How to Recognise Depression in Older People?

Have you ever wondered how depression in older people is diagnosed?

 Is it diagnosis the same as for younger people? Or, how is it different?

Are most older people depressed and is it a normal part of ageing?

Is everyone who sells their property and moves into a nursing home depressed?

Over the years I have delivered extensive training on recognising mental health symptoms in the elderly, particularly those who live in aged care facilities. I wanted to tap into this topic a bit more, as depression with the elderly can often be overlooked and masked by their other health conditions. Further, knowing that someone is depressed does not fix the problem – we need to implement strategies to help them with their emotions and offer the right type of support. In this article I will offer further background on depression in old age and offer some practical strategies to addressing it.

Depression is the most common mental health condition in late life. Older adults who have serious medical problems, as well as those living in nursing homes or other institutional settings, often suffer from depressive symptoms. Depression in nursing home patients, as well as those who are medically ill is often under diagnosed (not diagnosed enough). There are a number of factors which contribute towards this trend including differentiating symptoms from other illness, attitude to mental health and willingness to discuss wellbeing.

Symptoms of depression

All of us have experienced sadness, and many of us have experienced depression, but it is not always easy to tell the difference, either when you are experiencing these mood changes yourself or when observing someone else. Distinguishing between depression and understandable sadness can be achieved by applying a medical approach with the following three rules of thumb:

1. Duration – symptoms are present for at least two weeks
2. Lack of fluctuation – symptoms of depression occur on most days, most of the time.
3. Intensity – the severity of depression symptoms must be of a degree that is definitely not normal for that individual

Other symptoms of depression include:

• Suicidal thoughts or behaviour
• Loss of confidence or self-esteem
• Feeling of helplessness
• Inappropriate or excessive feelings of guilt
• Feelings of hopelessness or worthlessness
• Avoiding social contact or going out
• Poor concentration and/or difficulty with memory
• Physical slowing or agitation
• Sleep disturbances (particularly waking up early)
• Reduced appetite with corresponding weight loss

Diagnosis in older people is complicated by the fact that depression and medical illnesses can present with similar symptoms. Depressed people often have physical symptoms, such as changes in sleep patterns, changes in appetite, fatigue and muscle or skeletal pain. In younger people with fewer medical conditions it is easier to differentiate these symptoms and determine that they are part of the depressive disorder.  

Common medical problems associated with depressive symptoms include:

• Alcohol and drug abuse
• Alzheimer’s disease
• Cancer
• Cardiac illness
• Cerebrovascular disease
• Cerebral neoplasms
• Chronic pain
• Central nervous system infections
• Endocrine disorders
• Inflammatory diseases
• Multiple sclerosis
• Nutritional deficits
• Parkinson’s disease
• Stroke
• Vascular dementia
• Viral and bacterial infections
• Vision loss

A growing body of evidence indicates that treatment of older depressed people is effective, whether with medications, psychotherapy, or a combination of the two. Despite these optimistic findings, older people frequently do not receive optimal treatment, or any treatment at all. This is due to the fact that accessing psychological service is more difficult in an aged care facility. In some instances even if a service provider is identified the older person can choose not to participate in psychotherapy. Over the years I have met many older adults who reported wanting to “give up living”, particularly as they were no longer living independently.

On the other hand, medication alone will not encourage the older person to build skills in integrating more into a nursing home facility and identifying social activities and goals. Further, there are a number of side-effects with taking medication, such as increased drowsiness and the increased risk of falls. Again, the older person can choose not to take the medication, or to trial it for a short period of time. Typically a trial is for at least couple of months, as it can take couple of weeks for the effects of medication to be seen.

Improving the quality of activities and engagement with the elderly in an residential setting is powerful strategy to addressing depression. This includes identifying suitable recreational activities in line with person’s interests, physical tolerances and sensory abilities. The next step is identifying suitable social goals, both short-term and long-term that are specific and realistic. This can often be overlooked, as with the medical model we can become too fixated on addressing the physical health. Increasing engagement, knowing how to respond to statements made by older person with depression, reducing isolation and meeting the social needs can significant improve the wellbeing of an older person and the quality of their life.  

 Here are some strategies on how to respond to an older person who may be depressed: