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Depression in Older People

By Debra Fulghum Bruce, PhD
 Medically Reviewed by Jennifer Casarella, MD on June 04,
2020

Clinical depression in older people is common. That

doesn't mean it's normal. Late-life depression
affects about 6 million Americans ages 65 and older.
But only 10% get treatment. The likely reason is
that older people often display symptoms of
depression differently. Depression in older people is
also frequently confused with the effects of
multiple illnesses and the medicines used to treat
them.

How Does Depression in Older People

Differ From Depression in Younger
Adults?

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Depression affects older people differently than

younger people. In older people, depression often
goes along with other medical illnesses and
disabilities and lasts longer.

Depression in older adults is tied to a higher risk of

cardiac diseases and of death from illness. At the
same time, depression reduces an older person's
ability to rehabilitate. Studies of nursing home
patients with physical illnesses have shown that the
presence of depression substantially increases the
likelihood of death from those illnesses. Depression
also has been linked with increased risk of death
after a heart attack. For that reason, it’s important
to make sure that an older adult you are concerned
about is evaluated and treated, even if the
depression is mild.

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Older people may not have the obvious symptoms

of depression. Instead, they may:

Feel tired

Have trouble sleeping

Be grumpy or irritable

Feel confused

Struggle to pay attention

Not enjoy activities they used to

Move more slowly

Have a change in weight or appetite

Feel hopeless, worthless, or guilty

Endure aches and pains

Have suicidal thoughts

Using a series of standard questions, a primary care

doctor can check for depression, allowing for better
diagnosis and treatment. Doctors are encouraged
to routinely check for depression. This can happen
during a visit for a chronic illness or at a wellness
visit.

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Depression also raises the risk of suicide, especially

in older white men. The suicide rate in people ages
80 to 84 is more than twice that of the general
population. The National Institute of Mental Health
considers depression in people 65 and older to be a
major public health problem.

In addition, advancing age often comes along with

the loss of social support systems due to the death
of a spouse or siblings, retirement, or relocation.
Because of changes in an older person's
circumstances and the fact that older people are
expected to slow down, doctors and family may
miss the signs of depression. As a result, effective
treatment often gets delayed, forcing many older
people to struggle unnecessarily with depression.

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How Is Insomnia Related to

Depression in Older Adults?

Insomnia is usually a symptom of depression.

Studies have found that insomnia is also a risk
factor for new depression or depression that comes
back, particularly in older adults.

To treat insomnia, experts sometimes recommend

avoiding or minimizing benzodiazepines (such as
Ativan, Klonopin, or Xanax) or newer "hypnotic"
drugs (such as Ambien or Lunesta) that, according
to the American Geriatric Society, may raise the risk
of impaired alertness, respiratory depression, and
falls.

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Experts often favor treating insomnia in the elderly

with the hormone melatonin, or a low-dose
formulation of the tricyclic antidepressant doxepin
(Silenor). Other potentially sedating
antidepressants, such as Remeron or trazodone,
are also sometimes prescribed for both purposes.
The sleep aid Belsomra has also been found to be
effective and safe in older adults. If there's no
improvement in the sleep disorder or depression, a
psychiatrist or psychopharmacologist may
prescribe other medications, psychotherapy, or
both.

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What Are the Risk Factors for

Depression in Older Adults?
Things that raise the risk of depression in older
people include:

Being female

Being single, unmarried, divorced, or

widowed

Lack of a supportive social network

Stressful life events

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Physical conditions like stroke, hypertension, atrial

fibrillation, diabetes, cancer, dementia, and chronic
pain further increase the risk of depression.
Additionally, these risk factors for depression are
often seen in older adults:

Certain medicines or combination of

medicines

Damage to body image (from amputation,

cancer surgery, or heart attack)

Dependence, whether through being

hospitalized or needing home health care

Disability

Family history of major depressive disorder

Fear of death

Living alone, social isolation

Other illnesses

Past suicide attempt(s)

Presence of chronic or severe pain

Previous history of depression

Recent loss of a loved one

Substance abuse

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Brain scans of people who develop their first

depression in old age often reveal spots in the brain
that may not get enough blood flow, believed to
result from years of high blood pressure. Chemical
changes in these brain cells may enhance the
likelihood of depression separate from any life
stress.

