DEPRESSION IN THE ELDERLY: SYMPTOMS, CAUSES AND TREATMENT - ARTE - 2025

The depression in the elderly has a high prevalence, impacting negatively on the quality of life of this population group. It is important to know and understand it, to know its possible etiology, risk factors and its prognosis in order to influence and intervene on it.

The presence of a depressive disorder in older people is a public health problem worldwide, since it increases mortality in this age group and decreases their quality of life.

Depression is, along with dementia, the most common mental illness in older people. The impact it has on this age group is increasingly noticeable and although serious, it often goes unnoticed.

It is the cause not only of personal and family suffering but also that other medical problems become complicated and develop.

Symptoms

The most significant symptoms that are a necessary condition for diagnosing a depressive episode in an older adult are depressed mood, significant loss of interest or loss of experiencing pleasure (anhedonia). In addition, the symptoms must cause a detriment to the activity and sociability of the patient.

The criteria for depression do not differ according to age group, so that the depressive syndrome is fundamentally similar in young, old and old. However, there are some variations or characteristics specific to these age groups.

For example, elderly people with depression have less depressive affect than people with depression in other age groups.

It is usually more severe in older adults than in the elderly, and in this last age group it usually presents more melancholy characteristics.

Older people with depression perform poorly, even worse than those with chronic diseases such as diabetes, arthritis, or lung disease.

Depression increases the perception of negative health in these patients and makes them use health services more often (two to three times more), so that the cost of health care increases.

However, less than 20% of all cases are diagnosed and treated. Even for those who do receive treatment for depression, efficacy is poor.

Differences between older adults and other age groups

More anxiety

Older people with depression tend to show more anxiety and somatic complaints than younger people who also suffer from depression. However, they show less sad mood.

Elderly patients with depression tend to perceive, compared to younger groups, that their depressive symptoms are normal and have less propensity to be sad.

More insomnia

The elderly tend to have more onset insomnia and early awakening, more loss of appetite, more psychotic symptoms within depression, are less irritable and have less daytime sleepiness than younger depressed patients.

Hypochondria

They also tend to show more hypochondriacal complaints. When they are disproportionate to the medical condition or there is no etiology to explain it, they are more common in older patients and are usually observed in around 65% of cases, being something significant at this age.

Forms of expression

It must be taken into account that although sadness is the most important symptom in depression, the elderly person often expresses it in the form of apathy, indifference or boredom, without the mood being experienced as sad.

Loss of enthusiasm and disinterest in activities that previously liked and interested you is frequent. It is usually an early symptom of depression at this stage.

Insecurity and loss of self-esteem

Many times the patient feels insecure, slow-thinking and underestimated. They are often more interested in the evolution of their physical symptoms than sadness or melancholy.

epidemiology

The prevalence of depression varies according to the instrument used (interview or questionnaires, for example) or the population group studied (hospitalized, in the community, institutionalized).

The epidemiology of depression in the group of elderly people could be indicated at around 7%.

However, we can include an interval between 15-30% if we also take into account those cases that, without fulfilling diagnostic criteria, present clinically relevant depressive symptoms.

If we take into account the field in which they fall, the figures vary. In those elderly who are in institutions, the prevalence is around 42%, while in those hospitalized it is between 5.9 and 44.5%.

Although the frequency seems to be the same between the different age groups, in gender, women seem to be more affected.

In any case, and varying the figures and despite the variability in the methodology used, there is an agreement on the existence of underdiagnosis and undertreatment.

Causes

We find different risk factors for developing depression in these last stages of life, such as:

• Mourning the loss of loved ones
• Retirement
• Loss of socioeconomic status
• Sleep disorders
• Lack of function or disability
• Female gender
• Dementia
• Chronic diseases
• Have had a life-long episode of depression
• Pain
• Cerebrovascular disease
• Deficient social support
• Negative life events
• Family rejection
• Perception of inadequate care

It should also be noted that suicide is higher in the elderly than in younger people (5-10% higher) and in this case affective-emotional disorders such as depression are a risk factor.

Suicide (of which around 85% is male) is characterized by previous threats, more lethal methods than in younger stages.

