Depression in the Elderly Many

Depression in the Elderly

Many American adults are living longer and healthier lives than ever before, and the elderly segment of the population is rapidly growing. Current U.S. Census Bureau projections indicate that the number of elderly in the United States will fully double by mid-century, and despite the advances in healthcare that have made longer life possible, many of these older adults will still suffer from age-related disorders. In some cases, these disorders can contribute to the incidence of depression in the elderly while in other cases, the depression specific cause or causes of depressive episodes remains unclear. What is known, though, is that depression can have an enormous adverse effect on people's lives and the elderly are at particularly high risk for developing this condition. The problem of depression among the elderly is also significant because of the potential adverse outcomes that are involved. Although virtually everyone experiences some level of depression from time to time during their lifetimes, most people fully recover from these depressive episodes with no lasting ill effects. In other cases, though, depression can results in a wide range of adverse outcomes, including suicide. This paper provides a review of the relevant peer-reviewed and scholarly literature concerning depression among the elderly, including a description of the condition, its potential causes among the elderly, as well as its effects and common treatments, followed by a summary of the research and important findings in the conclusion.

Review and Discussion

Background and Overview

Depression is a major public health threat, with more than 18 million Americans currently suffering from the condition which affects an individual's thoughts, moods, feelings, behavior, and even physical health (Williamson, 2008). Although the precise causes of depression differ from individual to individual, stressful episodes are known to cause depression, while in other cases, depression seems to just occur without any discernible cause (Williamson, 2008). Most people tend to experience more than one depressive episode in their lives, although it is possible for depression to never occur or only occur a single time during an individual's lifetime (Williamson, 2008). In yet other cases, depression can assume chronic levels that require a lifetime a treatment (Williamson, 2008).

A number of adverse health-related outcomes of special concern to the elderly are associated with depression as well, including a four-fold increase in the risk of developing coronary disease; likewise, people with depression may experience more severe problems with diabetes and the condition can even diminish the effectiveness of the insulin therapy used to treat diabetes (Williamson, 2008). In this regard, Nemeroff (2008) notes that, "Depression is a major and independent risk factor for the development of coronary artery disease (CAD) and stroke [and] depression is a major risk factor for first-ever stroke in 85-year-olds" (p. 857). Depressed elderly patients with these comorbidities can be safely treated pharmacologically, but Nemeroff adds that, "Because vascular disease is very common in the elderly, it is of great interest to focus on these comorbidities in this risk population" (p. 858). In fact, these comorbidities were the focus of a study by Robinson, Spalletta, Jorge, Bassi, Colivicchi, Ripa and Caltagirone (2008) in which the authors report, "The association of post-stroke depression in the elderly with increased mortality has been reported by several investigators during the past 15 years. These studies have consistently found that increased mortality is associated with mild and severe depression" (p. 867). Yet another finding that has been consistently reported has been an increased mortality that is associated with acute post-stroke depression, a condition that is discernible as early as one year post-stroke, but which persists for a minimum of 7 years post-stroke (Robinson et al., 2008).

In addition, depression has been shown to cause a 10 to 15% increased risk of developing bone density loss and individuals who suffer from cancer, Alzheimer's disease, or Parkinson's disease tend to experience more negative outcomes than those who do not suffer from depression (Williamson, 2008). According to Gudmundsson, Skoog, Waern, Blennow, Palsson, Rosengren and Gustafson (2008), "Consequences of depression include disability, reduced life satisfaction and increased mortality" (p. 833). In addition, depression has been found to contribute to a higher incidence of suicide, with most of the people who commit suicide having a mental disorder which is most commonly depression (Williamson, 2008). There are several different types of depression, though, and these are described further below.

Types and Symptoms of Depression

In the general population, there are five primary types of depression as follows:

1. Major depressive disorder. This type of depression is a mood disturbance that lasts 2 or more weeks.

2. Dysthymia. This type of depression is a milder, more continuous form that persists for at least 2 years.

3. Adjustment disorder. This type of depression is associated with some form of loss (i.e., a loved one or employment) or a diagnosis of a catastrophic illness such as cancer; in the majority of instances involved adjustment disorders, sufferers are able to recover but in some cases these events can trigger even more severe and persistent forms of depressive illness.

4. Bipolar disorder. Formerly termed "manic depression," bipolar disorder is characterized by recurrent episodes of depression and elation (mania).

5. Seasonal affective disorder. This final type of depression is defined as a pattern of depression associated with the changes in seasons and/or a lack of exposure to sunlight (Williamson, 2008).

