ABSTRACT
It is testament to the advances of modern medicine that we have a population with more older people than ever before. While we are increasingly adept at managing their physical comorbidities, we have made relatively little progress in addressing the psychological impact of ageing. In this article we consider the prevalence and complex aetiology of depression in older people who often have to deal with profound loss, while simultaneously managing multiple comorbidities. We consider the challenges of diagnosing depression faced by healthcare professionals including access to resources and training, and what differentiates depression from socially appropriate low mood. Finally, we discuss treatment options and the difficulties that clinicians face when they have only limited resources and skills available, but a desire to help. We consider the role for antidepressants, and when not to prescribe, before addressing the challenges of providing talking therapies and social interventions.
Introduction
Put yourself in the shoes of Barry. Barry is 84; he is fictitious, but his story is not an uncommon one. He was once a successful businessman, who was married to Joan, had three children, cycled daily and was the chair of the Rotary Club. Life was comfortable. Barry was needed and valued at work, at home and by his friends; he took pride from this and was financially and emotionally rewarded for it. He now lives alone. Joan died 2 years ago; his children live far away, but call weekly. His work life is a distant memory, and his Rotary friends are mostly housebound or have died. He has multiple painful comorbidities, is housebound and has limited ability to perform activities of daily living. To pass the time and forget, Barry watches television and drinks a quarter bottle of whiskey per night.
Barry's life is dominated by loss; loss of health, loss of family, loss of a social role, loss of productivity. His low mood is understandable. Perhaps anything other than low mood would be abnormal?
When we assess Barry he meets all the diagnostic criteria for depression. Guidelines tell us we should consider cognitive behavioural therapy for Barry, but he cannot leave the house to access the service. We consider social prescribing, but the hour-long befriending service does little to lighten the other 167 hours of the week. Failing this, we might consider an antidepressant tablet, but we know it will not change his situation. Is Barry depressed? Or are we haplessly looking at a desperately sad situation through a medical lens, which will inevitably end with both the clinician, Barry and Barry's family feeling like they have failed?
This opinion piece will explore the how and when older people experience depression, the role of clinicians in identifying and addressing it, and discuss when and how we should go about managing it.
Depression is present in around 17% of older people and 8% will have major depression.1,2 This number is even higher when we consider older people who are admitted to hospital: 8–23%.3 These rates are independent of mood disorders associated with dementia, which in themselves are very prevalent: around 34% in hospital and 29% in the community.4,5
Most depression is treatable, and those with active symptoms have worse outcomes than age-matched ‘non-depressed’ controls. They experience higher rates of morbidity, mortality, pain, cognitive impairment and disability.6–10 They are more likely to require hospital admissions and while they are there they are more likely to stay longer and be readmitted soon after discharge.11 People with depression are more likely to neglect themselves, self-harm or end their life by suicide, particularly older men.12 If left unattended to, then people can experience appetite loss and demotivation leading to anorexia and associated malnutrition.13 At its most extreme, they can experience terrifying psychotic symptoms or catatonia.14
The symptoms of depression are well defined. The International Classification of Diseases 11th revision (ICD-11) and Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-V) largely agree on the criteria: depressed mood, diminished interest in almost all activities, fatigue and loss of energy, insomnia or hypersomnia, change in appetite or significant weight loss, psychomotor agitation or retardation, feelings of worthlessness and guilt, diminished ability to concentrate or think, recurrent thoughts of death or suicide.15,16 Older people can present with depression ‘atypically’. It is not uncommon to find depression in the absence of depressed mood or sadness; instead, people report feeling emotionless or empty.17,18 Other differences are a greater emphasis on feelings of guilt and worthlessness. Older people with depression are also more likely to experience nihilistic delusions or delusions of poverty.19
Symptoms can be mild, with subtle changes to a person's demeanour, only noticeable to those who know them well. Likewise irritability (a common presentation of depression in older people17) can be accounted for as a personality trait. Diagnosing a person presenting with all nine DSM symptoms with depression is a relatively simple task. It is the subtle, mild, atypical symptoms that challenge. It is perhaps one reason for the under-diagnosis and under-treatment of older people with depression.20 This is particularly pronounced in those with sub-syndromal depression, or mild depression.21 Seeking collateral history from family members when symptoms are mild can be an immensely helpful source of clinical information in these situations, who often report that their loved one is ‘not their usual self’.
