Depression in old age

With increasing age, health risks increase as well. Older age is a risk factor for one’s psychological health just as much as physical wellbeing. When a person reaches a certain age – 60-65years, major changes happen in their life that may lead to a serious emotional reaction. Leaving the workforce, for instance, losing a spouse, loneliness, physical disability or the emotional aspect of coping with the thought that one is entering the final stages of their life.

Over a certain age, health problems tend to pile up: dizziness, back pain, joint pain, decreasing eyesight, blood pressure problems, decreasing bone density, muscle weakness, dementia syndromes, etc. Mood impairment is often overlooked, underestimated or overshadowed by other, more physical symptoms. Depression is not a definitive outcome of aging, however, depressive symptoms are widely found in the elderly population and increase with age. A lack of stimulating social contact, as well as decreasing mental and physical efficiency, can take their toll on the mind. A study on depression in old age (+75years), where 2850 participants aged 75 years or more were tested, found that the prevalence of depressive symptoms was assessed to be 31.1%. This is considerably higher than what has been found in younger elderly samples (60-75 yrs). In other words, of every 100 elderly people, 31 are most probably experiencing prevailing depressive symptoms. For reference, as per 2017 3,4% of the global population suffers from depression, meaning depression prevalence in the elderly is potentially much higher than in the general population.

Prevalence of depression in old age

Depression is great at hide and seek in older patients. Even if they visit their doctors regularly, there is some chance that symptoms of depression get unrecognized and simply blend in with symptoms of normal aging or other physical illness. Feeling weak, slow, having difficulty concentrating, sleep disturbances, being sad: all those symptoms can be written off as something to be expected from simply being over a certain age². Patients themselves often underestimate the potential seriousness of such changes. Meanwhile, depression can stay undiagnosed and, thus, become a serious health risk for an elderly person.

Predictability

Ill physical health is a great predictor for a decline in mental health as well. The relationship between the two is very complicated and has to be approached with caution. While depression may be an emotional response to the mere fact that one has a chronic illness, it may also be a consequence of a number of illnesses themselves. The biological mechanisms in the body are extremely complex, and depression, sometimes, is a secondary effect of cancer, thyroid issues, vitamin deficiencies or infections.

On the other hand, some physical illnesses lead to permanent disabilities, restricting mobility and independence. This may lead to feelings of inferiority, being a burden, feeling of worthlessness. Lastly, most elderly need to take at least one or two prescription medications for some existing health issue. These medications can potentially trigger depression such as steroids, painkillers, high blood pressure drugs, etc.

Cognitive impairment and depression are both very commonly associated among the elderly. A study ⁴ from 2004 concluded that depression and cognitive impairment are correlated and, also, co-occur in old age. Cognitive impairment is a predictor of potential depression symptoms. In other words, if an elderly person starts to experience cognitive deterioration, most probably, they will experience depression symptoms as well.

In conclusion, it is advisory that all elderly people keep close attention to their mental state. A potential change in the mental disposition may be a sign of a physical problem, and vice versa.

Loneliness and social isolation play a big role in regards to depression. Living alone in old age is fairly common, family connections are often reduced, social connections are reduced as well. Depending on the local region, some old people have difficulty with transportation, live in secluded villages or areas, or, simply, most of their friends are already gone. Different factors may result in isolation, but the outcome of this social isolation is not beneficial.

If possible, it is advisory for the elderly to find a way to be a part of a community. Whether it is hobby-related, simple friendly gatherings, even having a pet at home – all of those will have beneficial consequences to overall morale.

Personal losses in life are difficult regardless of age. However, in older age, these losses tend to happen more frequently in shorter periods of time, and can be extremely traumatizing. Losing a spouse after decades of marriage, losing old friends, losing a pet. The loss is not necessarily physical, though, it can be symbolic and just as hard: a certain lifestyle, physical strength and health, cognitive abilities etc.

