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Depression - elderly

Definition

Depression is a medical illness in which a person has persistent feelings of sadness,often with discouragement and a lack of self-worth.

Depression in the elderly is a widespread problem, but is often not recognized or treated.

Causes, incidence, and risk factors

See: Depression - major for more information about the causes of depression.

In the elderly, a number of life changes can increase the risk for depression, or make existing depression worse. Some of these changes are:

• Adapting to a move from home to an apartment or retirement facility
• Chronic pain
• Feelings of isolation or loneliness as children move away and their spouse and close friends die
• Loss of independence (problems getting around, caring for themselves, or driving)
• Multiple illnesses
• Struggles with memory loss and problems thinking clearly

Elderly people often use alcohol to self-treat depression, but this may make symptoms worse.

Depression can be a sign of a physical illness. It can be a psychological reaction to the illness, or directly caused by the physical illness.

• Physical illnesses that increase the risk for depression include: thyroid disorders, Parkinson's disease, heart disease, cancer, and stroke.
• Symptoms of depression may occur as part of dementia ( Alzheimer's disease).
• Symptoms of depression are also a side effect of many drugs commonly prescribed for the elderly.

Many older people will not admit to feeling depressed, for fear that they will be seen as "weak" or "crazy." Some older people will not report their depression because they believe that feeling sad is "normal," or that nothing can be done about it.

Symptoms

Many of the usual symptoms of depression may be present in the elderly. See: Depression - major for more details.

Depression in the elderly may be hard to detect. Common symptoms such as fatigue, appetite loss, and trouble sleeping can be part of the aging process or a physical illness. As a result, early depression may be ignored, or confused with other conditions that are common in the elderly.

Clues to depression in the elderly may include:

• Being more confused or forgetful.
• Eating less. The refrigerator may be empty or contain spoiled food.
• Not bathing or shaving as often. Visitors may notice smells of urine or stool. Clothes may be dirty and wrinkled.
• Not taking care of the home.
• Stopping medicines or not taking them correctly.
• Withdrawing from others. Not talking as much, and not answering the phone or returning phone calls.

Signs and tests

A discussion of your symptoms, physical exam, and blood and urine tests will help determine if a physical illness is causing the depression.

Sometimes your primary care doctor will send you to an expert in depression, such as a psychiatrist, to help with diagnosis and treatment. This may be especially useful for telling the difference between depression and normal grieving, which occurs more often in this age group.

Treatment

See: Depression - major for more information about medications and other therapies used to treat depression.

The first step is to address any physical illnesses and stop taking any medications that may be making your symptoms worse.

If these steps do not relieve the depression, antidepressant medications and talking through problems (psychotherapy) with a psychologist, psychiatrist, or other therapist is usually helpful.

Antidepressant drug therapy should be carefully monitored for side effects, which can be more common in the elderly. Doctors usually prescribe lower doses of antidepressants for older people, and increase the dose more slowly than in younger adults.

To better manage depression at home, elderly people should:

• Exercise regularly, seek out pleasurable activities, and maintain good sleep habits.
• Learn to watch for the early signs of depression, and know how to react if it gets worse.
• Minimize alcohol use and avoid illegal drugs. These substances can make depression worse over time, and they may also impair judgment about suicide.
• Surround themselves with people who are caring and positive.
• Talk about their feelings to someone they trust.
• Take medications correctly and learn how to manage side effects.

Support Groups

Expectations (prognosis)

Depression usually responds to treatment. If it is not detected, depression can lead to complications. The outcome is usually better for people who have access to social services, family, and friends who can help them stay active and engaged.

Complications

The most worrisome complication of depression is suicide. Depression and older age are both risk factors for suicide. Men account for most suicides among the elderly, and divorced or widowed men are at the highest risk. Families should pay special attention to elderly relatives who live alone.

Other complications include reduced functioning at work and in social relationships.

Calling your health care provider

Call your health care provider if you feel persistently sad, worthless, or hopeless, or if you cry often. Also call if you are having trouble coping with stresses in your life and want to be referred for talk therapy.

Go to the nearest emergency room or call your local emergency number (such as 911) if you are thinking about suicide (taking your own life).

If you are caring for an aging family member and think they may have depression, contact their health care provider.

Prevention

Staying physically, mentally, and socially active may help reduce the risk of depression in older age.

References

Cassano P, Fava M. Mood disorders: major depressive disorder and dysthymic disorder. In: Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL, eds. Massachusetts General Hospital Comprehensive Clinical Psychiatry. 1st ed. Philadelphia, Pa: Mosby Elsevier;2008:chap 29.

Unutzer J. Clinical practice: late-life depression. N Engl J Med. 2007;357:2269-2276.