Updated August 27, 2021

Depression

what questions should I and my family be asking?

• Do you feel that your mood is low?

• Do you lack engagement with care providers?

• Does your mood stop you from doing the activities and hobbies you usually enjoy doing?

• Do you have poor motivation to look into the treatment of other illnesses?

• Are you satisfied with your life?

• Do you often get bored?

• Do you often feel helpless?

• Do you prefer to staying home than going out and doing new things?

• Do you feel pretty worthless the way you are now?

• Are you happy most of the time?

• Do you feel that you have more problems with your memory more than most?

• Do you think it’s wonderful to be alive right now?

• Do you feel full of energy?

• Do you feel your situation is hopeless?

• Do you feel that most people are better off than you are?

What actions can i take for this agenda?

• Contact your local support hotlines for suicide prevention. The Canadian Suicide Hotline number is 833-456-4566 and is available all day every day. They are experts in helping you deal with suicidal thoughts

• Always talk to your doctor. They are capable of guiding you and can screen for depression, diagnose, and treat it. If not, they can refer you to a specialist in that field like “geriatric psychiatry”

• Remember that older adults are at increased risk of depression and that you are not alone. Your family doctor usually knows you more than your other physicians. They can be a great asset to help with your mental health. It is important to have a family doctor if you do not have one

• There are a lot of studies showing that exercise can improve depression in older adults. The exact reason as to how this helps is not known. It is likely a mix of weight loss, feeling better, functioning more, and having a social element to exercise

• Depression is complex so always discuss your options to know what is best for you. You can choose non-medication or medication options. Usually combining both has shown even better results

What does being depressed mean?

• Depression is an abnormal mental health condition

• It is more than just being sad

• It is a collection of symptoms that involves low mood and loss of interest

• It impacts your function while causing distress

• Depression affects around 5-10% of older adults over the age of 65

• Hospitalized older adults have rates over 30%

• Patients with stroke, heart disease, or cancer have rates over 40%

Why is depression a burden?

• Depression is the fourth leading cause of disease burden worldwide. It causes the most total years lived with disability. It is the most common mental illness in older adults

• Depression also increases the risk of thinking (cognitive) impairment such as dementia, death, and heart disease

• It can be challenging to diagnose in older adults because of the abnormal (atypical) way they present compared to a younger population

• 80% of mental health treatment for depressed older adults is delivered in an outpatient setting

• Depression often goes undiagnosed in primary care and is often untreated

Depression is caused by a combination of factors and presents differently in older adults

it is from changes in our brain chemistry, environment, genes, and social stressors

What are the symptoms? How does it present?

• The depressed mood and lack of interest in life and activities are the main symptoms. These can be present from weeks to months

• There are other symptoms such as:

• Low energy

• Feeling worthless

• Feeling guilt

• Feeling suicidal

• Increased or decreased sleep

• Increased or decreased appetite

• Increased or decreased weight

• Having thoughts about death or suicide

How is depression different in older adults?

• Depression does not present as it usually would in middle-aged adults

• Older adults can have other symptoms such as poor memory

• Even physical symptoms from their change in mood such as chest or stomach pain are more common in older adults

• Older adults often deny having a low mood too. They can also have lower attention and self-esteem

• Depression is under-diagnosed in older adults because of how abnormal it may present

• Depression can be caused by thinking (cognitive) impairment like dementia or co-exist with anxiety

• Refer to the “mind” agenda for more details

depression causes a low mood and lack of interest

Older adults can have symptoms that younger adults do not such as low self-esteem, cognitive impairment, and physical symptoms

what is the difference between depression and grief (bereavement)?

• Grief (bereavement) is the feeling of intense sadness and sorrow from a stressful event or trigger

• An example is grief caused by a loved one’s death

• Grief can have symptoms that look like depression but it is not

• Grief is normal and usually resolves on its own

• Depression is not normal and needs to be diagnosed and treated

• The main difference between grief and depression is that those with grief:

• Have a specific loss whereas those with depression may not

• Focus on the loss whereas those with depression focus on themselves

• Prefer to be close to others and find it comforting whereas those with depression prefer to be alone

• Have a wide range of emotions whereas those with depression focus on their low mood

• Focus on guilt over the loss whereas those with depression feel guilt in general

• Have preserved self-esteem whereas those with depression do not

• Have thoughts of death that are about joining the one they lost whereas those with depression have thoughts about death because of worthlessness

How is depression screened for and diagnosed?

