Depression in people over the age of 65 has certain characteristics and raises specific issues that deserve to be discussed.
First of all, when faced with a depressed older person, a common attitude is to consider a depressive change in personality and behavior as a natural part of old age. In other words, there is a widespread belief that an older person is “a little depressed because depression is part of aging.” This is not true and is simply related to the imprecise idea that people may have of depressive illness.
Furthermore, in older adults, when changes in behavior and attitude occur, people typically expect a condition such as “dementia” or intellectual decline. However, specialist assessment may subsequently establish that what was involved was merely so-called pseudodementia, and that the changes actually result from a depressive illness.
It is nevertheless true that distinguishing a depressed older person from a non-depressed one is more difficult if the same criteria used for a younger person are applied. Generally speaking, there are fewer manifestations, and they must be assessed in relation to the person’s previous level of functioning. Thus, a depressed older person is no longer the same as they were before—not merely because, “for their age,” they have a slower pace of activity or reduced vitality.
For example, an older person may develop what is known as “masked depression,” meaning that they do not report psychological symptoms—such as a melancholic, irritable, sad, or gloomy mood—but instead primarily complain of various physical problems or of a decline in intellectual abilities, such as memory or concentration, often with a worried attitude. It is common for the person to notice and emphasize these aspects, while family members and acquaintances are instead more concerned about their emotional state and loss of vitality or drive.
For this reason, assessment of depression in people over 65 should pay particular attention to psychological aspects, in order to avoid confusion or the masking of these symptoms by whatever the person places at the forefront of their concerns. Comparison with family members is very useful, often revealing contrasting perceptions in which the person minimizes the change in their mood, while family members minimize the basis of the person’s physical concerns.
As for memory and concentration, or intellectual abilities more generally, the attitude of the depressed older person is usually passive: they do not answer questions, appear not to have understood, are inattentive and therefore do not remember what was said afterward, claim not to know how to perform simple tasks, and may appear genuinely unable to carry them out anymore. The attitude is self-critical, with a greater tendency to give up, withdraw, and blame themselves for “no longer being capable” of carrying out a whole range of activities.
Some forms of depression may precede other neurological diseases, such as Parkinson’s disease and certain dementias, including Alzheimer’s disease. In these cases, the depression is often atypical or nonspecific, meaning that it lacks the core symptoms of depression and is instead characterized predominantly by irritability, intolerance, apathy, and generalized anxiety.
In older adults, treatment does not differ substantially from general treatment in terms of the choice of medications. It should nevertheless be noted that some antidepressants have not been adequately “tested” in elderly age groups, and that studies evaluating the side effects and effectiveness of antidepressant medications typically exclude people with significant comorbid medical conditions—conditions that, in fact, are common among older adults.
Medications with even relatively minor side effects affecting the heart, intestines, or urinary system tend to be avoided because they may worsen conditions that are already developing or are not yet symptomatic, such as prostate enlargement, heart failure, or constipation. Some medications may also worsen cognitive functions, particularly memory.
Metabolism is typically slower in older adults, and therefore medications are generally introduced more gradually and with lower average maintenance doses. In reality, the blood concentrations ultimately reached may be similar, but the elimination of the medications is slower.
In older patients who have no contraindications, electroconvulsive therapy is also an option that may be considered.