In this literature review, the different terms (elderly, older adults, in the aged) all refer to the same meaning.
Introduction
Nowadays, with the demographic ageing, it is predicted that the number of patients who suffer from psychological disorders will grow. Among them, depression is one of the most frequent mental disorders in older people. Consequently, depression is a widespread problem and a key domain of public health because, left untreated, it may result in the onset of physical, cognitive, functional, and social impairment, as well as decreased quality of life (Limosin, Manetti, René, & Schuster, 2015). Furthermore, it increases the risk of suicide. However, in the elderly, depression remains underdiagnosed (only 15 to 30% of cases are detected) because it may be difficult to distinguish depression, as a pathological condition, from an “existential despair” (Vaughan, Goveas, & Corbin, 2015).
Causes of Depression in Older Adults
There is no single cause of depression in any age group. Some research indicate that there could be a genetic link to the disease. However, biological, social, and psychological factors could play too a role too in depression in older adults (Sözeri-Varma, 2012). Indeed, it was determined that depressive symptoms seen in older adults are related to : advancing of age, being a female, living alone, divorcement, low education level, functionality disorder, comorbid physical illness, low level cognitive dysfunction, cigarette and alcohol use (Heun & Hein, 2005). Elderly with a history of previous depression carry the highest risk. The knowledge of risk factors might help identify subjects at increased risk of depression for early intervention approaches.
What are Symptoms of Depression in Elderly ?
In general, a major depressive disorder can be diagnosed through the presence of five (or more) symptoms defined by the American Psychiatric Association (2013) in the DSM-5 : depressed mood, markedly diminished interest or pleasure in all activities, significant weight loss when not dieting or weight gain, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or excessive or inappropriate guilt, diminished ability to think or concentrate, and recurrent thoughts of death. At least one of these symptoms (depressed mood or loss of interest or pleasure) must be present during a period of two weeks and represent a change from previous functioning. The conditions in which depressive disorder continues for two weeks but it meets lower than five diagnosis criteria are called as minor depressive disorder.
However, the elderly often display the symptoms of depression differently, and that complicates the diagnosis (Monfort, 2009). Indeed, somatic symptoms, which are usually a key to diagnosis of depression in young age, are less useful in the elderly. For instance, sleep disturbance is a common symptom of depression, but such disturbances are also common in the non-depressed elderly. Additionally, depressed mood is not their main symptom. These symptomatic differences delay the appropriate treatment and this is why we consider that depression lasts longer in elderly. However, some symptoms are characteristic of depression in the elderly, such as the decline in cognitive performance, which is undeniably more marked in this population (Gasser, Salamin, & Zumbach, 2017).
How to Measure Depression in the Aged ?
As we have seen, clinical signs of depression in the elderly are sometimes different from those observed in the general population. Most existing depression-rating scales have been developed and validated in younger population and their applicability with older adults has not been demonstrated. Geriatric Depression Scale (GDS), developed in 1983, has been tested and is widely used with the older population. This scale can be used with healthy, medically ill or/and mild to moderately cognitively impaired older adults. Consequently, the GDS scale is the most used to appreciate the intensity of depression. The GDS Long Form is a brief 30-item questionnaire in which participants are asked to respond by saying yes or no in reference to how they felt over the past week (Yesavage et al., 1983).
A short form was created in 1986 and consists in 15 questions. This version is easier to be used on physically ill and mildly to moderately demented patients, who have short attention spans and/or feel easily fatigued. Scores of 0-4 are considered normal; 5-8 indicate mild depression; 9-11 indicate moderate depression; and 12-15 indicate severe depression (Sheikh & Yesavage, 1986). So, the presence of depression warrants prompt intervention and/or treatment.
What Treatments are Available for Depression in Elderly ?
There are several treatment options available for depression (Charazac, 2011). They include lifestyle changes, medicine, psychotherapies, or electroconvulsive therapy (only used for severe depression that has not responded to standard medication). Sometimes, a combination of these treatments may be used.