• Depression is a “clinical diagnosis” meaning we look at the symptoms and signs from the history to diagnose it. Of course, there might be a need to do blood work and brain imaging to rule out other causes of depression

• There have been many studies recommending the use of screening questions for older adults yearly looking for depression. As such, when visiting your doctor, it is ideal to have screening questions to look for depression. After that, a more thorough assessment can be done

• A common screening tool used is something called the Geriatric Depression Scale (GDS). A score of five or more would indicate possible depression but would need to be assessed further

• It is highly suggested that a trained doctor apply these screening tools for the best accuracy and diagnosis

Grief can increase the risk of depression. It is normal to have feelings of grief however depression needs to be diagnosed and treated

why is it difficult to diagnose depression in older adults compared to younger adults?

• Having another medical illness with symptoms similar to depression

• For example, low energy, loss of appetite, sleep changes, and memory changes overlap

• Medication side effects can also have symptoms similar to depression

• Lack of time in the clinical exam to assess mental health problems in patients with complex issues

• Social stigma for mental illness on the part of the patient, family, or healthcare provider

what increases the risk of depression?

• Older age

• Female gender

• Social isolation

• Grief (bereavement)

• Low social support

• Having long-term (chronic) illnesses

• Widowed, divorced, or separated marital status

• Retired or unemployed

• Uncontrolled pain

• Lack of sleep (insomnia)

• Functional impairment

• Alcoholism

• Family history of mental illness

IS suicide linked with depression?

• Yes, depression is a major risk factor for suicide

• Suicide is defined as ending one’s life on purpose

• Older adults attempt suicide less often than younger adults, but sadly are more successful at completion

• Older men have the highest suicide rates compared to women and younger adults

• Sadly, most older suicide victims were in their first episode of depression

Depression can be complicated in older adults because of how differently it may present

many risk factors lead to depression

Depression increases the risk of suicide and needs to be treated

Can depression increase the risk of thinking (cognitive) impairment such as dementia?

• Yes, late life depression is linked with dementia

• Studies have shown that the risk is around twice as high compared to those who do not have depression

• This can be challenging since dementia can cause depression too

• Refer to our “mind” agenda for details

what about the other types of being depressed?

• There are types of depression as the term “depression” is a general term

• The type we are discussing in this agenda is known as “major depressive disorder”

• Other types that are not discussed here exist such as minor depressive disorder, depression from strokes, and depression from dementia

• You can also have mood changes from other medical conditions. For example, low thyroid levels or low steroid levels among other diseases

Depression can increase the risk of thinking (cognitive) impairment some studies have found

Dementia can also cause depression

is there treatment for being depressed?

• Yes, there are several well-studied treatment options. Some use “talking” treatments, some use medications, and others use both

• Cognitive Behavioral Therapy (CBT) is a non-medication talking treatment that involves sessions with a trained mental healthcare provider

• Studies have shown that it is helpful for mild to moderate depression and is equally as good as medications

• There are also medications to treat depression called “antidepressants”

• Two of the most common classes are “SSRIs” and “TCAs”

  Examples of SSRIs are:

• Citalopram (Celexa)

• Escitalopram (Lexapro)

• Fluoxetine (Prozac)

• Paroxetine (Paxil, Pexeva)

• Sertraline (Zoloft)

  Examples of TCAs are:

• Amitriptyline (Elavil)

• Clomipramine (Anafranil)

• Desipramine (Norpramin)

• Imipramine (Tofranil)

• Nortriptyline (Pamelor)
  

• Both of them have good evidence for older adults however SSRIs are used as first-line. This means they have the best evidence to be used first before other types of medications for depression

• The reason that SSRIs are recommended first is not just how effective they are but also because they are much more tolerated in older adults than the other medications such as TCAs

• TCAs have many more side effects compared to SSRIs and can be harmful in older adults. TCAs can cause low blood pressure and increase the risk for confusion and falling

• It is important to discuss these options with your doctor to know what is right for you

• These are general suggestions. It is important to remember that depression is complex and everyone is different. Never start or stop treatment without talking to your doctor first

• Everyone should be treated with the non-medication means mentioned. Some will need medications to help on top of that too

What are the side effects of these medicines?