In the elderly segment of the population, a number of symptoms that are associated with depression such as thoughts of dying, fatigue, loss of libido, reduced sleep, and sleeplessness are frequently regarded as simply being part of the normal aging process (Benek-Higgins, Mcreynolds, Hogan & Savickas, 2008). According to these researchers, "In fact, some physicians still do not consider depression as a potential diagnosis in the elder population because it mimics features of existing physical problems" (Benek-Higgins et al., 2008, p. 283). As an example, Benek-Higgins and her associates point out that a stroke in later life can result in a number of the same symptoms that characterize depression, as well as the side effects that result from taking medications for heart disease, hypertension, arthritis, cancer and diabetes mellitus. In elderly women, thyroid dysfunction and diminished estrogen levels can hamper an accurate diagnosis of depression (Benek-Higgins et al., 2008). Moreover, because memory loss frequently accompanies old age and is also a symptom of dementia, elders are commonly diagnosed with dementia rather than the underlying condition of depression (Benek-Higgins et al., 2008). Although all elders are unique and will manifest depressive symptoms differently, some of the more well-known symptoms associated with depression among the elderly include the following:

1. Insomnia;

2. Hypersomnia;

3. Eating too much or too little;

4. Loss of energy, fatigue, and a general diminished ability to concentrate;

5. Irritability is a frequent sign of depression in elder men, as are complaints of stomach problems, palpitations, and shortness of breath (Benek-Higgins et al., 2008).

Some of the physical indications of depression in the elderly involve changes to their appearance, a stooped posture, social withdrawal, hostility, suspiciousness, slowed speech and movements, wringing of hands, picking of skin, pacing, and outbursts of aggression (Benek-Higgins et al., 2008). There are five basic areas of functioning that have been shown to be negatively impacted by depression which are mutually exacerbating:

1. Emotional;

2. Motivational;

3. Behavioral;

4. Cognitive; and,

5. Physical aspects of an individual's life (Benek-Higgins et al., 2008).

Finally, it should also be pointed out that many depression sufferers also experience the same symptoms of anxiety (Williamson, 2008).

Current and Future Trends in the Elderly Population

According to current U.S. Census Bureau projections, by 2030, American adults aged 65 years and over are expected to account for fully one-fifth of the total U.S. population (Schoenborn & Heyman, 2009). Moreover, U.S. Census Bureau projections also indicate that during the 3-decade period from 1995 to 2025, the number of elderly people is expected to double in almost half (21) of the 50 states (Sarenski, 2008). Likewise, during the 30-year period from 2000 to 2030, the 65-year-plus segment of the American population is projected to more than double to around 70 million elderly citizens (Smith & Baughman, 2007). In fact, by the year 2050, demographers project is that 20% of the population or 82 million people will be age 65 years and over (Sarenski, 2008).

It is reasonable to expect that those individuals who reach the age of 65 years and above will live even longer as well, with life expectancy of the average citizen having increased to almost 80 years; furthermore, the 85-year plus segment of the American population is the fastest growing age group and is expected to fully triple in size during the period 1980 to 2020, from 2.3 million to 6.9 million (Durant & Christian, 2007). Taken together, it is apparent that there are going to be lot more older people in the United States in the years to come, and a significant percentage of these elderly will develop a depressive order of some type or experience a recurrence of a previous episode, and these issues are discussed further below.

Depression in the Elderly

Although many of the elderly citizens in the United States in the future will enjoy better health than in years past, many will still suffer from various age-related healthcare and mental health problems as they grow older that may contribute to the development of depressive disorders. In fact, older people in particular have a number of factors working against them that appear to contribute to the incidence of depression in this population. For example, St. John and Keleher (2007) report that the elderly frequently experience social isolation and exclusion in ways that contributes to a higher incidence of depression. Likewise, Williamson (2008) notes that, "Depression in the elderly can cause a great deal of needless anguish and suffering for the family and patient. For the typical elderly patient, the symptoms described to physicians on regular visits are usually physical rather than mental" (p. 19).

The elderly are frequently unwilling or unable to share their feelings concerning sadness, hopelessness, loss of interest in normally pleasurable activities, or extremely prolonged grief following a personal loss (Williamson, 2008). According to Gudmundsson and his associates (2007), many elderly suffer from depression, with the prevalence for any type of depressive disorder among this segment of the population being estimated at between 10%-15%. Elderly women are more likely to experience depression than their male counterparts, and women aged 70-74 years in the Gudmondsson et al. study were found to have a lifetime prevalence rate of 43.3%. The precise cause of this higher prevalence rate of depression among elderly women remains unclear; however, it is believed that among the elderly, depression is attributable in some part to associated organic changes and vascular disease in the brain (Godmundsson et al., 2007). In this regard, Gudmundsson et al. note that, "The occurrence of atrophy and cerebrovascular disease, such as white matter changes evidenced using brain imaging, is linked to depression in the elderly. In addition, low levels of serotonin and estrogen are associated with lower mood and are involved in brain metabolism" (2007, p. 833).

According to Takami, Okamoto, Yamashita, Okada and Yamawaki (2007), in elderly patients who have a history of depression, there is an elevated risk of relapse compared to younger patients. These authorities emphasize that, "Evidence from several studies suggests that elderly patients with a history of multiple episodes of depression are at high risk of recurrence, and that prior depression appears to be an important risk factor for depression in the elderly" (Takami et al., 2007, p. 594). Unfortunately, the elderly are also more difficult to treat for depression than younger people, particularly elderly who have a history of one or more previous depressive episodes in their lives (Takami et al., 2007). While there may be several factors involved in this, it is believed that the treatment responses and neuropsychological functions of the elderly may be impaired following several depressive episodes compared to individuals who have only suffered from an isolated episode of depression (Takami et al., 2007). According to Takami and his associates, "These findings suggest that the presence of prior depressive episodes in elderly patients might affect their neuropsychological function and treatment response" (Takami et al., 2007, p. 594).

