;5:16-20.  
4 Guy G. Potter, PhD and David C. Steffens, MD, MHS, Depression and Cognitive Impairment in Older Adults, Psychiatric Times, November 1, 2007.
5 Depressionin the Elderly.  The Cleveland Clinic
6 National Institute of Mental Health
7 Tsuang MT, Faraone SV. The genetics of mood disorders. Baltimore, MD: Johns Hopkins University Press, 1990.
8 Tsuang MT, Bar JL, Stone WS, Faraone SV. Gene-environment interactions in mental disorders. World Psychiatry, 2004 June; 3(2): 73-83.

Quick Facts

  • Depression is one of the most common mental disorders experienced by elders.
  • Of the 35 million Americans age 65 or older, about 2 million suffer from full-blown depression and another 5 million suffer from less severe forms of the illness.
  • The risk of depression in the elderly increases with other illnesses and when ability to function becomes limited
  • While people 65 and older account for 12 percent of the population, they represent 16 percent to 25 percent of suicides.
  • Depression makes all other medical problems more difficult to treat.
  • There is no single cause for depression.  It can be related to one or a combination of factors from a host of medical conditions and medications to injuries to environmental factors to substance abuse.
  • Depression is not just a "blue" mood.  It is a very real and serious medical illness and, therefore, requires medical attention and treatment.
  • Depression is not a normal or a necessary part of aging. 
  • Although most depression in older adults is associated with a sad mood, it often presents as a preoccupation with somatic symptoms related to appetite changes, vague GI symptoms, constipation, and sleep disturbances.  Older adults are more likely than their younger counterparts to present with an agitated depression.
  • There is no ironclad diagnostic test to identify depression. An evaluation usually starts with standard physical exam tests and work-ups to rule out other possible causes for the symptoms. Then the patient will participate in interviews to learn about his or her attitudes and behaviors.   
  • Depression is often harder to recognize in the elderly than in their younger counterparts.
  • The goal of treatment for depression is remission, not simply a lessening of symptoms.
  • Depression is treatable in 65 to 80 percent of elderly patients.

The quick facts above were adapted from information available from National Institutes of Health; Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; National Institute of Mental Health; National Institute on Aging.

Ask Your Doctor

This list of questions is a good starting point for discussion with your doctor. However, it is not a comprehensive list.

  • How do I know if I suffer from depression or am simply going through a "rough patch"?
  • How did you reach your diagnosis?  What specifically leads you to believe that I suffer from depression?
  • How much experience do you have in treating depression, especially in older adults?
  • Which treatments do you prefer, and why?
    • What type of psychotherapy?
    • What type of medication?
    • What about neurotherapeutic treatments?
  • If my treatment will include antidepressants:
    • How long may it take for them to begin to work?
    • How long will I have to take them?
    • How might they affect my other medical conditions?
    • Could they interact with any of my other medications?

Key Point 1

When a person is not thinking clearly, it can be caused by many different issues.  Depression is one of them. 

There are many different levels of unclear thinking.  It can range from simply focusing on overly negative and self-critical thoughts to the delusions and hallucinations of psychotic depression. Causes can be just as wide ranging – from a host of medical conditions and medications to injuries to environmental factors to substance abuse.   

The critical task for the physician is two-fold:  first to determine if the person is a danger to themselves or others and then to precisely pinpoint the cause.  He or she will consider a long list of physical conditions including:

  • Reaction to drugs, alcohol, or prescription medications (or sudden withdrawal from them)
  • Exposure to carbon monoxide or other toxins
  • Heat stroke
  • Hypothermia    
  • Head injury such as trauma or stroke
  • Dehydration that causes electrolyte imbalances
  • Low blood sugar
  • Low oxygen levels
  • Any medical illness in an older adult (something as seemingly innocuous as a urinary tract infection can cause mental changes or confusion in the elderly)
  • Certain nutritional deficiencies
  • Seizure disorders
  • Kidney or liver failure
  • Hypothyroidism (for more information see Second Opinion, Hypothyroidism Episode 512
  • Brain tumor
  • Sleep deprivation

Once physical conditions are considered and rejected, the physician will consider:

  • Alzheimer's disease
  • Anxiety disorder
  • Dementia
  • Depression
  • Schizophrenia
  • Dissociative disorders
  • Psychosis

Lateonset depression and cognitive impairment often occur together,suggesting a close association between
them (1-2).   However, it is not known whether depression leads to cognitive decline or viceversa.2-3 

There are things you can do to keep your brain sharp. The Mayo Clinic recommends:

  • Exercising your mind. This includes crossword puzzles, reading, and interacting with people.
  • Staying physically active (which improves blood flow).
  • Eating a healthy diet.
  • Developing a system of reminders and cues, such as keeping a diary.
  • Learning relaxation techniques.

When a depressed person is not thinking clearly, it is less likely that they will reach out for help.  It is up to their family and friends to help them get the medical support they need.      

Migliorelli R, Teson A, Sabe L, Petracchi M, Leiguarda R, Starkstein SE. Prevalence and correlates of dysthymia and major depression among patients with Alzheimer's disease. Am J Psychiatry 1995;152: 37-44.
2 Jorm AF. History of depression as a risk factor for dementia: an updated review. Aust N Z J Psychiatry2001;35: 776-81.
3 Schweitzer I, Tuckwell V, O'Brien J, Ames D. Is late onset depression a prodrome to dementia? Int J Geriatr Psychiatry 2002;17: 997-1005.