First, most of the available antidepressants are believed to be equally effective in elderly but the risk of side effects or potential reactions with other medicines must be carefully considered. Antidepressants may take longer to start working in older people than they do in younger people. Many doctors recommend the use of psychotherapy in combination with antidepressant medicines (it is uncommon for an older person to ask for a psychotherapy).
Cognitive-behavioral therapy has the most empirical support in treating late-life depression, and are recommended by a lot of guidelines in this indication (Kindynis, Burlacu, Louville, & Limosin, 2013). This approach can be used alone for mild depression, or in combination with medication in moderate depression. This type of psychotherapy postulates that a negative, dysfunctional thinking affects a person’s mood, sense of self, behavior, and even physical state (Driessen & Hollon, 2010) . So, the goal of cognitive behavioral therapy is to help a patient learn to recognize his negative patterns of thought, evaluate their validity, and replace them with healthier ways of thinking. However, this method requires good introspection abilities, which is not always the case with older people (because of dementia or memory disorders, insufficient motivation, etc.).
At last, lifestyle changes can involve different elements : daily exercise, healthy eating habits, going out, increasing social support, etc.
To conclude, we chose the theme of depression in the elderly to take stock of current knowledge. We observed that this research topic is relatively recent because the symptoms of depression were often associated with a normal state of old age. Consequently, future research will need to investigate several points : early identification of depressive symptoms, and psychotherapy adapted to the elderly with dementia. This may allow better medical care of all elderly depressive patients (with or without associated disease).
Written by Housty Tiphaine and Barbier Charlotte. M2 PPCECC
Bibliography
American Psychiatric Association. (2013). Major Depressive Disorder. Retrieved from https://images.pearsonclinical.com
Charazac, P. M. (2011). Les états dépressifs. Dans P. M. Charazac (Ed.), L’aide-mémoire de psycho-gériatrie : En 24 notions (pp. 201-264). Paris : Dunod.
Driessen, E., & Hollon, S. D. (2010). Cognitive Behavioral Therapy for Mood Disorders: Efficacy, Moderators and Mediators. The Psychiatric Clinics of North America, 33(3), 537–555.
Gasser, A. I., Salamin, V., & Zumbach, S. (2017). Dépression de la personne âgée ou maladie d’Alzheimer prodromique : quels outils pour le diagnostic différentiel ?. L’Encéphale.
Heun, R., & Hein, S. (2005). Risk factors of major depression in the elderly. European Psychiatry, 20(3), 199-204.
Kindynis, S., Burlacu, S., Louville, P., & Limosin, F. (2013). Thérapie des schémas du sujet âgé : impact sur la dépression, l’anxiété et les schémas cognitifs typiques. L’Encéphale, 39, 393-400.
Limosin, F., Manetti, A., René, M., & Schuster, J. (2015). Dépression du sujet âgé: Données épidémiologiques, aspects cliniques et approches thérapeutiques spécifiques. NPG Neurologie – Psychiatrie – Gériatrie, 15(89), 256-261.
Monfort, J. C. (2009). Les dépressions des personnes âgées. Dans J. C. Monfort (Ed.), La psychogériatrie (pp. 49-67). Paris : Presses universitaires de France.
Sheikh, J. I., & Yesavage, J. A. (1986). Geriatric Depression Scale (GDS): Recent evidence and development of a shorter version. Clinical Gerontologist: The Journal of Aging and Mental Health, 5(1-2), 165-173.
Sözeri-Varma, G. (2012). Depression in the Elderly: Clinical Features and Risk Factors. Aging and Disease, 3(6), 465–471.
Vaughan, L., Goveas, J., & Corbin, A. (2015). Depression and frailty in later life: A systematic review. Clinical Interventions in Aging, 10, 1947-1958.
Yesavage, J. A., Brink, T. L., Rose, T. L., Lum, O., Huang, V., Adey, M. B., & Leirer, V. O. (1983). Development and validation of a geriatric depression screening cale: A preliminary report. Journal of Psychiatric Research, 17, 37-49.