Prevention of depression in old age

In recent years, brain research has been able to clearly show that the ageing process and stress reduce neuroplasticity in the brain, whereas physical activity, varied surroundings and learning encourage it. This is why physical training is one of the few methods that can quickly, easily and effectively improve neuroplasticity. Sport and movement have an effect on the growth, differentiation, survival and repair processes of brain cells.

“Doing sports” often sounds overwhelming and quite scary, especially to someone over 60 years old. Keeping the cardiovascular system active and healthy via physical activity is highly recommended. A walk in the neighbourhood or in a nearby forest, going for a swim in the local pool, easy and relaxing yoga, walking the dog, dancing, etc. Consider joining a local activity group – socializing is only adding value to the benefits of the activity itself.

Another part of physical health is keeping your body weight and following a healthy diet. Body weight and diet are directly connected to hormone regulation, physical health and mood. It is advisory to stick to whole foods, healthy fats, lots of vegetables, and, accordingly, avoid fried foods, junk food, any type of pre-packaged “snacks”.

Limiting alcohol intake and smoking cessation are also key points to good mental health and physical wellbeing.

Another important aspect of a healthy lifestyle is exercising the brain. Cognitive impairment is closely related to depression, so it is crucial to “exercise” the brain regularly. Just like muscles in the body, the principle here is “use it or lose it”. Especially for the elderly who suffer (or are at risk) from dementia, Alzheimer’s disease, etc. There are numerous ways to do that and probably the simplest is talking. Having a mindful conversation is always stimulating for the brain. Reading a book, playing an instrument, gardening, any craft hobby, puzzles and crosswords, whatever you choose is going to be beneficial for your brain and disposition.

Symptom checklist:

Simply being sad or stressed, however, does not automatically mean that one has depression. Please see the checklist below that will help you navigate your symptoms:

● Depressed mood by self-report or observation made by others
● Loss of interest or pleasure
● Fatigue/loss of energy
● Feeling of worthlessness/excessive or inappropriate guilt
● Recurrent thoughts of death, suicidal thoughts or actual suicide attempts

● Diminished ability to think/concentrate or indecisiveness
● Psychomotor agitation or retardation
● Insomnia/hypersomnia
● Significant appetite and/or weight loss

How to treat depression in old age?

Lifestyle changes mentioned above are not classified as clinical interventions, but are as important and powerful when it comes to mental health. There are two main options for depression treatment: psychotherapy and medication.

Antidepressants: they work on biochemistry level to improve the way the brain uses and produces certain neurotransmitters. As well as contemporary psychiatric medications are researched, it might take several attempts, before finding the best medication for each individual case. They need time to work – 4-6 weeks, and in that period a lot of the symptoms – sleep, appetite, concentration are known to improve before the depressed mood lifts completely. Sometimes people start feeling better and decide to stop taking their medication without consulting their doctor. This is highly unrecommended as it can cause withdrawal symptoms or return of depression.

A review from 2005 on the pharmacotherapy of antidepressants in the elderly concluded that antidepressant treatment of four weeks is likely to have a beneficial effect. To prevent relapse and depression recurrence, medication should be continued for as long as six months after good initial response.

It is very important not to discontinue taking the prescribed antidepressants or alternate the dosage without medical supervision. Often, when patients feel better, they decide to half the dosage or stop taking their medication completely because they feel healthy. The great misconception in this situation is the notion that the medicine would still work, but with less strength. In reality, the medicine doesn’t work at all as the dosage was below the minimum. Consequently, it is very important for patients to discuss all changes in the dosage of medication with their psychiatrist beforehand.

Psychotherapy: there is a broad spectrum of psychotherapy schools and types. In rare cases of severe clinical depression, patients are unable to even begin psychotherapy before a course of antidepressants takes place. Generally, however, psychotherapy goes hand in hand with antidepressants from the very beginning or, for some, psychotherapy is enough all by itself. There are different subtypes and schools in psychotherapy: the so called “evidence based therapies”, like CBT, that work on changing the ineffective pattern of thought; there are psychodynamic therapies: where one will discuss his experiences, relationships, etc. When making your choice, make sure to find a trained and certified specialist to help you cope with depression.