Depression in the elderly is different from depression in a young person. Older people have more somatic complaints and minimize their state of sadness. They are often hypochondriac and have an increased risk of chronic diseases.

Depression is one of the forms of mood disorders that are generally classified as follows:

1. Depression
2. Dysthymia
3.  Bipolar  (or manic-depressive) disorder
4. Cyclothymia

Depression includes:

1. major depression which causes the individual to work normally, sleep well and eat well, concentrate and enjoy the pleasures of life. A person usually has several episodes of major depression;
2.  dysthymia, with less severe symptoms but lasting longer (at least two years);
3. minor depression, with symptoms of less severe intensity than in the two previous cases and which are temporary.

Mood disorders are the most common mental disorders in the elderly. Indeed, old age is a period of vulnerability conducive to the onset of mood disorders.

Here are some risk factors that may trigger depression in the elderly:

• Loneliness (or feelings of loneliness) and social isolation.
• Consequences of retirement (e.g. feeling useless, loss of activity).
• Interpersonal conflicts.
• Death of close friends.
• Anniversary date of the bereavement.
• Loss of autonomy due to physical illnesses.
• Hormonal disruption due to dysregulation of melanin or thyroid hormones.
• To be female.
• Suffer from a chronic disease (cancer, diabetes, heart disease).
• Restless sleep.
• Have a family history of depression.
• Take certain medications.
• Consuming too much alcohol.
• Leading a stressful life (caring for someone with a chronic illness).

Major depression in the elderly is not properly taken care of because those around you mistakenly believe that it is normal to be sad because you have lost a loved one or because you are losing your autonomy. However, in the case of depression, the sadness persists.

Prevalence of depression

The prevalence of depression in people aged 65 and over is estimated at around 1%, while 5% of people over 65 suffer from depressed mood. Here are the prevalence percentages according to age categories.

Etiologies

Genetic causes : Having a first-degree relative who suffers from recurrent depression increases the risk of suffering from depression by two to four. Studies with homozygous twins confirm the role of heredity, with an increased risk of around 40%.

Physiological causes : activation of the hypothalamic-pituitary axis associated with an abnormally high level of cortisol is observed in patients with major depression, leading to inhibition of growth factors (including BDNF) and dysregulation of monoaminergic neurotransmitters (noradrenaline, serotonin, and dopamine).

Psychological causes : A certain view of life (tendency to a negative view of oneself, events and a pessimistic approach to the future)

Social causes : acute stress caused by different events: job loss, poverty, social exclusion, family conflicts, excessive demands, physical health problems, death of a loved one can be the cause of depression, as well than harmful experiences during childhood or adolescence.

Diagnostic criteria

The diagnostic criteria are those taken from the American psychiatry manual DSM IV and the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10, World Health Organization). However, classifications of depression are not entirely suitable for older people because they tend not to express their sadness verbally.

DSM V Criteria

• A: at least 5 symptoms during the same 2-week period and represent a change from normal functioning; at least one of the following symptoms: One of the following symptoms:
  1. depressed mood;
  2. anhedonia (loss of interest or pleasure)
  3. significant weight loss or gain (5%) or increased or decreased appetite almost daily;
  4. insomnia or hypersomnia;
  5. psychomotor agitation or retardation;
  6. fatigue or loss of energy;
  7. feeling of worthlessness or excessive or inappropriate guilt;
  8. loss of concentration;
  9. recurrent thoughts of death, suicidal ideation or attempted suicide.
• B: Symptoms cause significant distress and impairment of daily functioning.
• C: The symptomatology is not attributable to the physiological effects of a substance or a medical condition.
• D: the onset of the depressive episode is not explained by schizophrenia or delusional disorder.
• E: no previous manic or hypomanic episode.

ICD-10 criteria

In the ICD-10 manual (2003), mood disorders are divided into seven parts. Most of these disorders tend to be recurrent. The onset of individual episodes can often be related to stressful situations or events. The change in mood is usually accompanied by a change in overall activity level.

1.  Manic episode
1.a Hypomania.
1.b Mania without psychotic symptoms.
1.c Mania with psychotic symptoms (delusions, hallucinations, agitation, or hyperactivity).

2.  Bipolar affective disorder
The mood and level of activity of the subject are profoundly disturbed, sometimes in the sense of elevation (hypomania or mania), sometimes in the direction of depression (depression). 
2.a Subject is currently hypomanic, and has had at least one other affective episode in the past.
2.b Subject is currently manic with no psychotic symptoms.
2.c Subject is currently manic, with psychotic symptoms.
2.d The subject is currently depressed, such as during a depressive episode of mild or moderate intensity. 2.e The subject is currently depressed, such as during a depressive episode of severe intensity without psychotic symptoms.
2.f Subject is currently depressed, such as during a depressive episode of severe intensity with psychotic symptoms.
2.g Simultaneous or alternating presence of manic and depressive symptoms.
2.h Bipolar affective disorder, currently in remission.

3.  Depressive episodes
3.a Mild depressive episode. The subject remains, most often, able to continue most of its activities.
3.b Moderate depressive episode. The subject experiences considerable difficulty in continuing his or her usual activities.
3.c Severe depressive episode without psychotic symptoms. Suicidal thoughts and acts are common, and several “somatic” symptoms are usually present.
3.d Severe depressive episode with psychotic symptoms (hallucinations, delusions) or psychomotor retardation or stupor. Usual social activities are impossible. Risk of suicide, dehydration, or malnutrition.

