B-TAC

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Advancing Care through Innovation, Observation and Collaboration.

Depression in Older Adults: Special Considerations

By: Kevin Liu, Database Intern, C-TAC

Depression is often overlooked and underdiagnosed in older adults, yet depression is highly prevalent in this population. In fact, depression is more prevalent in older adults than dementia and conservative estimates have shown that at least five million seniors (65 years and older) in the US are currently struggling with severe depression (Allan, Valkanova, & Ebmeier, 2014; Koenig & Blazer, 2007). This prompts two questions: First, why is depression prevalent in older adults? Second, why is depression in older adults so often underdiagnosed?

To answer the first question, we must consider the circumstances many older adults are facing. They often suffer various forms of loss, such as the loss of loved ones, friends, occupation, finances, physical ability, physical attractiveness, social support or connectedness, autonomy, and sources of self-worth (Gallagher-Thompson & Thompson, 2010). At the same time, they are likely experiencing other stressors, such as role changes, difficulties adjusting to these role changes, chronic medical conditions, and unstable financial situations. Given the sheer number of these stressors, one can see why depression may become such a prevalent issue in later-life.

That being said, older adults whose onset of depression occurs in later-life should be distinguished from older adults who have had depression since a much younger age or depressed individuals of other age groups. An older adult who has been able to successfully cope with the stressors associated with the earlier phases of life is likely to be highly resilient and has developed effective coping strategies over the course of their life. Though the stresses and difficulties associated with old age may have overwhelmed their adaptive resources, we should also recognize that these older adults likely have strong emotion regulation strategies and resilience, which can be important to utilize and build upon during therapy.

The answer to the second question of why depression in older adults is often underdiagnosed is multi-faceted. First, depressed older adults tend to express markedly different symptomatology in comparison to depressed individuals of other age groups. For example, older adults tend to focus on their somatic symptoms, such as sleep difficulties or changes in appetite, or they may present with symptoms more indicative of anxiety (Allan & Ebmeier, 2013). Second, symptoms of depression like difficulty concentrating and psychomotor slowing are sometimes difficult to distinguish from typical forms of cognitive impairment that older adults tend to exhibit. In a similar vein, common medical conditions in older adults, such as B12 deficiency and hypothyroidism, can produce symptoms similar to those of depression, which can complicate diagnosis. Third, many common psychometric measures and assessments for depression are not specifically tailored to older adults. For this reason, older adult specific measures like the Geriatric Depression Scale, which eliminates somatic items and simplifies the response structure, are generally more suitable for the assessment of depression in older adults. Finally, a certain degree of psychological distress and depressive symptoms in response to medical conditions that older adults tend to develop is perceived to be normal. Indeed, we should be careful to distinguish “normal” sadness in response to physical illness from pathological sadness indicative of depression, but it is also certainly not the case that older adults with medical conditions cannot also be depressed. This is especially important given the fact that studies have shown chronic illness to be a risk factor highly correlated with increased incidence of depression and suicidal ideation (Gürhan, Beşer, Polat, & Koç, 2019). Interestingly, this link between negative emotions and chronic physical health problems becomes stronger as a person’s age increases, becoming strongest in old age (Kunzman et al., 2019). These are especially salient considerations given the higher mortality rates in depressed older adults with comorbid medical conditions in comparison to non-depressed older adults with the same conditions (Murphy, Smith, Lindesay, & Slattery, 1988).

As a final note, it is important to bear in mind that challenges such as loss and physical illness are unfortunately an unavoidable part of aging, depression is not an unavoidable or even normal part of the aging process. Depression in older adults can often successfully be treated and doing so can result in markedly increased quality of life and help older adults maintain participation in roles that are meaningful to them, such as in the family or as a volunteer and employee. Given the increasing average life expectancy of populations all over the world, finding ways to maintain a high quality of life in later-life is especially important.

Further Resources:
Geriatric Depression Scale
National Institute of Mental Health page on older adults and depression

References:

Allan, C., & Ebmeier, K. (2013). Review of treatment for late-life depression. Advances in Psychiatric Treatment, 19(4), 302-309. doi:10.1192/apt.bp.112.010835

Allan, C. E., Valkanova, V., & Ebmeier, K. P. (2014). Depression in older people is underdiagnosed. The Practitioner258(1771), 19–22, 2–3.

Gallagher-Thompson, D., & Thompson, L. W. (2010). Treating late-life depression: A cognitive-behavioral therapy approach. Therapist guide. Oxford ; New York: Oxford University Press.

Gürhan, N., Beşer, N. G., Polat, Ü, & Koç, M. (2019). Suicide risk and depression in individuals with chronic illness. Community Mental Health Journal, 55(5), 840-848. doi:10.1007/s10597-019-00388-7

Koenig, H. G., & Blazer, D. G. (2007). In D. G. Blazer, D. C. Steffens, & E. W. Busse, (Eds.), Essentials of  geriatric psychiatry(pp. 145–176). Washington, DC: American Psychiatric Publishing, Inc.

Kunzmann, U., Schilling, O., Wrosch, C., Siebert, J. S., Katzorreck, M., Wahl, H.-W., & Gerstorf, D. (2019). Negative emotions and chronic physical illness: A lifespan developmental perspective. Health Psychology.

Murphy, E., Smith, R., Lindesay, J., & Slattery, J. (1988). Increased mortality rates in late-life depression. The British Journal of Psychiatry: The Journal of Mental Science152, 347–353. https://doi.org/10.1192/bjp.152.3.347

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