What Treatments Are Available for

Depression in Older Adults?
Treatments for depression include medicine,
psychotherapy or counseling, or electroconvulsive
therapy or other newer forms of brain stimulation
(such as repetitive transcranial magnetic
stimulation, or rTMS). Sometimes, a combination of
these treatments may be used. The option a doctor
might recommend depends on the type and
severity of depression symptoms, past treatments,
and overall health, among other factors.

How Do Antidepressants Relieve

Depression in Older People?
Studies have found that while antidepressants can
be helpful in older adults, they may not always be
as effective as in younger patients. Also, the risk of
side effects or potential reactions with other
medicines must be carefully considered. For
example, certain older antidepressants such as
amitriptyline and imipramine can be sedating, may
cause confusion, or might cause a sudden drop in
blood pressure when a person stands up. That can
lead to falls and fractures.

Medications you might get include:

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Selective serotonin reuptake inhibitors

(SSRIs) like citalopram (Celexa), escitalopram
(Lexapro), fluoxetine (Prozac), paroxetine
(Paxil), and sertraline (Zoloft)

Serotonin and norepinephrine reuptake

inhibitors (SNRIs) like desvenlafaxine (Pristiq),
duloxetine (Cymbalta), and venlafaxine
(Effexor)

Serotonin modulators and stimulators (SMS)

including vilazodone (Viibryd) and
vortioxetine (Trintellix)

Atypical antidepressants, such as bupropion

(Aplenzin, Wellbutrin), mirtazapine
(Remeron), and trazodone (Oleptro ER)

Monamine oxidase inhibitors (MAOIs), like

isocarboxazid (Marplan), phenelzine (Nardil),
selegiline (Eldepryl, Emsam, Zelapar), and
tranylcypromine (Parnate)

Antidepressants may take longer to start working in

older people than they do in younger people. Since
older people are more sensitive to medicines,
doctors may prescribe lower doses at first. In
general, the length of treatment for depression in
older adults is longer than it is in younger patients.
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Can Psychotherapy Help Relieve

Depression in Older Adults?
Most depressed people find that support from
family and friends, involvement in self-help and
support groups, and psychotherapy are helpful.
Psychotherapy is especially beneficial for those
who have gone through major life stresses (such as
loss of friends and family, home relocations, and
health problems) or who prefer not to take
medicine and have only mild to moderate
symptoms. It’s also helpful for people who can’t
take drugs because of side effects, interactions with
other medicines, or other medical illnesses.

Psychotherapy in older adults can address a broad

range of functional and social consequences of
depression. Many doctors recommend
psychotherapy along with antidepressant
medicines.

When Is Electroconvulsive therapy

(ECT) Used?
ECT can play an important role in the treatment of
depression in older adults. When older people can’t
take traditional antidepressant medicines because
of side effects or interactions with other
medications, when depression is very severe and
interferes with basic daily functioning (such as
eating, bathing and grooming), or when risk for
suicide is especially high, ECT is often a safe and
effective treatment option.

What Problems Affect Treatment of

Depression in Older Adults?
The stigma attached to mental illness and
psychiatric treatment is even more powerful among
older people. This stigma can keep older people
from admitting that they are depressed, even to
themselves. Older people and their families
sometimes also may wrongly identify depression
symptoms as "normal" reactions to life stresses,
losses, or the aging process.

Also, depression may be expressed through

physical complaints rather than traditional
symptoms. This delays appropriate treatment. In
addition, depressed older people may not report
their depression because they wrongly believe
there is no hope for help.

Older adults may also be unwilling to take their

medicines because of side effects or cost. In
addition, having certain other illnesses at the same
time as depression can interfere with the
effectiveness of antidepressant medicines.
Alcoholism and abuse of other substances may
cause or worsen depression and interfere with
effective treatment. And unhappy life events
including the death of family or friends, poverty,
and isolation may also affect the person's
motivation to continue with treatment.

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