Key Point 2

Finding the appropriate treatment for depression often takes time and trial.  Proper treatment can result in dramatic improvement in mental and physical health, so it is important to take the time necessary to find the treatment that works best for you.

Depression is a very real and serious medical illness.  It, therefore, requires medical attention and treatment. 

If you have several of these symptoms and they last for more than two weeks, talk to your doctor.1

  • An "empty" feeling and ongoing sadness
  • Persistent anxiety
  • Tiredness, lack of energy
  • Loss of interest or pleasure in everyday activities, including sex
  • Sleep problems, including trouble getting to sleep, very early morning waking, and sleeping too much
  • Eating more or less than usual
  • Crying too often or too much
  • Aches and pains that do not go away when treated
  • A hard time focusing, remembering, or making decisions
  • Feeling guilty, helpless, worthless, or hopeless
  • Being irritable
  • Being restless or agitated
  • Thoughts of death or suicide

Seeking treatment is your first step to recovery.

The main treatments for depression are psychotherapy and medication. For some people, either treatment alone may work. For others, a combination of the two may be needed.  When these first-line treatments do not work or you can not take the medications because of adverse side effects or co-existing medical conditions, neurotherapeutic treatments may provide relief.   These treatments include electroconvulsive therapy (ECT), vagus nerve stimulation (VNS), transcranial magnetic stimulation (TMS) and deep brain stimulation (DBS). 

Psychotherapies
These are referred to as the "talking" therapies and they come in many forms.  Popular types for treating late onset depression include cognitive-behavioral therapy, supportive psychotherapy, problem-solving therapy, and interpersonal therapy.Cognitive-behavioral therapy helps you identify and change pessimistic thoughts and beliefs that can lead to depression. Supportive, problem-solving and interpersonal therapies are geared toward helping you develop new ways to cope with problems. 

Medication
Antidepressants are used most often for serious depressions, but they can also be helpful for some milder depressions. Antidepressants are not "uppers" or stimulants, but rather take away or reduce the symptoms of depression and help depressed people feel the way they did before they became depressed.3   There are several different types of antidepressants, each working in different ways with different applications.  Finding the right medication and the right dosage can be a long process. Older adults tend to be more sensitive to drug side effects and because they are often taking other medications, they can be more vulnerable to drug interactions.  They are also likely to have a slower response than younger patients (8 to 12 weeks which is double the time it may take a younger person to experience a change according to the Cleveland Clinic).  If the first or even second medication does not work, you should not give up.  You may need to try several different medicines, take more than one medicine or add other forms of treatment for optimal effect.  When antidepressants are prescribed by a physician who is familiar with those that are best for geriatric patients, they can work just as well for older adults as they do for their younger counterparts.    

Electroconvulsive Therapy (ECT)
Statistically ECT is the most effective treatment for depression.  In fact, older patients seem to respond better than younger ones.  Patients who have opted for ECT commonly report high satisfaction after initial doubts.  Many say the impact of the procedure is "nothing" compared to the illness it overcomes.  Some 80-90 percent of people with severe depression improve dramatically with ECT.  It involves producing a seizure in the brain of a patient under general anesthesia by applying electrical stimulation to the brain through electrodes placed on the scalp.  Repeated treatments are necessary to achieve the most complete anti-depressant response.  Memory loss and other cognitive problems are common yet typically short-lived side effects of ECT.  While some people report lasting difficulties, modern advances in ECT technique have greatly reduced the side effects of this treatment compared to those of earlier decades.

Vagus Nerve Stimulation (VNS) 
VNS approved by the FDA in July 2005 as an additional treatment for long-term or recurrent depression in adults who have not had success with four or more antidepressant medicines. A device is put into the chest and sends an electrical current to mood centers of the brain.  There is controversy among physicians about how the studies on VNS were conducted and whether this is, in fact, an effective therapy. 

Transcranial Magnetic Stimulation (TMS) 
A TMS device, NeuroStar, manufactured by Neuronetics Inc. was approved on October 8, 2008, by the FDA for use in adult patients with major depression who have previously tried medication and not improved satisfactorily.  It is not yet widely available and many physicians still consider this to still be an experimental therapy.  According to Neuronetics, the therapy stimulates nerve cells in an area of the brain that is linked to depression by delivering highly focused MRI-strength magnetic pulses. A large electromagnetic coil is held against your scalp near your forehead to produce the pulses.  Patients do not require anesthesia or sedation and remain awake and alert for the 40-minute outpatient procedure.  

Deep Brain Stimulation (DBS)
This therapy was first developed and approved for treatment of Parkinson's disease and essential tremor. It is under study for the treatment of severe depression so is still considered to be experimental.   

There are also lifestyle changes that individuals with depression can make.  They include increased exercise, an improved diet, regulating sleep and reducing or eliminating caffeine and alcohol.

Of utmost importance is to remember that depression is not a static thing.  Since it can fluctuate in severity and range, it requires regular monitoring and therapeutic adjustments.

NationalInstitute on Aging.
2 Alexopoulos GS, Katz IR, Reynolds CF III, Carpenter D, and Docherty JP. The Expert Consensus Guideline Series: Pharmacotherapy of Depressive Disorders in Older Patients. Postgraduate Medicine Special Report. October 2001.
3 Medications.  National Institute of Mental Health.

Medline Plus

Medline Description: 

Conduct an off-site search for Depression in Later Life information from MedlinePlus.  These up-to-date search results are based on search terms specific to Second OpinionKey Points.

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