• SSRIs can cause nausea, stomach pain, short term anxiety, loss of appetite, and weight loss

• TCAs can cause sedation, constipation, low blood pressure, abnormal heartbeats, confusion, and increase risk of falls

• Overall, SSRIs are much more tolerated in older adults than TCAs given the side effects mentioned. Also, overdosing on SSRIs is less dangerous than doing so with TCAs

Depression treatment can be divided into “talking” therapy like CBT or medications such as antidepressants

It is important to discuss treatment options with your doctor to know what is right for you

How long will it take for medications to work?

• Usually, it takes up to 12 weeks to truly see the benefit of antidepressants in older adults

• It is recommended to continue on them for at least that time before judging whether to stop them or change treatment

• There are things one can do if no benefit is seen

• Changing to another medication or increasing the dose are both good options. You must discuss treatment choices with your doctor first before making any changes

• If it gets complex, they can even refer you to a mental health specialist. There is a field called “geriatric psychiatry” that focuses on the treatment of mental health disorders in older adults

• Even with treatment, some days can still have low mood emotions regardless. It takes a combination of treatments tailored to your needs and time to reach the best results

Treating depression with medications and “talking” therapies can take up to 12 weeks or more for results

studies are showing that combining the “talking” therapies with antidepressants is more effective in treating depression than each option on its own

Anxiety

what questions should I and my family be asking?

• Do I feel worried or fearful a lot?

• Am I worried about most things or something specific?

• Did a big life stressor happen recently such as a loved one dying?

• Is my anxiety keeping me from living my life?

• Is my anxiety keeping me from doing the things I want to do?

• Am I eating and sleeping well?

• Do I get anxiety attacks (panic attacks) causing me to feel
  chest pain, trouble breathing, nausea, sweating, or heart racing?

WHAT ACTIONS CAN I TAKE FOR THIS AGENDA?

• Contact your local support hotlines for suicide prevention. They are experts in helping you deal with suicidal thoughts

• Talk to your family doctor and ask about a therapist or psychiatrist

• Avoid alcohol, caffeine, smoking, unhealthy eating, and not sleeping well

• Exercise and stay active

• Relaxation techniques such as meditation, breathing exercises, and yoga

• Have a plan on what to do when you have a panic attack

• Consider medications such as from the class of “SSRI”

• Consider Cognitive Behavioral Therapy (CBT)

• Always talk to your doctor first before starting medications or CBT

WHAT IS ANXIETY? WHAT ARE ANXIETY DISORDERS?

• Anxiety can be a normal response to stress

• It means worrying and being fearful about something or many things

• It can be generally towards most things or something more specific

• A common example is being anxious about a test or a job interview

• Anxiety should not keep you from doing the things you enjoy doing

• It should also not keep you from sleeping, eating, work, having healthy relationships, and doing the daily tasks you wish to do

• If it does, it could be an anxiety disorder. This kind of anxiety is not normal and is considered a mental illness. This should be treated

WHY IS anxiety A BURDEN?

• Anxiety can decrease your quality of life

• It can increase your risk of depression and thinking (cognitive) impairment such as dementia

• Older adults are at increased risk of anxiety

• It is as common as 5 to 10% or more in older adults

ANXIETY IS NOT NORMAL IF IT AFFECTS YOUR DAILY LIFE AND DOING THINGS YOU WANT TO DO. ANXIETY DISORDERS CAN STRAIN YOUR SLEEPING, EATING, WORK, AND RELATIONSHIPS

OLDER ADULTS ARE AT INCREASED RISK OF ANXIETY DISORDERS. IT CAN PRESENT DIFFERENTLY IN OLDER ADULTS TOO

ARE THERE DIFFERENT TYPES OF ANXIETY DISORDERS?

• Yes, the term “anxiety” is a broad term

• There are different types of anxiety such as:

• Generalized Anxiety Disorder (GAD): Worrying a lot over many things or events. Usually, the worry is not on something specific but “general” things. This type is more common in older adults

• Post-traumatic Stress Disorder (PTSD): Stress lasting more than a month after big life stressors. Examples of this can be from having a life-threatening illness or being involved in a car accident

• Panic Attacks: Also known as an anxiety attack. It is a feeling of sudden and intense fear. Symptoms involve chest pain, trouble breathing, sweating, shaking, nausea, and heart racing

• Social Anxiety: Worrying about social experiences and talking with others

• Phobias: Irrational fear of situations or objects

WHAT IS A panic attack?

