Elsevier

The Lancet

Volume 365, Issue 9475, 4–10 June 2005, Pages 1961-1970
The Lancet

Seminar
Depression in the elderly

https://doi.org/10.1016/S0140-6736(05)66665-2Get rights and content

Summary

In elderly people, depression mainly affects those with chronic medical illnesses and cognitive impairment, causes suffering, family disruption, and disability, worsens the outcomes of many medical illnesses, and increases mortality. Ageing-related and disease-related processes, including arteriosclerosis and inflammatory, endocrine, and immune changes compromise the integrity of frontostriatal pathways, the amygdala, and the hippocampus, and increase vulnerability to depression. Heredity factors might also play a part. Psychosocial adversity—economic impoverishment, disability, isolation, relocation, caregiving, and bereavement—contributes to physiological changes, further increasing susceptibility to depression or triggering depression in already vulnerable elderly individuals. Treatment with antidepressants is well tolerated by elderly people and is, overall, as effective as in young adults. Evidence-based guidelines for prevention of new episodes of depression are available as are care-delivery systems that increase the likelihood of diagnosis, and improve the treatment of, late-life depression. However, in North America at least, public insurance covers these services inadequately.

Section snippets

Diagnosis

For a diagnosis of major depression to be made, DSM-IV and ICD-10 state that either depressed mood or loss of interest or pleasure must be present (panel 1). Although not part of the diagnostic criteria, late-life major depression is often associated with peripheral body changes and cognitive impairment. Changes to the body include hypercortisolaemia, increased abdominal fat, decreased bone density, and increased risk for type 2 diabetes and hypertension.4 Non-demented elderly people with major

Epidemiology

1–4% of the general elderly population has major depression,2 equivalent to an incidence of 0·15% per year. Twice as many women as men are affected. Both the prevalence73 and the incidence74 of major depression double after age 70–85 years. Similarly, the number of elderly people with bipolar disorder is increasing, because the absolute number of old people is rising and, possibly, because the proportion of elderly individuals with this illness is increasing.75

Minor depression (panel 1), has a

Pathophysiology

Dorsal neocortical structures are hypometabolic and ventral limbic structures are hypermetabolic during depressed states.78, 79 Similar changes arise in experimentally induced sadness,79 but are quickly reversed when stimuli are removed. The persistence of the changes in depressed patients suggests that additional biological factors predispose to depression and sustain depressive symptoms (figure).

Frontostriatal pathways in the brain mediate positive affect-guided anticipation, and

Heredity

In addition to changes in brain structures, hereditary factors could predispose to late-life depressive syndromes (figure). In community-residing elderly twins, heredity accounted for 18% of the variation in depressive symptoms.104 Elderly people who are depressed are, however, less likely to have a depressed relative than younger patients who are depressed.105 Personal or family history of a depressive disorder affects the incidence of depression after stroke as much, if not more, than the

Prevention

There is a hypothesis that positive mental health can be enhanced if people believe they have the ability to act in a way that will result in achievement of their goals.2, 112 As such, elderly individuals with chronic medical illnesses at risk for depression who receive instruction on body-mind relations, relaxation techniques, cognitive restructuring, problem solving, communication, and behavioural management of insomnia, nutrition, and exercise, have increased self-efficacy and reduced

Management

The aims of treatment are to reduce the symptoms of depression, to prevent suicidal ideation, relapse, or recurrence of symptoms, to improve cognitive and functional status, and to help patients develop the skills needed to cope with their disability or psychosocial adversity if appropriate.117 Behavioural rehabilitation should be combined with antidepressant treatment to improve function as depressive syndromes subside.

Treatment planning should start with an assessment that focuses on

Care delivery

Most elderly individuals who are depressed are treated in primary-care settings.3, 32 However, primary-care doctors rarely diagnose depression and, when they do, often provide inappropriate treatment.3, 33, 131 Barriers to adequate diagnosis and treatment include doctors' reluctance to discuss emotional problems, time constraints, and medical comorbidity, complicating diagnosis and competing for clinical attention.132, 133 Perceived stigma134 contributes to patients' reluctance to initiate

Outlook

Late-life depressive disorders often arise in the context of psychosocial adversity, chronic medical diseases, and disability, and besides suffering and family disruption worsen medical outcomes. Although ageing and disease-related brain abnormalities that predispose to late-life depression have been identified, a direct lesion-depression association is unlikely. Behavioural abnormalities are subserved by high-level interactive and redundant neural systems. When damaged, these systems can cause

Search strategy and selection criteria

I searched MEDLINE and Ageline abstracts to 1980 with the keywords “depression”, “depressive disorder”, “bereavement”, “geriatric aging”, “late-life”. I focused, however, on empirical studies, meta-analyses, and authoritative reviews published after 1990, since most progress in understanding late-life depression took place after this date. Among them, I selected work published in English on the diagnosis, recognition, pathophysiology, prevention, and management of late-life depression.

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