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Q&A: Identifying, treating depression in elderly patients
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About 5% to 10% of elderly patients have depression or depressive symptoms, according to a presentation by Jin Hui Joo, MA, MD, assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, at Johns Hopkins Science Writers’ Boot Camp.
Depression in the elderly is not a part of aging; however, change that adults endure as they age, including physical and cognitive decline can increase the risk of depression. Psychologically, some older adults have difficulty accepting functional changes related to aging that can contribute to depression, she said.
In an exclusive interview, Healio Internal Medicine spoke with Joo about the signs of and risk factors for depression among older adults, as well as how PCPs can help elderly patients cope with changes and associated depression. – by Alaina Tedesco
Question: What are signs of depression in older adults?
Answer: Older adults who seem to be withdrawn, down, in discomfort or not as energetic may be displaying signs of depression. Depressed elderly patients also may not enjoy being around people as much and may not be as sociable.
Physical aches and pains, such as headache or joint pain, are also tied to depression.
In mild cases, some signs of depression in the elderly that clinicians may observe is that they don’t take care of themselves like they used to. For example, they don’t bother to groom themselves as well, put on makeup or dress nicely. Additionally, they may not initiate activities as much, such as exercising, walking or calling friends.
Elderly patients with depression may also have trouble sleeping at night. They may demonstrate changes in appetite, so weight gain or weight loss may be a sign of depression.
Older adults with depression might express suicidal thoughts in severe cases and even mild cases depending on the context. Physicians should take such expressions seriously. It is useful to discuss the feelings, thoughts and existing life stressors that may be contributing to the suicidal thoughts. It is useful to make the older adult feel cared for rather than frightened or ashamed of expressing suicidal thoughts. This will help engage the person in care.
Q: Are there any risk factors for depression in older adults?
A: Genes have a role in depression, so if a patient has a family history of depression then they are at greater risk. Trauma and adverse childhood events are related to depression as well. Risk for depression seems to be related developmentally so even adverse events that happen as a child are related to risk for mood disorders and mental health issues later in life.
Older patients with a lot of medical problems that limit their functioning or quality of life are more susceptible to depression. Functional limitations contribute to the risk for depression, but there are also physiological connections. For example, pain, diabetes, hypertension and a host of medical illnesses can increase the risk for depression.
Acute stress that is not going to be resolved quickly can also put an elderly patient at risk for depression. Acute stress most commonly stems from relationship issues. An older adult may not have a great relationship with their children who may be in a caregiving role, which can make things very difficult. If they had a spouse who recently passed away that is also something that should be addressed because that can put them at risk as well. Addressing issues of acute stress may be helpful in preventing depression.
Another risk factor for depression among older adults is social isolation and lack of social support and connections with the people around them.
Q: How can PCPs help older adults accept the inevitable changes they endure as they age ?
A: The first thing physicians can do is recognize that something is not right. The patient may tell their PCP themselves but, depending on the patient and the physician, mental health issues may not come out easily in primary care setting. Physicians will find it useful to understand the importance of recognizing and addressing depression and its relationship with physical health and chronic medical conditions.
Probing, asking questions or completing a screening questionnaire for depression can help PCPs get started in recognizing that there is an issue. Once a PCP identifies an elderly patient for depression, then they can do something about it.
PCPs often refer patients with depression, but typically that doesn’t work very well because patients typically don’t follow up and mental health care is very difficult to get in the community because of the low number of providers, cost limitations and transportation time.
If PCPs have time, a very basic intervention is to listen and provide psychosocial support. Physicians should listen without offering solutions because sometimes part of the depression that can be helped is just to hear the person out and let them express it. If the depression is severe enough and the patient wants something more like medications or a referral to a psychiatrist, then that can be provided.
The primary thing is recognizing that it is important and assessing it. I believe it’s also important to not automatically refer. What can be very useful is if PCPs can do some active listening with the patient: listen to them talk about their struggles and what the problem is. Once that is done some sort of a problem-solving approach can take place.
Q: What are some interventions for older patients that can reduce depressive symptoms?
A: The first thing that should be tried depending on severity is a psychosocial intervention. One of the basic things that anyone can do is psychosocial support, including active listening and providing empathy in a very safe setting for them to express themselves.
Interventions for depression should be tailored to the patients’ needs.
A problem-solving approach may help to address the issues that are recognized as contributing to low mood. Additionally, cognitive behavioral therapy in which the clinician reframes the situation and has the patient look at the situation in a way that is adaptive and enables them to take some sort of action will alleviate the stressor that may be causing the depression.
Other interventions, especially if the patient is socially isolated, is to ask for permission to talk to their children or people in their social network to get them involved in the care of the patient. Sometimes people are available and sometimes they are not but it’s always good to ask and to let them know that social isolation can be deadly and is something that should be addressed.
It’s also useful to think about community-based resources that patients can use short of referring to a psychiatrist. They may benefit from an aging organization program or social program. Senior centers are common and may be a good fit for the patient.
Often patients don’t want medications, but in many severe cases medication is required before therapy or related services can be initiated. Most often an elderly patient needs both. Even in severe cases, research shows that medicine and psychotherapy together offer the greatest benefits. Referral to a clinical social worker can also be helpful.
Q: How does depression fit into a patient’s overall well-being ?
A: In the medical setting, it is important to understand that mood disorders and physical conditions are tightly connected. It’s to the detriment of the patient to ignore mood disorders and mental health conditions because that can negatively affect how well they manage their physical condition and their overall well-being.
Disclosure: Joo reports no relevant financial disclosures.