The studies of functional neuroimaging conducted to date among the depressed elderly have indicated diminished global and regional cerebral perfusion and glucose metabolism, especially in the anterior cingulate cortex and prefrontal cortex; the findings to date, though, concerning the long-term effects of these conditions on the prevalence of depression among the elderly have been mixed (Takami et al., 2007). In this regard, Takami and his colleagues conclude that, "Although clinically the presence of a prior depressive episode appears to play a role in relapse and recurrence in elderly depression, the pathophysiological mechanisms involved are unclear" (Takami et al., 2007, p. 594).

According to Kyomen, Hennen, Whitfield, Renshaw, Gottlieb and Gorman (2007), depression is also highly prevalent among elderly patients with dementia, a combination of disorders that creates further exacerbates patient and caregiver morbidity. This issue was the focus of a study by Steffens, Potter, McQuoid, MacFall, Payne, Burke, Plassman and Welsh-Bohmer (2007) who identified an incidence of dementia among depressed elderly that was fully 300% higher than that reported among control counterparts after 5 years. According to these authorities, "The presence of mild cognitive impairment among older depressed subjects may persist after depression has remitted, and such impairment has been shown to confer an especially high risk for later dementia" (Steffens et al., 2007, p. 840). Similar findings are reported by Bhalla, Butters, Becker, Houck, Snitz, Lopez, Aizenstein, Raina, Dekosky and Reynolds (2009) who recently observed, "Late-life depression (LLD) may be associated with persistent cognitive impairment in some individuals after effective treatment of depressive symptoms" (p. 308).

There is some evidence that late-life depression is associated with the onset of mild cognitive impairment and dementia, including vascular dementia and Alzheimer's disease (Bhalla et al., 2009). This is yet another area that is cited by numerous authorities as requiring additional research. In this regard, Bhalla and her associates conclude that, "It is not clear whether depression represents a risk factor for or occurs in the prodromal stage of dementia. Thus, the nature of the relationship between depression and persistent cognitive impairment after resolution remains unclear and warrants further investigation" (2009, p. 309).

While the elderly living at home are at risk of developing depression, their counterparts who reside in long-term care facilities are at an even greater risk. In this regard, Anstey, Von Sanden, Sargent-Cox and Luszcz (2007) report that, "Community studies estimating the prevalence of depression in the elderly have found lower rates in community samples compared with the high rates reported in studies of institutionalized adults" (p. 497). Despite this higher prevalence rate for depression among the elderly in institutional settings, additional research is needed to clarify its magnitude and type. According to Astey and her colleagues, this research is important for a number of reasons, but it is complicated by the conventional approaches used to assess and diagnose depression among the elderly. As Astey et al. emphasize, "Exclusion of institutionalized adults from epidemiologic studies leads to difficulty in obtaining accurate figures for prevalence of depression in the population. Different measurement instruments make comparisons between studies difficult, and measurement instruments may not be valid in different settings" (p. 498). Similarly, in a study by Bonin-Guillaume, Jouve, Sautel, Fakra and Blin (2008), the authors report that, "Studies on elderly medical inpatients have found depression-prevalence rates as high as 35%. But only a few patients fulfill Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnosis criteria for Major Depressive Disorders (MDD)" (p. 331). Likewise, McDonald (2009) emphasizes that in spite of the growing amount of research being devoted to depression, there remains a dearth of timely and relevant studies concerning depression among the elderly and how best to treat it. According to McDonald, "Most researchers and clinicians agree that the primary reason for this failure is a lack of recognition of depression in the elderly. Nowhere is this more apparent than the data from primary care practices, where approximately 5%-10% of elderly patients suffer from significant depressive symptoms and only a minority receive adequate pharmacotherapy" (p. 537). This point is also made by Benek-Higgins, McReynolds, Hogan and Savickas (2008) who emphasize that, "It is estimated that half of the 35 million people in the United Slates who are over the age of 65 are in need of mental health services, though fewer than 20% are actually being treated" (p. 283).

Comorbid mental and physical issues can complicate assessment and diagnosis of depression in the elderly because their symptoms of depression are frequently obscured by a wide range of physical problems (Benek-Higgins et al., 2008). Furthermore, a majority of elderly who suffer from depression fail to receive treatment based on a longstanding misperception that depression is simply part of the normal aging process and that the elderly are unable to benefit from psychotherapy (Benek-Higgins et al., 2008). The diminished cognitive abilities of many elderly depression sufferers, though, may also adversely affect their ability to benefit from psychotherapeutic interventions that could be effective with younger patients (McDonald, 2009).