• A panic attack is also known as an anxiety attack

• It is a type of anxiety

• It makes one feel a sudden and intense fear

• Symptoms involve chest pain, trouble breathing, sweating, shaking, nausea, and heart racing

• Some even feel like they are going to die

• Some even expect the attacks to happen at certain times of the day

• One way to decrease the attacks is to do breathing exercises

• Always speak to your doctor if you feel you’re having panic attacks. You might need medications or see a psychiatrist to help

“ANXIETY” IS A BROAD TERM AS THERE ARE MANY TYPES OF ANXIETY. THE MOST COMMON TYPE IN OLDER ADULTS IS GENERALIZED ANXIETY DISORDER

A PANIC ATTACK IS A QUICKLY OCCURRING FEELING OF WORRY CAUSING ONE TO FEEL INTENSE FEAR

WHAT CAUSES ANXIETY DISORDERS?

• Anxiety is caused by three major features:

• Outside stressors: Relationship strain, death in the family, or hurtful experiences

• Medical factors: Symptoms of a disease, medications, or family history of mental illness

• Brain chemistry: Imbalanced chemicals and electrical signals in the brain

HOW ARE ANXIETY DISORDERS DIAGNOSED?

• Anxiety disorders are based on a “clinical diagnosis”

• This means it is diagnosed based on the symptoms and signs

• There is no specific blood test or brain imaging that will diagnose anxiety

• Your doctor might order blood work to rule out other causes

• You might be referred to a specialist such as a psychiatrist to help too

ANXIETY DISORDERS ARE CAUSED BY A COMBINATION OF OUTSIDE STRESSORS, MEDICAL FACTORS, AND BRAIN CHEMISTRY

ANXIETY DISORDERS ARE DIAGNOSED BY THE HISTORY AND ANSWERS YOU PROVIDE TO YOUR DOCTOR. THERE IS NO SPECIFIC BLOOD OR IMAGING TEST

WHAT LIFESTYLE CHANGES CAN I DO TO HELP?

• Getting enough sleep

• Relaxing activities such as yoga or meditating

• Breathing exercise

• Staying active

• Eating a healthy diet

• Avoiding alcohol

• Avoiding caffeine

• Quitting smoking cigarettes

• Quitting harmful substances such as alcohol and drugs

WHAT medicines CAN HELP WITH ANXIETY?

• Some medications can help

• Always talk to your doctor before starting them

• Medications are only one part of treating anxiety

• They address the brain chemical balance but not other issues

• Looking at lifestyle changes can also help as mentioned above

• Seeing a therapist or psychiatrist helps too

• Medications in the class known as "SSRIs" have been studied well

• This class of medications is usually well tolerated in older adults

• Even though they’re called "antidepressants" they also help with anxiety as they are “anti-anxiety” too

• Examples of these medications are Citalopram, Escitalopram, Sertraline and Mirtazapine

• Always talk to your doctor, family physician, geriatrician, pharmacist, or psychiatrist before starting these medications

THERE ARE MANY WELL-STUDIED LIFESTYLE CHANGES YOU CAN DO TO DECREASE YOUR ANXIETY

Some medications CAN HELP WITH ANXIETY. THE CLASS KNOWN AS “SSRI” IS WELL STUDIED AND OVERALL WELL TOLERATED IN OLDER ADULTS. TALK TO YOUR DOCTOR ABOUT MEDICATIONS

WHAT IS COGNITIVE BEHAVIORAL THERAPY (CBT)?

• Cognitive Behavioural Therapy (CBT) is a type of “talking” therapy

• It is a way to treat anxiety and other mental illnesses

• It involves talking to a therapist for several sessions to talk about your anxiety

• They help dig deep into why and how you feel the way you feel

• They teach older adults how to self-monitor feelings, relax, and what to do in those situations

• Research has shown great benefits with CBT

• Studies have shown that combining CBT with medications boosts treatment success for anxiety

• If someone has thinking (cognitive) impairment such as dementia, CBT may not work. They may not retain the information

HOW DO ANXIETY DISORDERS PRESENT IN OLDER ADULTS? Are they different from younger adults?

• Yes, anxiety symptoms in older adults present differently than in younger adults. Sometimes, anxiety can cause physical symptoms

• For example, these can be in the form of chest pain or nausea. Other examples are not eating or sleeping well

• Older adults tend to not mention or disclose to their doctors or families about anxiety too

Anxiety CAN PRESENT DIFFERENTLY AND IN MORE SUBTLE WAYS in older adults

What resources can help with this agenda? 

References

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