Most older people with depression will never meet a psychiatrist. Their depression is unlikely to be the primary reason for presentation or seeking help. A much more common scenario is where the older person is being seen by a healthcare professional for a physical health disorder, while they also have undiagnosed comorbid depression. The clinician will only become aware of this if they ask about it or are explicitly told by the patient. The time pressures of a busy clinic or ward round, and a lack of awareness, can stop clinicians asking about depression. The stigma of discussing mental illness for the older person inhibits them speaking out. It is little surprise therefore that depression is under-diagnosed in the community and a hospital setting.21,22 Even when it is diagnosed, it can be argued that it is under-treated.23
It will be a near universal mantra that we should aim to reduce feelings of sadness, loneliness and hopelessness in older people; it is human to want to do so. As discussed above there are also clear societal, health and welfare advantages. However, before considering how and when to treat depression we need to consider the aetiology and treatment goals.
Aetiology
The aetiology of depression is complex and usually multifactorial. The monoamine hypothesis is the most widely accepted biological theory: this suggests that depression results from deficiencies in serotonin, noradrenalin and dopamine at the synaptic cleft.24 It is the origin of every conventional antidepressant drug, but is clearly not the whole picture. 30% of cases of depression are treatment-resistant, suggesting that other aetiological factors are at play.25
Psychological and environmental and social factors can also trigger and/or propagate depression and are well understood.26,27 Accumulation of assets (including wealth, education and supportive family networks) and deficits (such as poor maternal health, poverty or unemployment) can affect mental health over one's life course and impact on depression.
Further impacts can occur in old age itself. For example, less generous pensions, diminished societal status, lack of age-friendly provisions to exercise or socialise, and a failure to integrate people into their communities may lower resilience, while bereavement of family or friends may be a ‘stressor’ that tips the balance of mental health into the negative.
Papadopoulos et al28 describe psychological wellbeing in later life as a person living a life that is meaningful, with both personal and cultural fulfilment. Green et al29 summarise this into five domains:
Personal: fostering meaningful family and intergenerational relationships.
Social: Having access to support networks, cultural activities and friendship networks.
Health: Maintaining physical and mental health, engaging in physical activity.
Resources: Having financial security, having access to comfortable living arrangements.
Local: Having access to cultural activities, local shops and medical resources.
With age, every domain is increasingly threatened, leading to the older person being more likely to experience an existential crisis defined by loss. A loss of role in society, a loss of cultural and family identity, a loss of independence, and with bereavement a loss of companionship. None of this loss will be replaced by an antidepressant.
