Elderly Depression and Care for the Elderly
Last Updated: April 2, 2013
Does it seem like just yesterday that your mom lit up when you
brought the grandchildren over? So why does she hardly smile and
seem irritable around the kids now? Has your dad always been a
lifelong baseball fan? So when did he start turning down box seat
tickets at the ballpark? Sudden changes in mood and interest can
signal more than just old age. The National Institute of Mental
Health (NIMH) reports that elderly depression is not only
widespread but "a serious public health concern." Recent research
suggests that as many as 15% of elders - that's 6.5 million
Americans-suffer from depression, and still more, 25%, report that
they suffer from persistent feelings of sadness.
A "Major Public Health Problem"
Dr. Gary Kennedy, chief of geriatric psychiatry at Montefiore
Medical Center and Albert Einstein College of Medicine in New York
and a leading authority on elderly depression, calls the condition
a "major public health problem." Kennedy says many health
practitioners who care for the elderly are unprepared and unable to
detect signs of depressed individuals. "Most don't ask the simple
questions that screen for depression," he says.
To make matters worse, seniors themselves often ignore-even
hide-their debilitating mental conditions. "Older adults are more
sensitive to the mental illness stigma than any other group," says
Kennedy. "They tend to think of mental health treatment as leading
to mental hospitals or nursing
While many elderly individuals may downplay their depression,
the illness can have frightening consequences if not addressed. In
older adult populations, it's common for depressed individuals to
critical medications such as insulin treatment or prescriptions
for serious heart conditions.
Research shows that elderly depression can double the risk of
cardiac disease and increase the risk of developing other
serious health conditions. In studies where nursing home patients
with physical illnesses were examined, the advent of depression
significantly increased the chance of death from those illnesses.
In addition, non-depressed elders are more likely to recover from a
heart attack, while depressed seniors have a greater chance of
dying after a cardiac incident.
"Depression can be a deadly illness," notes Kennedy. "It's
associated with suicide." In fact, the United States has seen a
significant increase in the elderly suicide rate in the past 10
years, and many health experts blame untreated depression. Though
adults over the age of 65 make up only 13% of the nation's
population, they account for 20% of all suicide deaths, according
to the National Institutes of Health.
The National Alliance for the Mentally Ill (NAMI) reports a
series of tragic statistics that underscores the lack of depression
screening by many primary care physicians:Before a depressed senior
commits suicide, 20% see a doctor the day they die, 40% the week
they die, and 70% in the month they die.
Do you feel that your parent's physician hasn't been probing
deep enough to determine if depression is an issue? Geriatric
psychiatrists and knowledgeable physicians who care for the elderly
ask the following questions to screen for elderly depression:
Have you been sad or depressed, or had feelings of helplessness,
most of the time over the last two weeks?
Have you lost interest in almost everything in the last two
While it's natural to experience some grief in the face of major
life changes, clinical depression doesn't go away by itself, lasts
for several months, and needs to be treated by a professional.
According to NAMI, unresolved depression can affect the immune
system, which makes the depressed person more susceptible to other
illnesses. If you suspect that your parent or loved one is
suffering from depression, pay attention to these health
Irritability. While your mother used to be a
content and happy person, is she now cranky and easily irritated by
small things? Sudden mood changes can suggest depression.
Loss of self-regard. Kennedy and other experts
say that one of the most obvious signs of depression in elders is
seen when they show a lack of pride in their personal appearance.
Perhaps your mother has stopped wearing makeup, or your father has
stopped bathing. Loss of pride in personal appearance can signal a
Social withdrawal. Did you have lunch with your
dad every Wednesday, but now he's making excuses about why he can't
join you? Depressed elders, note experts, tend to take on the
"hermit mentality," shutting out others-even loved ones-and
avoiding social situations.
Increased pain. One of the greatest myths about
depression, says Kennedy, is that it's only in the mind. In fact,
"depression amplifies physical pain," he says.
Has your parent suffered a
stroke or had a major surgery recently? Elders
recovering from major illness or surgery, says Kennedy, are "much
more likely to develop a depressive episode, and some go on to have
a depression disorder." In fact, research shows that 15% of people
who are discharged from a hospital leave with depressive
Has your parent lost a spouse, child, or relative to
death recently? "Depression in
bereavement is common," says Kennedy, who notes that elderly
persons have a much higher risk of plummeting into depression after
the loss of a loved one than a younger person.
While 50% of depressed elders will eventually recover on their
own without any intervention, half will not-an important reason to
make sure your parent gets help. "More often than not, the
depressed senior is brought in by someone else," says Kennedy.
That's good, he says, because studies show that elders who have a
support network are more likely to pull through a depressive
episode than those who are isolated.
But there are tactful ways of approaching such a sensitive
topic, especially when an adult child approaches the matter with
compassion and sensitivity. Kennedy suggests saying things like:
"You don't have to feel this way, let's get you some help"; or "I
want to understand your condition better. Let's talk to the doctor.
I'll go with you."
While families can be enormously helpful to their depressed
loved one, occasionally the opposite is true. "Sometimes families
are falsely reassuring," explains Kennedy. "Instead of dealing with
an issue head on, they can say 'let's look on the bright side.'"
