Clinical Notes : Mental Health

86. Depression in the elderly

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Types of depression (at any age) :

Symptoms caused by major depression can vary from person to person.

Individuals may present with specific features of depression inluding :

  • Anxious distress

    • depression with unusual restlessness or worry about possible events or loss of control

  • Mixed features

    • simultaneous depression and mania, which includes elevated self-esteem, talking too much and increased energy

  • Melancholic features

    • severe depression with lack of response to something that used to bring pleasure and associated with early morning awakening, worsened mood in the morning, major changes in appetite, and feelings of guilt, agitation or sluggishness

  • Atypical features

    • depression that includes the ability to temporarily be cheered by happy events, increased appetite, excessive need for sleep, sensitivity to rejection, and a heavy feeling in the arms or legs

  • Psychotic features

    • depression accompanied by delusions or hallucinations, which may involve personal inadequacy or other negative themes

  • Catatonia

    • depression that includes motor activity that involves either uncontrollable and purposeless movement or fixed and inflexible posture

  • Seasonal pattern

    • depression related to changes in seasons and reduced exposure to sunlight

  • Peripartum onset

    • depression that occurs during pregnancy or in the weeks or months after delivery (postpartum)

Signs and symptoms of depression in the elderly :

  • More common in OOH setting :

    • Neglecting personal care (skipping meals, forgetting meds, neglecting personal hygiene)

    • Unexplained or aggravated aches and pains

    • Sleep disturbances (difficulty falling asleep or staying asleep, oversleeping, or daytime sleepiness)

    • Fixation on death or angor animi; thoughts of suicide

  • Other signs and symptoms :

    • Sadness or feelings of despair

    • Loss of interest in socializing or hobbies

    • Weight loss or loss of appetite

    • Feelings of hopelessness or helplessness

    • Lack of motivation and energy

    • Loss of self-worth (worries about being a burden, feelings of worthlessness or self-loathing

    • Slowed movement or speech

    • Increased use of alcohol or other drugs

    • Memory problems, slowed movement and speech


Depressed older adults may not feel “sad”

While depression and sadness might seem to go hand and hand, many depressed seniors claim not to feel sad at all. They may complain, instead, of low motivation, a lack of energy, or physical problems. In fact, physical complaints, such as arthritis pain or worsening headaches, are often the predominant symptom of depression in the elderly

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Risk factors for depression:

  • Physical ill health

    • Chronic illness

    • dementia

    • stroke

    • Parkinson’s

    • chronic pain

  • Social factors

    • Social isolation

    • being a carer

    • bereavement

  • Prior history of depression

  • Substance misuse may be either a cause or consequence of depression

  • Medication causing or aggravating depression

    • Blood pressure medication (e.g. clonidine)

    • Beta-blockers (e.g. Lopressor, Inderal)

    • High-cholesterol drugs (e.g. Lipitor, Mevacor, Zocor)

    • Tranquilizers (e.g. Valium, Xanax, Halcion)

    • Calcium-channel blockers

    • Medication for Parkinson's disease

    • Sleeping pills

    • Ulcer medication (e.g. Zantac, Tagamet)

    • Heart drugs containing reserpine

    • Steroids (e.g. cortisone and prednisone)

    • Painkillers and arthritis drugs

    • Estrogens (e.g. Premarin)

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Screening questions :

  • During the last month, have you often been bothered by feeling down, depressed or hopeless?

  • During the last month, have you often been bothered by having little interest or pleasure in doing things?

If the answer to either of these questions is positive, further assessment of mental state, functional abilities and social situation should be undertaken by a trained person. 

Brief assessment :

A quick assessment tool, such as the Geriatric Depression Scale, may be used in the OOH setting to detect depression in the elderly with a greater degree of confidence.

Again, if positive then further assessment of mental state, functional abilities and social situation should be undertaken by a trained person. 


Is it grief or depression?

As we age, we experience many losses.

Loss is painful—whether it’s a loss of independence, mobility, health, a long-time career, or a loved one. 

Grieving over these losses is normal and healthy, even if the feelings of sadness last for a long time.

Distinguishing between grief and clinical depression isn’t always easy, since they share many symptoms. However, there are ways to tell the difference.

  • Grief is a roller coaster involving a wide variety of emotions and a mix of good and bad days. In grief there are still moments of pleasure or happiness.

  • With depression, on the other hand, the feelings of emptiness and despair are constant.

  • While there’s no set timetable for grieving, if it doesn’t let up over time or extinguishes all signs of joy—laughing at a good joke, brightening in response to a hug, appreciating a beautiful sunset—it may be depression.


Diagnosing depression in the presence of dementia :


This is a diagnostic challenge, and specialist referral is usually required.

Some symptoms of depression such as tiredness, weight loss and psychomotor retardation also occur in dementia. 

A history of the symptoms from an informant may be helpful. 

Risk of suicide in older people with depression :

Older adults with depression are at higher risk of completed suicide that younger people, so specific enquiry into suicidal thoughts should always be made.  Risk factors for suicide in older people include:

  • Older age, male sex

  • Social isolation

  • Bereavement

  • History of attempts

  • Evidence of planning

  • Chronic painful illness or disability

  • Drug or alcohol use

  • Sleep disorders

Management in OOH setting:

  • Treat presenting co-existing physical health problems. 

  • General advice should include

    • good sleep hygiene,

    • maintaining physical activity

    • limiting alcohol intake

  • Consider providing handout for information and encouragement to seek formal assessment and/or referral, and individualised management plan

  • Refer back to family GP for formal evaluation and/or referral

  • Defer prescription of antidepressants until formal evaluation and/or referral


Geriatric Depression Scale - 15

App for iPhone and iPad



Geriatric Depression Scale 2.0

App for android devices



NICE guidelines : CG90

Depression in adults: recognition and management

Published October 2009   

Updated April 2018


Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 2008 British Association for Psychopharmacology guidelines

Cleare A. et al

British Association for Psychopharmacology

Journal of Psychopharmacology 2015, Vol. 29(5) 459 –525



Nonpharmacologic versus pharmacologic treatment of adult patients with major depressive disorder

American College of Physicians

Qaseem A. et al

Ann Intern Med. 2016;164(5):350-359.


Practice guideline for the psychiatric evaluation of adults

American Psychiatric Association

Third Edition



Clinical practice guidelines for mood disorders

Royal Australian and New Zealand College of Psychiatrists

Australian and New Zealand Journal of Psychiatry 2015, Vol. 49(12) 1-185.


Cole MG, Dendukuri N.

Risk Factors for Depression Among Elderly Community Subjects : A Systematic Review and Meta-Analysis

Am J Psychiatry 2003; 160:1147–1156


Wijkstra J, Lijmer J, Burger H, et al.

Pharmacological treatment for psychotic depression.

Cochrane Database Syst Rev. 2015 Jul 30;(7)


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