Furthermore, older people are increasingly likely to experience illnesses associated with depression and/or prescribed medications that can lower mood and increase anxiety as a side effect. 33% of people post stroke, 31% of people post myocardial infarction and 35% of people living with Parkinson's disease will have clinically significant depressive symptoms. 17% and 20% of people post stroke and with Parkinson's respectively will develop severe depression.30–32
The list of physical health disorders associated with depression goes on and is summarised by Goodwin et al,33 but to name only a few it includes:
Endocrine disease: Cushing's disease, thyroid disease
Infections: encephalitis, hepatitis
Neurological disease: epilepsy, multiple sclerosis
Rheumatological disease: systemic lupus erythematosus
Of the medications we prescribe commonly to older people corticosteroids, betablockers and levothyroxine are all associated with depression.34–36
All of these psychological and physical insults are impacting on an ageing brain that has less efficient and fewer neurons, a worsening vascular supply, a lifetimes accumulation of pathological substances such as beta amyloid and atherosclerotic plaques, and a reduced ability to regenerate.37 The vascular depression hypostasis is perhaps the most commonly cited structural brain change associated with depression–a single infarct or accumulation of infarcts in the prefrontal cortex associated with depression.38,39
None of the risk factors we have considered above are rare events, and it is perhaps surprising that the prevalence of depression in older people is not even higher. Perhaps this comes down to how we classify depression? The DSM diagnostic criteria listed above would clearly tell us it is when the person experiences five or more symptoms for more than 2 weeks. While it makes life easy to delineate mental illness using clear cut-offs, it does not help the likes of Barry, whom we considered at the start of the article. Barry is experiencing profound loss, and the point at which that experience becomes an illness, or whether it ever should be called an illness at all, is debatable. Where is the pathology? It is convenient and easy to call loss and sadness an illness; it allows us to neatly classify it and use guideline-driven evidence medicine to treat it. Contextually, however, the aetiology of Barry's emotional experience if very different from a 30-year-old with few social or psychological stressors who has a primary depressive disorder. We diagnose and treat them the same, however. It is convenient (perhaps even lazy) to do so. Looking at it without the medical lens, it makes little sense.
Diagnosis
The majority of doctors who are not psychiatrists will have learnt how to assess and diagnose depression during medical school psychiatry training. In the UK this is a 4–6 week course. The information retained during training will decay over time and is unlikely to be updated as part of standard continuous professional development. Some, but not all, GPs will have had some psychiatry posts as part of their training programme, usually lasting 6 months, and the diagnosis and management of depression is a core aspect of training in general practice and geriatric medicine.40 It is also worth noting that assessment of mood is a key component of comprehensive geriatric assessment. This is a structured assessment and management plan, usually led by a geriatrician, or someone with equivalent expertise, that not only looks at the current medical problem, but also routinely involves assessment of mood, cognition, functional abilities and social and environmental aspects of care.41
Doctors without formal psychiatry training feel less confident assessing and diagnosing depression.42 It should be standard practice to assess patients for depression on admission to hospital,43 yet in a recent UK audit less than 5% received this.44 There is no available published evidence on the confidence of hospital-based physicians in diagnosing and treating depression; however, it is low in other specialties, even ones that see high depression prevalence, such as obstetrics.45 When doctors are underconfident at recognising depression, they are also underconfident at assessing suicide.46
Even when a healthcare professional has the confidence and skills to assess mental health, they need time to do so. A full psychiatric history is time consuming and is rarely the priority examination in someone attending a medical appointment or ward round.
Screening tools for depression are a possible solution to this. Population-based screening programs have been in and out of vogue in various countries over the last 20 years.47 The debate on when or who to screen will not be settled here; however, depression screening tools both for the general population and specifically for older people are plentiful.48 One of the more commonly used screening tools in the UK is the patient health questionnaire 9 (PHQ-9), which has good sensitivity (0.88) and specificity (0.85) and has been specifically tested in older people.49,50 Other commonly used screening tools designed for older people include the Brief Assessment Schedule deck of cards,51 the Geriatric Depression Scale (GDS)52 or shortened versions of it such as the GDS-15 or GDS-5.53,54 The ‘two question screen’ is shorter still and yet has comparable performance with the geriatric depression scale.55 Still though, none will differentiate loss, sadness and pathological depression; that needs context and history.
Treatment
On the face of it, psychiatric treatment for depression is relatively simple and is well defined in guidelines. There are three main strategies: antidepressants, talking therapies or social/environmental adaptations. Where symptoms are life threatening electroconvulsive therapy may be considered, but that is beyond the scope of this article.
