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INTRODUCTION

Depression in older adults is a persistent or recurrent disorder resulting from psychosocial stress or the physiological effects of disease and is commonly referred to as late-life depression. This psychological problem is more common than dementia and can lead to disability, cognitive impairment, exacerbation of medical problems, increased use of health-care services, and increased risk of falls and suicide. The presence of depression complicates the treatment of other physiological problems. Unlike dementia, depression is treatable and thus diagnosis is very important. Unfortunately, depression is severely underrecognized and undertreated. This lack of identification and treatment can be traced to providers assuming that the signs and symptoms of depression are normal age changes and/or normal responses to life events or medical problems.

Old age can be a time of loss and those losses can trigger depressive symptoms. It is challenging to be able to separate out true depression from sadness. Generally, sadness in response to losses should not be sustained for longer than 6 months. For example, an older adult may lose a spouse, a home, and a pet all within a short period of time. Time is needed to adjust to these losses and grieve. When the individual continues to experience feelings of sadness and other associated symptoms of depression, concerns should be raised about depression.

Older individuals may not present with the typical symptoms of depression, such as depressed mood or sadness. Conversely, they may have these symptoms but not complain about them or admit they exist. They may, however, respond to focused questions about whether or not they feel depressed. Thus, it is important to ask older individuals directly about depression using brief screening tools or even by just asking if they feel depressed. The signs and symptoms indicative of depression (eg, change in appetite or sleep), which are part of the tools commonly used to screen for depression in younger adults, may not work as well with older people because they are related to symptoms of physical illness. Although it may be a slow and difficult diagnostic process, it is critical to rule out medical problems (acute or chronic) prior to a definitive diagnosis of depression. Even once it is identified, depression is often not treated due to concerns about drug side effects associated with antidepressants and polypharmacy and beliefs that psychotherapy and other nonpharmacological interventions will not be effective for older individuals. Although it is appropriate to be concerned about drug side effects, it is important to appreciate that treating depression can dramatically improve the quality of life of older adults.

Sorting out the complex interrelationships between symptoms and signs of depression caused by physical illnesses and those caused primarily by an affective disorder or related psychiatric diagnosis is challenging for clinicians. New guidelines from the Diagnostic and Statistical Manual of Mental Disorders version 5 (DSM-5) recommend that individuals be screened for substance abuse, other psychiatric disorders (eg, schizophrenia), or ...

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