An in-depth exploration of depression in older adults: part 2

In the second article of a two-part series, distinguished consultant psychiatrist Professor Farooq Khan explores the challenges of diagnosing depression in older adults and age-specific treatment options.

Are there specific challenges or barriers to diagnosing depression in older adults?

Diagnosing depression in older adults presents several unique challenges and barriers. Understanding these barriers is crucial for healthcare providers to accurately identify and treat depression in this population. Here are some key challenges and barriers:

Attribution to ageing

Depression in older adults is often misattributed to ageing, with symptoms like fatigue, sleep disturbances, and cognitive decline seen as normal. Older adults may accept feelings of sadness or loss of interest as a natural part of ageing and not seek help.

Physical health issues

Chronic illnesses such as heart disease and diabetes can mask depression symptoms, complicating diagnosis. Additionally, side effects of medications for physical health conditions can mimic or exacerbate symptoms of depression, leading to diagnostic confusion.

Cognitive impairment

There are symptoms of depression, such as memory problems and decreased concentration, can overlap with signs of cognitive impairment or dementia, complicating diagnosis.

Stigma and cultural factors

Stigma and cultural factors also play a significant role, as older adults might be reluctant to discuss mental health due to longstanding stigmas or cultural beliefs against it.

Communication barriers

Communication barriers arise when older adults struggle to articulate their emotions, especially if they experience cognitive decline or are unaccustomed to discussing mental health. Healthcare providers may focus on physical health, overlooking mental health issues.

Social and environmental factors

Social isolation from retirement, loss of loved ones, and reduced mobility can contribute to depression and make it harder to recognise. Living alone or in care facilities may lead to a lack of social support, making depression symptoms less noticeable.

Symptom presentation

Depression in older adults often manifests as somatic complaints, such as aches and pains, rather than typical emotional symptoms like sadness. This atypical presentation, along with increased anxiety and irritability, can lead to underdiagnosis.

Healthcare system barriers

Healthcare providers often lack training to recognise and treat depression in older adults, with short appointments focused on physical health, neglecting mental health. Overcoming these barriers requires improved education and training for healthcare professionals, use of screening tools, integrated physical and mental healthcare, awareness campaigns, strong rapport, and support from family, social, and community networks.

How can family members and caregivers differentiate between normal ageing-related changes and signs of depression?

Distinguishing between normal ageing-related changes and signs of depression in older adults can be challenging. However, family members and caregivers can look for specific signs and patterns to help differentiate between the two. Here are some key distinctions and guidelines to consider:

Normal ageing vs. depression: key elements

Mood and emotions

In normal ageing occasional feelings of sadness or "blues" that do not persist and mood generally remains stable and there is enjoyment in life and activities.

With depression there is persistent sadness, hopelessness, or feelings of worthlessness that last for weeks or longer. The individual may seem constantly down or irritable.

Interest in activities

With normal ageing there is some decrease in enthusiasm for certain activities due to physical limitations, but still finding joy in many activities and hobbies, while with depression there is a marked loss of interest or pleasure in almost all activities, including those that were previously enjoyed.

Energy levels

In normal ageing there is a gradual decrease in energy, while maintaining the ability to engage in daily activities, while in depression there is significant fatigue and loss of energy that interferes with daily functioning, leading to a noticeable reduction in activity levels.

Cognitive changes

In normal ageing there will be very occasional forgetfulness and occasional lapses in concentration, but overall cognitive function remains relatively intact.

In depression patients experience difficulty concentrating, making decisions, and severe memory problems that affect daily life.

Physical symptoms

In normal ageing there are common physical complaints related to ageing such as arthritis or reduced mobility, while in depression is unexplained aches and pains, changes in appetite or weight, and sleep disturbances (insomnia or excessive sleeping) without a clear physical cause.

Social engagement

In normal ageing there will be enjoyment of social interactions, though the frequency may decrease due to mobility issues or loss of friends.

However, in depression there is withdrawal from social activities, isolation, and reduced interest in spending time with family and friends.

Feelings of worthlessness or guilt

With normal ageing there is occasional feelings of regret or sadness, particularly related to life changes or loss, while in, depression this presents with excessive or inappropriate feelings of guilt or worthlessness that are persistent and often unrelated to any specific situation.

Thoughts of death or suicide

In normal ageing there is acceptance of mortality and occasional contemplation about death as a natural part of life, while in depression there is frequent thoughts of death, dying, or suicide, and expressing a desire to die or making plans for suicide.

Steps for family members and caregivers

Family members and caregivers should observe and document changes by tracking symptoms, noting their duration, frequency, and severity to identify persistent patterns. They should communicate openly, encouraging non-judgmental conversations about emotions and well-being, and seek professional help through comprehensive evaluations and mental health screenings to obtain accurate diagnoses.

Furthermore, they should provide support and encouragement by showing empathy, engaging in enjoyable activities, and promoting a healthy lifestyle, as well as educating themselves and others about depression in older adults, sharing information to build a supportive network.

What treatment options are available for depression in older adults, and are there any age-specific considerations?

Treating depression in older adults requires a comprehensive approach that considers the unique challenges and needs of this age group

Psychotherapy

Cognitive behavioural therapy (CBT) focuses on changing negative thought patterns and behaviours. Interpersonal Therapy (IPT) addresses issues in personal relationships that may contribute to depression. Problem-Solving Therapy helps individuals develop coping skills to manage stressful life events.

Medications

• Selective Serotonin Reuptake Inhibitors (SSRIs):
• Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs)
• Tricyclic Antidepressants (TCAs) and Monoamine Oxidase Inhibitors (MAOIs)

Older adults often take multiple medications, increasing the risk of drug interactions. Careful medication management is essential. Sensitivity to side effects such as dizziness, sedation, and risk of falls must be monitored closely. It’s generally recommended to start with a lower dose and increase gradually to minimise side effects.

Lifestyle Modifications

Exercise: Regular physical activity, such as walking, swimming, or yoga, can improve mood and overall health.

Tailored programmes: Exercise programs should be tailored to the individual’s physical abilities and limitations.

Balanced diet: A nutritious diet rich in fruits, vegetables, whole grains, and lean proteins can support overall health and well-being.

Hydration: Ensuring adequate fluid intake is crucial, as dehydration can exacerbate symptoms of depression and cognitive decline.

Social Support

Participation in activities at senior centres can provide social interaction and reduce feelings of isolation. Engaging in volunteer work offers a sense of purpose and fulfilment. Regular interaction with family members provides emotional support, while joining peer support groups for older adults with depression fosters a sense of community and shared experience.

Medical Treatments

Electroconvulsive therapy (ECT): Considered for severe depression that does not respond to other treatments. It can be effective and safe for older adults, although careful medical evaluation is necessary.

Transcranial magnetic stimulation (TMS): A non-invasive treatment option that uses magnetic fields to stimulate nerve cells in the brain. It may be suitable for older adults who do not respond to medications.

Monitoring and Follow-Up

Regular medical monitoring and mental health assessments are essential to track treatment progress and adjust as needed. You must manage comorbidities and account for cognitive decline. Address sensory impairments with adaptive strategies and consider mobility issues by offering home-based or telehealth options for therapy.

If you are suffering from depression and would like to book a consultation with Dr Khan, do not hesitate to do so by visiting his Top Doctors profile today.