Depression Among Older People

Depression among older people is a mixed bag. It includes people who have suffered from depressive episodes since younger adulthood (early-onset), those in whom the first episode of depression is after middle age (late-onset), and possibly a third group in whom depression starts much later (after 70 years). Of course, cut-offs using chronological age are not impervious to exceptions, and applying any findings to individuals should take into account their biological age, ie, how fit and healthy they are.

There are certain commonalities among these groups of older people with depression. For example, all have to deal with increasing limitations put on their lives by various physical illnesses (comorbidities) that are common in old age, such as high blood pressure, heart disease, diabetes, stroke, arthritis, deafness, and dementia. We can also make some generalizations about both causes and treatments of depression from younger age to older age. For example, life events and the brain chemical serotonin may be involved in depression at any age, and antidepressants may work in any age group (although most, or probably all, randomized controlled trials of any new antidepressant exclude older people).

However, there may be some interesting differences among groups of older people with depression. For example, our research¹ has shown that older people who self-harm for the first time in old age have a much higher intention to kill themselves at the time of self-harm than middle-aged people with a first episode of self-harm, and older people are more likely to try to kill themselves again if they have problems with their physical health. Hence, in this group of older people, collaboration between primary care physicians and psychiatrists may be particularly important to prevent further episodes of self-harm. In a separate study,² we found that, although older patients with late-onset depression who commit suicide differ from older patients with early-onset depression who commit suicide—eg, more recent life events, less alcohol misuse, and less frequent history of past self-harm in the late-onset group—recent self-harm as a final pathway was present in at least a quarter of both groups of patients. This finding provides opportunities for interventions to prevent repetition of self-harm and suicide.

Vascular diseases, which may compromise optimal blood supply to the brain, may be involved in causation of late-onset depression,³ and patients with vascular diseases often do not respond well to antidepressants.⁴ These patients often have mild difficulties with certain brain function (for example, planning or changing plans to suit changing external circumstances), which persist even after improvement or resolution of depression. Recent research⁵ also suggests that the relationship between vascular diseases and depression may be particularly apparent in older patients who present with somatic or physical symptoms (eg, tiredness) rather than psychological symptoms (eg, sadness).

Lastly, I would also like to point out that, in older people, the relationship between depression and dementia is complex, with 3 possibilities.⁶ First, depression is a risk factor for Alzheimer’s disease and dementia. Second, depression may be a prodrome or presenting symptom of dementia. Third, depression may develop during the course of dementia; up to 30% of patients with Alzheimer’s disease, and a greater percentage with other dementias, develop major depression.

Financial disclosure:Dr Purandare had no relevant personal financial relationships to report.

References

1. Oude Voshaar RC, Cooper J, Murphy E, et al. First episode of self-harm in older age: a report from the 10-year prospective Manchester Self-Harm project. J Clin Psychiatry. 2011;72(6):737–743. Abstract

2. Voshaar RC, Kapur N, Bickley H, et al. Suicide in later life: a comparison between cases with early-onset and late-onset depression. JAffect Disord. 2011;132(1–2):185–191. PubMed

3. Paranthaman R, Burns AS, Cruickshank JK, et al. Age at onset and vascular pathology in late-life depression [published online ahead of print July 13, 2011]. Am J Geriatr Psychiatry. PubMed

4. Bella R, Pennisi G, Cantone M, et al. Clinical presentation and outcome of geriatric depression in subcortical ischemic vascular disease. Gerontology. 2010;56(3);298–302. PubMed

5. Marijnissen RM, Bus BA, Holewijn S, et al. Depressive symptom clusters are differentially associated with general and visceral obesity. J Am Geriatr Soc. 2011;59(1):67–72. PubMed

6. Enache D, Winblad B, Aarsland D. Depression in dementia: epidemiology, mechanisms, and treatment. Curr Opin Psychiatry. 2011;24(6):461–472. PubMed