Why is it difficult to recognize depression in an older person?

Just another day at the doctor's office...

Pedro is an 88-year-old man. I've known him for a long time. Like other times, he's come to the office alone today. He knows he can talk to me freely; we've shared his problems and difficulties, and his good times, for many years. He's very aware of what I know about his life, especially the constant support he knows I provide, a support that is always present in the memory of his wife, who passed away some years ago. Pedro lives alone and, fortunately, can still take care of himself, although he has occasionally told me about lapses in his daily life that make him wonder if he's losing his mind.

Today Pedro explains to me the recurring aches and pains in his overworked bones. They're meant to be his way of telling the doctor, who, of course, needs to know he's in pain. But Pedro's eyes hold a different kind of pain, and after a few seconds of hesitation, they begin to shine in a different way.

Pedro explains to me that he feels very lonely, that although his children don't live far away, he gets the impression they don't want much to do with him. At his age, of course, "he's just a burden and can't be of any use." All his friends have passed away, and although his wife died a few years ago, he still goes to the cemetery every week to bring her flowers. He still feels a great emptiness. And he thinks a lot about the sea. He has many memories of his lifelong work as a fisherman. It was very hard work, but he loved it, and it gave meaning to his existence. That's why, until recently, he continued going out in a small rowboat that he keeps in a hut on the beach. And it's at that moment that Pedro looks at me very intently with those glassy, moist eyes in which I can now see the sea, and he says to me, calmly but with emotion: "Doctor, I've thought about it a lot, I'm going to take my boat and row, row out to sea until I become one with the sea, with that sea that has given me so much." That's what I want most."

The reality of depression in older people

Pedro's story brings us closer to the reality of depression in older adults. His situation could be that of any elderly person with depression, but with specific characteristics in its presentation that can make accurate diagnosis and treatment difficult .

First, it's important to remember that older adults, due to their age-related characteristics, are more frail and have greater functional limitations , as well as a higher rate of comorbidity with various health conditions. A common mistake in consultations is to downplay the potential impact of these difficulties, attempting to "normalize" the situation. Thus, often the focus isn't on the elderly person who has come to the appointment accompanied by their son or daughter, but rather on these "things that need to be considered during a consultation": checking blood pressure, ordering tests, reviewing medication regimens (especially ensuring they have enough pain medication or even absorbent pads for urinary incontinence), making sure they are seen by other specialists, such as bone or eye specialists, etc.

Despite the frequent visits many of these individuals make to primary care services, they are not always given the opportunity to express their feelings , to openly tell us what they feel. How do these physical limitations affect their quality of life? Do they feel supported or alone? How do they perceive their daily lives? How do they envision their future?

The emotional and affective state of the elderly person should be properly explored in order to detect cases of possible undiagnosed depression.

We are aware of the limitations of health systems, which in many cases are overloaded, but we must also be aware of the importance of properly focusing available resources for the greatest possible benefit to the population served.

We thus encounter very frequent situations in which, for example, the family or caregiver explicitly refers to the elderly person's sleep difficulties. Although we all know that the sleep-wake cycle is physiologically altered with age, or that it could even be a symptom of a depressive disorder, apparent insomnia is often elevated to a diagnostic category and frequently treated with pharmacological regimens of dubious or even harmful use (benzodiazepines or neuroleptics). While acknowledging the occasional benefit of some of these medications, the elderly person's emotional and affective state should be properly assessed before prescribing them, in order to detect cases of possible undiagnosed depression.

Risk factors for depression in older adults

Many factors can converge in a person to trigger depression. Some of these factors are related to predisposing factors , personality structure, or psychological vulnerability linked to genetic characteristics. In this regard, many older adults may have a history of emotional, adjustment, or depressive disorders throughout their lives, which is important to consider.

However, there are risk factors that can contribute to the development of depression , such as those related to socioeconomic status, family dynamics, or the physical and functional limitations associated with some comorbidities. We must also consider other precipitating factors, such as feelings of abandonment or isolation, which can trigger a depressive episode in a person at risk.

How to recognize depression in older people?

Several factors can make recognizing depression difficult. While some of these aspects relate to the structure of the healthcare system itself or the attitudes of professionals, others are related to the specific characteristics of depression when it occurs in older adults.

