Trillian's Depression Page

Depression In Late Life

Depression in the aging and the aged is a major public health problem. It causes suffering to many who go undiagnosed, and it burdens families and institutions providing care for the elderly by disabling those who might otherwise be able-bodied. What makes depression in the elderly so insidious is that neither the victim nor the health care provider may recognize its symptoms in the context of the multiple physical problems of many elderly people. Depressed mood, the typical signature of depression, may be less prominent than other depressive symptoms such as loss of appetite, sleeplessness, anergia, and loss of interest and enjoyment of the normal pursuits of life. There is a wide spectrum of depressive symptomatology as well as types of available therapies.

Because of the many physical illnesses and social and economic problems of the elderly, individual health care providers often conclude that depression is a normal consequence of these problems, an attitude often shared by the patients themselves. All of these factors conspire to make the illness underdiagnosed and, more importantly, undertreated.

Depression in late life occurs in the context of numerous social and physical problems that often obscure or complicate diagnosis and impede management of the illness. There is no specific diagnostic test for depression so that an attentive and focused clinical assessment is essential for diagnosis. Because elderly depressed people often do not present themselves for evaluation or because their depressive symptoms are not typical, the illness is underdiagnosed and under rated. This is particularly true when it is secondary to physical illness, even though these secondary depressive symptoms also respond to treatment.

Estimates of depression in elderly people vary widely as a function of setting, threshold of diagnosis, and definition of depression; however, there is a consensus that the size of the problem is underestimated. The highest rates are found in nursing homes and other residential care settings. Risk factors appear to operate similarly in young and old, although the hallmark of depression in older people is its comorbidity with medical illness.

The course of recovery and frequent recurrence is similar in young and old; however, suicide is dramatically increased in elderly depressed, as is mortality from other causes.

Depressed elderly people should be treated vigorously with sufficient doses of antidepressants and for a sufficient length of time to maximize the likelihood of recovery. Maintenance treatment with antidepressants should be continued with the same doses that produced remission of the acute episode. ECT is often effective for depression in the elderly but is generally underused or unavailable. Psychosocial treatments can also play an essential role in the care of elderly patients who have significant life crises, lack social support, or lack coping skills to deal with their life situations. These approaches may also be indicated in patients who cannot or will not tolerate biologic treatments.

The system of care currently provided to elderly depressed persons is inadequate, fragmented, and passive. Ageist attitudes among some health care providers compromise their ability to recognize depression in their elderly patients and to intervene in an appropriate and timely fashion. The prevalence of depression is particularly high among patients in nursing homes, but staff in many of these facilities are not equipped to recognize or treat depressed patients.

Families and primary care physicians remain at the front line in recognizing depression and facilitating patient access to professional help; however, large numbers of elderly people live alone, have inadequate support systems, or do not have contact with a primary care physician. The isolation of these individuals compounds their depression, and specialized efforts are needed to locate and identify them and to provide in-home care relevant to their needs. Although lack of services is a major problem, a greater problem may be our inability to deliver services to those community-dwelling elderly people who need them the most.

HOW DOES DEPRESSION IN LATE LIFE DIFFER FROM DEPRESSION EARLIER IN LIFE?

The recognition of depression may be more difficult in late compared with early life. In the elderly age group, both clinicians and patients may incorrectly attribute depressive symptoms to the aging process. They may not fully appreciate the degree of impairment because of lower functional expectations in the post-retirement years. The particular constellation of symptoms may differ because elderly persons may more readily report somatic symptoms than depressed mood. Because both the patient and the evaluating clinician are often more concerned about concurrent medical conditions, depressive symptoms may be overlooked. Finally, the concomitant presence of dementia may compromise accurate recognition and reporting of symptoms. As a result, depression is often underdiagnosed in elderly people, despite a high frequency of potentially treatable depressive symptoms.

Depression in late life frequently coexists with multiple chronic diseases and disabilities, for example, cancer, cardiovascular disease, neurological disorders, various metabolic disturbances, arthritis, and sensory loss. These conditions create psychosocial concerns, medical and physiologic burdens, and functional disabilities that may directly contribute to the pathogenesis of depressive symptoms as well as complicate treatment. However, current data indicate that depressive symptoms may respond to treatment in many of these patients.

Depression in late life occurs in the context of numerous social, developmental, and biological diversities. Advancing age is accompanied by loss of important social support systems due to death of spouse or siblings, retirement, or relocation of residence. At the biologic level, there is variability in the regulation of homeostasis, organ system reserve, immunologic responsiveness, and body composition. These sources of heterogeneity have major implications for risk of illness, diagnosis, and treatment. For example, levels of antidepressant drugs and toxic metabolites may be disproportionately increased in the "old-old," making this subgroup particularly vulnerable to adverse side effects.

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