Other risk factors are associated such as:

• Being a widower or divorced
• Living alone
• Substance abuse
• Stressful life events

Regarding the etiology, it should be noted that the etiopathogenic factors are the same that influence mood disorders in other age groups: neurochemical, genetic and psychosocial.

However, in this age group, the psychosocial and somatic precipitating factors are more important than in other population groups.

Forecast

We found that the prognosis is generally poor, given that relapses are common and there is a higher overall mortality than in people of different ages.

In both the elderly and the elderly, the response obtained to treatment with psychotropic drugs and the response to electroconvulsive therapy are similar.

However, the risk of relapse is higher in the elderly, especially if they have already had a depressive episode before in the early stages.

Some studies have shown that, when there is an associated medical illness, the time for depression to subside may be longer. Thus, drug treatments in these cases should be longer.

There is a worse prognosis when there is cognitive impairment, the episode is more severe, disability or comorbidity is associated with other problems. Thus, the presence of depression increases mortality from various causes in the older age group.

In some patients a complete recovery may not be achieved, so they end up maintaining some depressive symptoms without fulfilling the diagnosis.

In these cases, the risk of relapse is high and the risk of suicide is increased. It is necessary to continue with the treatment so that the recovery is complete and the symptoms subside.

Evaluation

To correctly assess the patient with suspected mood disorder, a clinical interview and physical examination should be performed. The most useful tool is the interview.

Since elderly patients with depression can be perceived as less sad, it is also necessary to inquire about anxiety, hopelessness, memory problems, anhedonia or personal hygiene.

The interview must be carried out with language adapted to the patient, simple, that is understood with empathy and respect for the patient.

You should inquire about the symptoms, how they started, the triggers, the history and the medications used.

It is appropriate to use a depression scale adapted to the age group. For example, for the elderly group, the Yesavage or Geriatric Depression Scale can be used.

Likewise, cognitive function should be explored to exclude the presence of dementia, since it can be confused with a depressive episode in these vital stages.

Treatment

Treatment must be multidimensional, and take into account the context in which you live.

For the pharmacological treatment of these patients, as in most intervention in psychiatric disorders, the individualization of each patient is required, considering other comorbidities or associated medical conditions and evaluating the negative effects or interactions that may occur.

The main objective of the treatment is to increase the quality of life, that its vital functioning is more optimal, that the symptoms subside and there are no more relapses.

We found various methods to treat depression: drug therapy, psychotherapy, and electroconvulsive therapy.

When depression is between moderate and severe, it is necessary to introduce psychotropic drugs, preferably accompanied by psychotherapy.

Phases in the treatment of depression

We find different phases in the treatment of depression:

A) Acute phase: remission of symptoms through psychotherapy and / or psychotropic drugs. We must bear in mind that psychotropic drugs take between 2-3 weeks to begin to take effect and generally the maximum reduction of symptoms occurs between 8-12 weeks.

B) Continuation phase: improvement in depression has been achieved but treatment is maintained for 4-9 months so that there are no relapses.

C) Maintenance phase: the antidepressant is continued indefinitely in the event that the depressive episode is recurrent.

Psychotherapy

Psychotherapy is important for patient management, and the psychological trends with the most evidence are cognitive-behavioral therapy, cognitive therapy, problem-solving therapy, and interpersonal therapy.

It can be especially useful when psychosocial factors have been identified in the origin or maintenance of depression or when drugs are poorly tolerated or do not show efficacy.

Likewise, when depression is mild, it could be managed only with psychotherapy. Through this, the patient can improve their relationships, increase their self-esteem and self-confidence and help them better manage their emotions with negative valence.

Electroconvulsive therapy

Electroconvulsive therapy is an option indicated for depression with psychotic symptoms, for those who are at risk of suicide or refractory to treatment with psychotropic drugs.

It is also suitable for those cases in which depression is accompanied by malnutrition or a deficit in food intake.

information

Likewise, it is necessary to include correct information about the disease, intervene in the social sphere (day centers, maintain an active life, promote social relationships).

It should be taken into account that, despite its severity, depression in the elderly may have a better prognosis than other diseases, since its character, if appropriate treatment is offered, is reversible.

References

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