Some of these characteristics are (Gómez, 2007):

• Many elderly people have difficulty recognizing that they are depressed and complaining.
• It is not uncommon for the core symptoms of depression , such as loss of interest, fatigue, loss of energy, decreased appetite, sleep disturbances, psychomotor slowing, or concentration problems, to be mistakenly attributed to aging .
• Depressive mood sometimes goes unnoticed due to the emotional flatness of some elderly people, which is interpreted as serenity.
• More than two-thirds of patients present with predominant somatic complaints , and in up to 30% of cases, somatization is the initial symptom of the illness. They complain of memory problems, gastrointestinal issues, general malaise, musculoskeletal pain, etc., along with a denial of feelings of depression and an absence of sadness.
• Hypochondriacal symptoms are common. These include cardiovascular, urinary, and gastrointestinal complaints. Often, a somatic illness is also present, further complicating matters. Nearly a third of elderly people with a physical illness also experience depression.
• Delusional symptoms are not uncommon in depressed elderly patients, so there is a risk of treating them only with neuroleptics.
• Anxiety can mask a depressive episode, leading to the isolated prescription of anxiolytics, with the risk of making the disorder chronic and developing pseudodementia.

Risk factors for depression and how to prevent it

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Depression and dementia: seeking the differential diagnosis

Much has often been said and written about the difficulties in diagnosing depression, which can be masked by a problem of dementia.

This is certainly a reality that must be taken into account, since, unfortunately, the cognitive decline that can affect many older adults can make diagnosing depression more difficult. However, the symptoms of cognitive decline generally have characteristics that distinguish them from depressive disorders.

Cognitive decline problems that can affect many older people can make it difficult to diagnose depression.

Among these characteristics, three key differences stand out, which can be very useful and sufficient from the outset. Sufficient, because they help us establish a diagnosis in case of doubt, and useful, because they help us establish therapeutic guidelines as soon as possible.

• Seeking help . In the case of cognitive impairment, it is usually a close family member who alerts us to the situation, while in the case of depression, when it occurs, although not as frequently as desired, it is the affected person who requests help.
• Social skills : People with cognitive impairment may initially maintain their social skills, whereas in people with depression, isolation often contributes to their withdrawal from social support. This has significant consequences, as we will see later.
• Associated factors : In the case of dementia, it is mainly confusion and disorientation and, although the person may present affective lability, it does not have the relevance of the emotional impact of the person with depression who, in addition to other alterations such as loss of appetite, usually manifests a marked depressed mood and, sometimes, even suicidal thoughts.

Promoting social and community support from primary care

Evidence indicates that the perception of loneliness and social isolation is a clear indicator of increased mortality. A meta-analysis of 148 prospective studies that examined mortality in relation to social relationships showed that the likelihood of survival was 50% higher in individuals who reported a sense of adequate social connection, compared to those who reported a perception of social isolation (Holt-Lunstad, 2010). Loneliness kills. It has been demonstrated that the influence of social relationships on mortality is comparable to risk factors such as obesity or smoking.

The evidence presented raises an interesting question from the perspective of primary care: Can we do anything for our elderly who perceive themselves as socially isolated?

In general, this question could be posed to everyone we serve, and the answer would be yes. We can, and I would even say we shouldn't hesitate to, address the risk factors that impact health. As we've seen, it's important to prevent the perception of social isolation within the population.

The protective effect of community-based social prescribing activities has been demonstrated in preventing the emotional impact of social isolation on older people.

In this regard, the protective effect of community-based social prescribing activities has been demonstrated in mitigating the emotional impact of social isolation on older adults. For example, some published studies have shown a 10-20% reduction in depression among individuals participating in community-based activities that promote mental health (such as caring for others or volunteering). This impact is even more pronounced among women than men (Netuveli et al., 2006).

F: English Longitudinal Study on Ageing, 2006

In order to promote community-oriented social prescribing strategies, it is desirable that primary care teams establish partnerships with local associations. Participation in activities that foster sociability and mutual support can be highly beneficial for the emotional well-being of older adults and can facilitate collaborative efforts in both the prevention and treatment of depression.

In patients with depression, these activities can provide additional benefits to antidepressant medication, given their clear indication and proven benefits. Among these activities, those that promote group physical exercise are particularly relevant, as they can counteract the functional limitations of this stage of life.