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Depression in older adults is a persistent or recurrent disorder resulting from psychosocial stress or the physiological effects of disease. This psychological problem can lead to disability, cognitive impairment, exacerbation of medical problems, increased use of health-care services, increased suicide, and increased risk of falls (Brown and Roose, 2011; Eggermont et al., 2012). It complicates the treatment of other physiological problems. Unfortunately, depression is severely under-recognized 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.
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Older individuals do not present with the typical symptoms of depression, such as depressed mood or sadness. 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 that are reported may be related to a physical illness and exacerbated or exaggerated by the depression. While it is sometimes a slow and difficult diagnostic process, it is critical to rule out medical problems (acute or chronic) prior to a definitive diagnosis of depression. Once 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. While side effect concerns are appropriate, it is important to appreciate that depression in older patients is treatable.
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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 health-care providers. Recognition and appropriate management of depression are critical, however, to optimize the management of comorbidities, maintain function and quality of life, reduce the need for health-care resources, and prevent further morbidity and even mortality. This chapter addresses these issues from the perspective of the nonpsychiatrist, highlighting diagnostic techniques and initial management options. It should be recognized, however, that the management of some older adults will best be done by involving psychiatrists and psychologists and possibly an integrated care model approach (Ellison, Kyomen, and Harper, 2012).
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The prevalence of major depression among older adults actually decreases with age, with this rate being approximately 5% to 10% of older person living in the community and presenting to primary care practices have diagnosable depression. Although an additional 2% of older individuals experience dysthymia (a chronic depressive disorder characterized by functional impairment and at least 2 years of depressive symptoms), this disorder also decreases with age. Major depression is found in 16% to 50% of older adults in nursing homes or acute care settings. The lower rate of major depression among community-living older individuals may be caused by selective mortality, institutionalization, missed diagnoses, and/or cohort effects ...