Depression is a medical illness in which a person has feelings of sadness, discouragement, and a lack of self-worth.

Depression can be caused by:

• Changes within the family
• Chronic pain and illness
• Difficulty getting around
• Frustration with memory loss
• Loss of a spouse or close friend
• Trouble adapting to a life change such as moving from a home to a retirement facility

Depression can also be a sign of a medical problem. It can be a reaction to the illness, or caused by the disease itself. It may be complicated by brain disorders that occur with age, such as Alzheimer's disease. Depression is also a side effect of many drugs commonly prescribed for the elderly.

Depression in the elderly is a widespread problem that is often not diagnosed and frequently undertreated. Many older people will not admit to the signs and symptoms of depression, for fear that they will be seen as weak or crazy. Some older people may be aware of their depression, but believe that nothing can be done about it.

Symptoms of depression may not be easy to identify in older adults. Their symptoms are often ignored, or confused with other ailments common in the elderly, such as:

• Alzheimer's disease
• Arthritis
• Cancer
• Dementia
• Heart disease
• Parkinson's disease
• Stroke
• Thyroid disorders

Symptoms of depression include:

• Abnormal thoughts about death
• Abnormal thoughts, excessive or inappropriate guilt
• Aches and pains
• Change in appetite (usually a loss of appetite)
• Change in weight
  • Unintentional weight loss (most common)
  • Weight gain
• Depressed or irritable mood
• Difficulty concentrating
• Fatigue (tiredness or weariness)
• Feelings of worthlessness or sadness
• Irresponsible behavior
• Loss of interest or pleasure in daily activities
• Memory loss
• Plans to commit suicide or actual suicide attempts
• Temper, agitation
• Thoughts about suicide
• Trouble sleeping
  • Daytime sleepiness
  • Difficulty falling asleep (initial insomnia)
  • Waking up many times through the night (middle insomnia)
  • Waking up early in the morning (terminal insomnia)

If you have these symptoms every day for more than 2 weeks, you likely have depression.

Depression in the elderly may be hard to detect because of several factors. Symptoms such as fatigue, appetite loss, and trouble sleeping also can be part of the aging process or a medical condition.

An elderly person may only have a decrease in the ability to perform everyday activities.

A physical exam will help determine if a medical illness is causing the depression. A psychological evaluation and other tests may be needed.

Blood tests may be done, including:

• Blood differential
• CBC
• Liver or kidney function tests
• Thyroid function tests

Sometimes relieving loneliness through group outings, volunteer work, or having regular visitors can help with depression.

Treating the medical conditions that cause depression, or stopping certain medications can relieve the symptoms of depression.

Talking through problems (psychotherapy) with a psychologist, psychiatrist, or other therapist is also an effective treatment. In cases of moderate-to-severe depression, people may get the best results by combining psychotherapy with antidepressant medications.

Short-term (about 12 weeks) group-based physical exercise programs involving walking or other forms of aerobic exercise can reduce depression in older adults.

Antidepressant drug therapy has been shown to increase the quality of life in depressed elderly people. These medications are carefully monitored for side effects. Doctors usually prescribe lower doses of antidepressants for older people, and increase the dose more slowly than in younger adults.

These medications include:

• Selective serotonin-reuptake inhibitors (SSRIs), such as fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), citalopram (Celexa), and escitalopram (Lexapro) are used as first-line treatments.
• Serotonin-norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine (Effexor) and Duloxetine (Cymbalta), as well as mirtazapine (Remeron) may also be tried.
• Tricyclic antidepressants are not used as often because of side effects, particularly for the heart.

Neuroleptic medications can help treat agitation in some people. Electroconvulsive therapy (ECT) can be used in people who are severely depressed if other treatments don't work.

Depression can respond to medical treatment. If it is not detected, depression can lead to complications. The outcome is usually worse for people who have limited access to social services, or to family or friends who can help them stay interested in activities.

Depression can be complicated by Alzheimer's disease or other forms of dementia. It also can complicate other medical conditions in the elderly.

Suicide in the elderly is one of the leading causes of death related to injury. Men account for most of these suicides, and divorced or widowed men are at the highest risk. Families should pay special attention to elderly male relatives who are alone. In addition to finding psychiatric help for them, family members should remove anything from their homes (such as knives) that they could use to harm themselves.

Call your health care provider if you feel worthless or hopeless, or if you cry often. Also call if you are having trouble coping with stresses in your life and want to be referred for counseling.

Go to the nearest emergency room or call your local emergency number (such as 911) if you are thinking about suicide (taking your own life).

If you are caring for an aging family member and think they might have depression, contact their health care provider. Often, older patients will not admit to the signs and symptoms of depression out of pride.

Preventing depression depends on the factors involved. Social supports that help people deal with loss, mobility changes, and other depression triggers can be helpful. In many cases, there is no way to prevent depression.

Some older patients may be screened for depression, especially if their condition changes.

Institute for Clinical Systems Improvement. Health Care Guideline: Major Depression in Adults in Primary Care. 11th ed. May 2008.

Unutzer J. Clinical practice. Late-life depression. N Engl J Med. 2007;357:2269-2276.