What is depression in the elderly and why it is difficult to recognise it
It is a mood disorder that can become a disabling condition if not treated in time, but which the person himself often finds difficult to recognise.
The depressed elderly person often complains of physical symptoms (somatisations of the psychic state or worsening of known physical illnesses) and cognitive difficulties: he minimises the sadness he feels, thinking that it is ‘normal’ after a certain age or out of shame at experiencing this feeling perhaps after a life of gratification (when he worked and was not ‘just a pensioner’, etc.).
Symptoms and alarm bells of depression in the elderly
The most obvious symptoms of major depression in the elderly are appetite and digestive disorders.
Other frequent symptoms are:
- insomnia;
- tiredness;
- pain;
- attention and memory problems;
- anxiety;
- tendency to isolate oneself.
A strong alarm bell is suicidal ideation: this symptom is more difficult to investigate and requires a high level of trust between doctor and patient in order to be confided in.
Possible triggers of depression
Depression has an uncertain origin and the cause(s) vary from person to person.
Often the cause is multifactorial.
Let us see with the psychiatrist what the possible triggers are.
From a bio-psycho-social point of view, familiarity is important: during the first psychiatric examination it is useful to tell the specialist, as well as the treating doctor beforehand, whether there have been other direct family members in the patient’s family (grandparents, parents, etc.) with a diagnosis of depression or other illnesses in the area of mood disorders in the past.
Possible causes of depression in the elderly include stressful events and chronic illnesses.
Also among the causes of this pathology are the changes that one typically experiences from the age of 65 onwards, i.e. from old age, such as retirement, financial worries, bereavements in the family, loss of autonomy, memory problems and other events.
These life events have a destabilising effect on the patient’s mental and physical health.
Diagnosis: the role of family members and GPs in detecting this condition
The patient avoids being examined out of shame or continually looks for a ‘physical’ cause, arriving at the psychiatrist late.
Typically, women feel guilty because they are ill and men feel shame and therefore great difficulty in seeking help for fear of the judgement of others.
One must listen with empathy to the patient and remember that mental health is as important as physical health, even in old age.
Clinical diagnosis by the psychiatrist
The first diagnostic tool is the patient’s clinical, family and general history, which is collected during the interview of the first psychiatric examination.
Following the visit to refine the diagnosis, a Magnetic Resonance Imaging (MRI) or CT scan of the brain may be prescribed by the specialist.
These diagnostic examinations will investigate age-related physiological changes or signs of atrophy or micro-vasculopathy, which are frequent in depression with senile onset (from the age of 65 or even earlier, from the age of 50).
Neuropsychological tests investigate current cognitive functions and can be repeated over time as a monitoring.
Depression, acceptance of diagnosis and treatment
Communication between doctor and patient in the acceptance of the diagnosis and adherence to therapy (compliance, ed.) by both patients and their families and caregivers is crucial.
The elderly often think that they are too old to care, that they are ‘weak’: this risks making their symptoms chronic, with negative repercussions on their health and autonomy.
This is why during the psychiatric examination we have to convey diagnosis, treatment and prognosis with proper optimism.
It takes a few weeks of therapy to see the effects, and then it must be continued as maintenance: the patient and carers must be aware of these treatment times, so as to ensure regular compliance and follow-up visits.
How depression in the elderly is treated
There are various strategies and therapies for the treatment of this pathology, which affects more and more over-65s.
They range from pharmacological and psychotherapeutic therapy to innovative transcranial stimulation techniques for specific cases.
Psychiatric treatment: between pharmacology, chronotherapy and transcranial stimulation
Antidepressant drugs with fewer drug interactions are preferred (serotonin reuptake inhibitors are the first choice): the elderly often take many drugs for several concomitant illnesses.
Thanks to these therapies, a 50%-85% recovery rate is achieved, although drugs alone are not always sufficient to restore the psychophysical balance of the depressed elderly patient.
In some specific cases, chronotherapies are proposed such as, for example, Light Therapy: these techniques act on the human being’s biological clock by resetting the systems involved in depressive symptoms.
Or, somatic techniques are proposed such as, for example, Transcranial Magnetic Stimulation or Transcranial Direct Current Stimulation: techniques that ‘wake up’ dormant brain areas in order to enhance the patient’s response to medication.
In severe or highly resistant cases, electroconvulsive therapy is well tolerated and gives good results (60-80%).
In our hospital for this therapy, we have a dedicated team that follows the depressed patient throughout the entire course of investigations and treatment.
Psychotherapeutic treatment
Often in the elderly, cognitive and relational patterns are more difficult to change, but psychological support can be proposed to cope better with the disease and life events, especially in mild cases or when contraindicated to medication, perhaps accompanied by neuro-cognitive training exercises (e.g. remembering the shopping list, doing crosswords or other puzzle games, reading books with many characters, etc.).
Diet and lifestyle
Loss of appetite and weight or disordered eating affect the physique, establishing a vicious circle: a balanced diet can help regain energy and support mood.
Movement benefits the physical state, depressive symptoms and self-esteem. In addition, we encourage the patient to resume sociability and interests that help keep cognitive faculties exercised.
Depression versus senile dementia: what links them and what differentiates them?
In depression in the elderly the contours between phases of illness and well-being, typical of major depression, are more blurred, with the risk of chronic ‘minor’ but disabling depressive states.
In senile dementia there is a progressive cognitive decline, with variable mood alterations.
In between, these influence each other: depression is a risk factor for dementia and in the elderly with dementia it is more frequent to observe depression as well.
For these reasons, it is important for the patient, or more frequently for the cohabiting family member and/or professional caregiver (e.g. carer), to pick up on the first signs of mood changes and to seek advice from the general practitioner and then the psychiatry specialist if the decline in mood and other symptoms persist for more than two weeks.
Depression and anxiety in the elderly: what links them and what distinguishes them?
The comorbidity of depression and anxiety is very high in general, even in the elderly.
Often in the elderly, depression is anxious with fears, insecurities, hypochondria, but the reverse can also occur: if the patient develops lasting anxiety, he or she may develop depression secondary to the depletion of inner resources, which is why it is important to treat it early.
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