But for a depressed person, there is no bright side. That's where a
mental health practitioner comes in. "Depressed elders need to talk
to a neutral third party about just how hard their depression is,"
When selecting a psychotherapist, look for someone who
specializes in geriatrics (care for the elderly). According to
Kennedy, there are only 3,000 such specialists in the nation, so
you may have to look beyond your immediate city or town, but
getting specialized care may well be worth the extra travel
Find Senior Living Communities
When it comes to elderly depression, each patient is different
and requires a customized treatment approach to his or her unique
needs and circumstances. Often the treatment plan will combine the
following different approaches:
Medication. "Most studies show that only half
of people treated with medicine get better," says Kennedy. Still,
many respond well to medication. According to the NIMH,
antidepressants influence the functioning of certain
neurotransmitters in the brain. The newer medications, selective
serotonin reuptake inhibitors (or SSRIs) such as Prozac® and
Paxil®1, are generally preferred over older medications
such as tricyclic antidepressants (TCAs) and monoamine oxidase
inhibitors (MAOIs), because they are known to have fewer and less
severe potential side effects.2
Whatever the medication, each dose has to be properly
administered to produce the desired effect. Many practitioners,
says Kennedy, "undertreat when it comes to depression in the
elderly. They think older adults don't need the full dose. But they
Also, he says, one of the biggest problems in antidepressant
prescriptions for seniors is the lack of follow-up by health
practitioners. "Many start them off on a low does, then wait a
month to increase it," explains Kennedy. That's too long, he says.
"It's just wrong to give the person a prescription and say, 'I'll
see you in a month.' We now know that in two weeks, some
improvement should be seen." If not, sometimes that means
increasing the dose, other times it means changing medications
altogether or prescribing a combination of two medications. A
conscientious doctor will work with the senior to find the right
balance of medication to treat depression.
And when the depression seems to be "cured"? Research published
in a recent issue of The New England Journal of Medicine reports
that elderly patients who remained on antidepressant drugs after
recovering from depression are significantly less likely to relapse
or have further depressive episodes than those who were taken off
their medication entirely.
"With most treatment methods," says Kennedy, "if you add
psychotherapy, you get the best results. Most people get medication
only, but the best treatment is combined with psychotherapy."
While it does take time-10 to 12 sessions to get the person to
the point where they've recovered from their depression, followed
by one session a month to sustain progress-results can be dramatic
and productive. Yet, many elderly patients resist such treatment
due to steep co-pays, which can be as high as 50%. The expense can
be a significant "obstacle for people to get treatment," according
to Kennedy, and is one of the reasons many elders are not getting
the help they need. Together with the Geriatric Mental Health
Foundation, he is lobbying for policy change on a national
Social support intervention. Kennedy recalls
one of his patients-an elderly Holocaust survivor in New York City.
"Her mother died in the tragedy when she was a child, so throughout
her life, she was very sensitive about being separated from her
daughter," he explains.
But as her daughter grew up, she moved on and became involved
with her own family and career. Feeling a tragic separation from
her daughter, the 79-year-old woman sank into a depression. She
stayed in, turned down social invitations, and developed a
significant pain syndrome complete with severe headaches and weight
loss. After a brief hospitalization for her symptoms, Kennedy was
brought in to provide psychotherapy.
"Through psychotherapy, I encouraged her to stay active and do
things that didn't depend on her daughter," says Kennedy. "Now
she's totally independent. She goes to music and theater events all
the time, and volunteers at a major museum. Through psychotherapy,
we were able to keep her socially engaged, and she's done
Exercise. According to researchers at Duke
University Medical Center in Durham, North Carolina, exercising
just three times per week can relieve and even cure the symptoms of
elderly depression. In fact, according to the study, activities
such as walking, light aerobics, or swimming may have greater
depression-fighting properties than the leading anti-depressant
Electroconvulsive therapy. For severe cases of
depression that do not respond to medication or where the
depression is accompanied by schizophrenia or psychosis, there is
the option of electroconvulsive therapy (ECT), which uses
electrical shocks to produce monitored seizures that release
certain chemicals, or neurotransmitters, in the brain-a process
that can provide dramatic short-term improvement for depression.
While ECT today is generally considered by psychiatrists to be a
very safe and effective procedure when performed under current
guidelines, controversy still surrounds it. An unfortunate history
of indiscriminate and sometimes abusive usage has resulted in
extremely negative depictions of it in popular culture. Some
psychiatrists believe ECT should be used only as a last resort, and
some strongly oppose it.
Psychotherapy. Sometimes a creative approach to
treating depression can provide some real breakthroughs. Kennedy
remembers another one of his patients who had lost her 40-year-old
son recently and presented with significant heart pain. "She had
episodes where she thought she was having a heart attack," says
Kennedy. But after medical tests showed her heart was functioning
just fine, he suspected that the woman might actually be suffering
from a "broken heart." He started her on a series of antidepressant
medications over the period of several months, but during
psychotherapy, he noticed that the woman was reluctant to talk
about her family-especially those whom she had lost.
"I decided to make a house call," says Kennedy. "I looked around
the home and saw that there wasn't a single picture of her family
anywhere." When he asked the woman about it, she said, "It's not
that I don't have any, it's just that it's too painful."
After some encouragment, the woman pulled out an old shoe box
filled with pictures of her deceased husband and son. "She was so
tearful, but from that day on, there was no broken heart. She
learned to see the loss in a new light." This type of intervention,
says Kennedy, can have encouraging effects on elders who are
grieving the loss of a loved one.
So what's the bottom line about elderly depression? Don't let it
go untreated. If you suspect your parent is suffering from minor or
major depressive symptoms, encourage him or her to seek help. By
making yourself a part of the solution, says Kennedy, you're
"opening a door that the senior may be too embarrassed to open
1All pharmaceutical brand names mentioned in this
article are registered trademarks of their respective
manufacturers. Their usage here is for informational purposes only
and does not imply any endorsement or promotion by A Place For Mom,
2Recently the FDA approved a transdermal patch form
of MAOI, Emsam®, which has a much lower risk side effects from
dietary and drug interactions than traditional oral MAOIs.