4.  Recurrent Depressive Disorder
4.a A disorder characterized by the repeated occurrence of depressive episodes, the current episode being mild, moderate, or severe in intensity, in the absence of any history of mania and without psychotic symptoms. 4.b Disorder characterized by the repeated occurrence of depressive episodes, the current episode of severe intensity with psychotic symptoms. 4.c Recurrent depressive disorder, currently in remission (F33-4)

5.  Persistent Mood
Disorders 5.a Persistent and usually fluctuating mood disorders in which most individual episodes are not severe enough to warrant a diagnosis of hypomanic episode or mild depressive episode.
5.b Cyclothymia: Persistent instability of mood, including numerous periods of depression or slight elation (F34-0).
5.c Dysthymia : chronic low mood.

6.  Other mood disorders

7.  Mood disorder, unspecified 

Depression in the elderly is different from depression in a young person. Older people have more somatic complaints and minimize their state of sadness. They are often hypochondriac and have an increased risk of chronic diseases.

Depression is one of the forms of mood disorders that are generally classified as follows:

1. Depression
2. Dysthymia
3.  Bipolar  (or manic-depressive) disorder
4. Cyclothymia

Depression includes:

1. major depression which causes the individual to work normally, sleep well and eat well, concentrate and enjoy the pleasures of life. A person usually has several episodes of major depression;
2.  dysthymia, with less severe symptoms but lasting longer (at least two years);
3. minor depression, with symptoms of less severe intensity than in the two previous cases and which are temporary.

Mood disorders are the most common mental disorders in the elderly. Indeed, old age is a period of vulnerability conducive to the onset of mood disorders.

Here are some risk factors that may trigger depression in the elderly:

• Loneliness (or feelings of loneliness) and social isolation.
• Consequences of retirement (e.g. feeling useless, loss of activity).
• Interpersonal conflicts.
• Death of close friends.
• Anniversary date of the bereavement.
• Loss of autonomy due to physical illnesses.
• Hormonal disruption due to dysregulation of melanin or thyroid hormones.
• To be female.
• Suffer from a chronic disease (cancer, diabetes, heart disease).
• Restless sleep.
• Have a family history of depression.
• Take certain medications.
• Consuming too much alcohol.
• Leading a stressful life (caring for someone with a chronic illness).

Major depression in the elderly is not properly taken care of because those around you mistakenly believe that it is normal to be sad because you have lost a loved one or because you are losing your autonomy. However, in the case of depression, the sadness persists.

Here are some clinical features of depression in the elderly that are sometimes the same as in younger subjects:

• persistent feelings of sadness and hopelessness.
• Pessimism.
• Inability to find a pleasant life as before.
• Disturbed sleep (sleeps little or not enough).
• Unexplained crying spells.
• Change in appetite and weight.
• Disinterest in sexuality.
• Fatigue, lack of energy.
• Clothing or bodily negligence.
• Feelings of worthlessness and guilt.
• Psychomotor restlessness or retardation.
• Loss of interest in things.
• Suicidal thoughts.
• Loss of self-esteem.
• Anxiety which is often the mask of depression.
• Hypochondriacal and delusional symptoms.
• Irritability and hostility.
• Inability to take pleasure in doing an activity, eating, etc. (anhedonia)
• Difficulty concentrating and remembering.
• Difficulties making decisions.

Diagnosis and assessment of severity

The Geriatric Depression Scale (or GDS): This is a test to diagnose depression in an older person.

The Hamilton Depression Scale : This is the most widely used test to assess the intensity of depressive symptoms.

Before starting treatment with an antidepressant, it is important to pay attention to the symptoms, with particular attention to the following:

• Dysphoric restlessness
• Suicidal risk
• Psychotic symptoms
• Possible comorbidity

Depression in the elderly associated with certain chronic diseases

Older people with depression have an increased risk of cardiovascular disease, Parkinson’s disease and Alzheimer’s disease. On the other hand, elderly people suffering from a chronic illness (diabetes, high blood pressure, heart problem) are two to four times more likely to have major depression than others of the same age and in good health.

Depression and somatic complaints

Somatic complaints are an integral part of depression in the elderly. Indeed, a depressed person can express his suffering through pain in his body. It is estimated that half to three quarters of depressed people who consult have somatic symptoms such as gastrointestinal disorders, joint pain or cardiovascular symptoms.

Treatment

Antidepressants. When the diagnosis of major depression is made in the elderly, studies report that the effectiveness of an antidepressant is recognized compared to a placebo, which is not the case if the depression is minor.

It is common for older people to try several antidepressants before finding the right drug, leading to a remission rate of over 80%. Combinations of antidepressants are not recommended.

It is important not to stop treatment without the advice of your doctor. Treatment should be continued for several months even if the beneficial effects are felt.

Electroconvulsive therapy (ECT) is sometimes used in severe depression in subjects refractory to antidepressants, at the rate of two to three sessions per week under general anesthesia for about a month. ECT is a therapy that involves stimulating the brain directly with electricity, magnets or implants. Some of these treatments are still in the experimental stage. If the depression persists despite medication, or if the depression is so severe that the individual is unable to eat or develops false beliefs (delusions) about their illness, the doctor may recommend ECT as the best option. Although it has been used for almost 80 years, the electroconvulsive therapy remains the most powerful and fastest treatment in severe depression.

Although ECT is effective and safe in the elderly, many misconceptions remain among patients and healthcare professionals. Admittedly, ECT can cause side effects such as confusion and memory loss that are usually temporary.