To prescribe, one is assuming that the depression will respond to monoamine upregulation. There are many antidepressant choices available, and prescribing in moderate to severe depression is guideline-driven.56,57 In the UK sertraline and mirtazapine are the most commonly used–mostly due to their more favorable side effect profiles when considered alongside the others.57,58 For those patients who have a primary depressive disorder they may well help. For those who are suffering loss, coping with a change in social role, managing chronic illness, or have structural age-related brain pathology they will at best have a placebo effect.23,59 At worst they will compound problems, causing side effects and increasing cholinergic burden. Antidepressants have their role, but we must consider what it is we are trying to treat, and how increasing noradrenalin or serotonin availability at the synaptic cleft will help.
Talking therapies are recommended in mild, moderate and severe depression.57 There is a good evidence base to support this. The most commonly prescribed are cognitive behavioral therapy (CBT) or psychoanalytic psychotherapy. In the UK there has been a drive to provide increased provision of CBT via the Improving Access to Psychological Therapy (IAPT) scheme. This is a national strategy and offers increased provision talking therapies to all (including older people).60 Yet older people appear to be referred less for talking therapy than younger people.61 This may be due to the stigma associated with talking therapies or faulty assumptions that talking therapies cannot be effective in older people. Some therapies are contraindicated in those with moderate to severe cognitive impairment. However, even in those with moderate severity dementia may respond to novel therapeutic techniques.62 Age should not be a barrier to accessing therapy.
Perhaps the hardest to define treatments are the practical, social or environmental adaptations that can be put in place for older people. These may be simple steps such as changing a prescription to remove or reduce a drug that has been causing low mood. It may be treating any reversible medical causes of depression, for instance infection, thyroid disease or seizures. Other conditions, such as Parkinson's, stroke and myocardial disease, are clearly not reversible; however patients and their families can be counselled on the possible psychological impact of these events and supported through them.63 There is also a good evidence base for the early use of antidepressant therapy here.58,64,65
Addictions to alcohol or drugs are increasingly prevalent in older people and are directly associated with mood disorders, yet they rarely discussed or asked about.66 Furthermore, older adults with depression are three to four times more likely to have alcohol related problems.67 If the patient is motivated to change, referrals to local drug and alcohol services may help to reduce harmful drinking or substance use, with a potential secondary improvement in mood.
The impact of making social changes is hard to quantify. However, social prescribing is a potential approach to de-medicalise mental health problems and improve wellbeing with a person centered approach.68 A trained link worker can talk to a patient and find out what matters to them, with a deep knowledge of how to access services in their local community. They can help build self-esteem and confidence and suggest groups, activities or exercises tailored to the individual's needs, thus preventing loneliness, providing a sense of purpose and providing emotional and psychological support at times of need. The ability for support will be dependent on community social care provision, the patient's family members and friends, and charities. The clinician reviewing the depressed older person has little ability to impact the availability of these things. It is all too easy in this situation for the clinician to feel bereft of treatment options and to reach for a prescription pad.
Conclusions
It is testament to the advances of modern medicine that we have a population with more older people than ever before. While we are increasingly adept at managing their physical comorbidities, we have made little progress to address the psychological impact of ageing. Our role as clinicians in the first instance is to acknowledge and appreciate this loss; the person sat in front of you is not a catalogue of symptoms and disease, they are a complex, emotional human that is potentially experiencing a slow and painful existential crisis as their social structures slowly crumble around them, while their brain simultaneously ages.
Depression in older age can be easily missed. A systematic approach, like comprehensive geriatric assessment or the use of screening tools, may help us identify depression. If we do find it, some cases may be amenable to therapy or an antidepressant. But for others, thinking more broadly about the social determinants of depression, using a life course approach and recourse to tools such as social prescribing may be more beneficial. The answer is not always to add another comorbidity to the list and reach for the prescription pad. We all have a responsibility to think, why is this person feeling sad, and what should be done to help them?
- © Royal College of Physicians 2023. All rights reserved.
References
Jump to section
Related Articles
Cited By...
- No citing articles found.