Depression

What does it look like?

Feeling depressed or sad is less common in geriatric depression. More often than their younger counterparts, these patients experience anhedonia, lack of motivation, and sense of guilt and worthlessness. Older adults are also susceptible to heightened anxiety as a component of depression. Sometimes this is called an “agitated depression.” This can look like ruminative worry, restlessness, and pacing. The subacute onset of symptoms should always raise suspicion for depression rather than an anxiety disorder.

Catatonia and psychosis are also more common in geriatric depression and warrant referral. Psychosis usually takes the form of guilty preoccupation, excessive worry about somatic issues, and delusions of poverty. Even if delusions are not obvious, older depressed adults tend to have preoccupation with these topics.

Mania or mixed mood states are often characterized by physical agitation, restlessness, decreased sleep, and being more talkative. Left untreated, this can evolve to include destructive behaviors like spending excessively, engaging in other risk taking behavior, and even psychosis.

How do I screen for it?

Validated screening measures are often helpful, but not a substitute for clinical assessment. The PHQ-9 can be a useful screen, but the reliance on physical symptoms of depression can create diagnostic uncertainty in older adults with chronic medical comorbidity or frailty. The Geriatric Depression Scale (GDS) is a 15-item screening tool with yes/no answers. It addresses many psychological aspects of geriatric depression with questions phrased in a manner that resonates with older adults. A score of ≥5 is suggestive of depression and warrants further exploration.

It is difficult to ask someone to look back on their life and recall specific instances of depression. In women, it is ideal to screen for postpartum depression. This is because the question helps link their recall to a prominent part of their past and because this is a vulnerable time for women to experience depression, anxiety, and even psychosis.

Some older adults do not identify with terms to describe emotional states like “mood” and “anxiety.” Rather, it may be best to ask them about their “spirits” or if they have any difficulty with “worries” or their “nerves.”

Asking about a family history of depression or bipolar disorder is often helpful. Screening should be about their own parents and siblings, but also about their children and grandchildren.

Review recent medication and medical changes that can mimic depression, agitation, or mania. Some of these include thyroid disease, steroid use, bupropion or stimulants use, and poorly controlled diabetes and OSA.

What are the treatment options?

Mild depression can often be treated with supportive psychotherapy or cognitive behavioral therapy (CBT). In treating depression, CBT aims to identify and challenge automatic negative assumptions (e.g. “I’m worthless,” “things will never get better”) through behavioral exercises and patient charting. There is also a focus on changing maladaptive behaviors that perpetuate depression in a process called behavioral activation. CBT requires a patient to have the ability to reflect on emotional states, reason about alternatives, and enact these changes. Therefore, it requires cognitive flexibility with preserved executive functioning and working memory. Patients with dementia can still benefit from CBT techniques. Often the caregiver is included in sessions and the focus is shifted to managing practical behaviors and adapting to the environment.

Seasonal depression is often successfully managed with light therapy, which minimizes the risk of systemic side effects.

For cases of moderate-severe depression, antidepressant treatment is warranted in addition to offering psychotherapy. Escitalopram and sertraline are often preferred initial agents in older adults because of their ease of dosing, relative lack of drug-drug interactions, and cardiovascular safety. Venlafaxine, duloxetine, mirtazapine, and bupropion are other medications that are often safe in this population and common in primary care practice.

In general, dosing should start “low and slow,” but the same goal doses exist in older adults as with younger patients.

Additional Resources

  1. Geriatric Depression Scale https://consultgeri.org/try-this/general-assessment/issue-4.pdf

  2. Patient instructions for use of light therapy https://sad.psychiatry.ubc.ca/resources/public-resources/light-therapy-procedure-for-using-the-10000-lux-fluorescent-light-box/

  3. University of Michigan depression toolkit for patients https://www.depressioncenter.org/depression-toolkit

  4. University of Michigan Depression Center resources for family member education and support https://www.depressioncenter.org/patient-resources/support-groups

If you are a Michigan Medicine provider, and would like access to our lists of behavioral health resources, you may contact Michele Brown at resoho@med.umich.edu

Select References

  1. Blazer D. Depression in late life: review and commentary. J Gerontol A Biol Sci Med Sci. 2003;58(3):249-65.

  2. Thompson LW, Gallagher D, Breckenridge JS. Comparative effectiveness of psychotherapies for depressed elders. J Conult Clin Psychol. 1987;55(3):385-90.