The symptoms of depression can be the same for older patients as younger adults. However, older patients with depression can often deny feeling sad or depressed. Here are some clues to indicate that an older patient might have depression.

• unexplained or aggravated aches and pains
• feelings of hopelessness or helplessness
• anxiety and worries
• concentration problems
• lack of motivation and energy
• slowed movement and speech
• irritability
• loss of interest in socializing and hobbies
• neglecting personal care

It can be easy to think of a patient’s presenting symptoms as a normal part of aging, for example it is common for people to experience trouble with concentration and difficulty maintaining sleep as they get older. Even feelings of guilt and worthlessness can appear to be a reaction to losing a loved one or retiring, respectively. One important factor is looking at the level of impairment to help determine if a more serious process is occurring.

Depression can occur co-morbidly with dementia and the two disorders each increase the risk of the other, but the cognitive concerns that occur with each are different. Persons with depression commonly report trouble concentrating and being motivated. Persons with dementia present with short-term memory loss and word finding difficulties, and may not be aware of the cognitive challenges. The cognitive decline seen in dementia is mostly a slow process whereas the cognitive decline seen in depression is more rapid. Here is a helpful chart to distinguish between depression and dementia.

One very important thing to be aware of is that the suicide risk is high among older patients with depression, particularly in Caucasian males. Research shows that 75% of people who commit suicide have visited their PCPs in the previous month but their symptoms of depression were either not disclosed or not assessed for. This is a serious and potentially preventable problem, and starts with improving psycho-education and awareness of depression in older patients.

It is also important to be aware that medical problems and medications can cause depressive symptoms in older adults. Medical problems that can cause depressive symptoms, either directly or as a psychological reaction to the illness, include Parkinson’s disease, stroke, heart disease, cancer, diabetes, thyroid disorders, vitamin B12 deficiency, dementia, lupus and multiple sclerosis. Medications that can cause of worsen depression include: beta-blockers, sleeping medications, benzodiazepines, calcium-channel blockers, ulcer medications, steroids, cholesterol medications, and pain medications. While the mood-related side effects of prescription medication can affect anyone, older adults are more sensitive because of less efficient metabolism of medication.

Treatment for depression should include treating underlying medical factors, increasing social engagement and therapy. Medication (primarily the SSRIs) can be an important part of the treatment as well, but it is important to utilize the lowest effective dose and monitor closely for side effects, which can include bone loss and increased risk for falls and fractures in elderly patients. Measures to reduce the risk of bone loss, like exercise and calcium and vitamin D supplementation, are important to consider adjunctively.

As mentioned previously, it is important to improve awareness of and assessment for depression in older patients, It not only can be a debilitating condition on its own, but it can also complicate the presentation of other medical problems and limit effectiveness of treatment for those other medical problems.

Females in their 40s and 50s often present to their primary care providers with new-onset depressive symptoms. In developing a treatment plan, it is important to assess if the symptoms are part of menopause or perimenopause or if they represent a new-onset depressive disorder. A complicating factor is that menopause can independently increase the risk of a depressive episode even in a woman without a history of depression.

During the assessment, it is important to obtain a thorough menstrual history as well as ask if the patient is experiencing other physical symptoms of menopause. The menstrual history should include if her cycle is regular or irregular, the heaviness of the flow, and when she had her last menses. Perimenopause begins when the cycle begins to vary and ends 12 months after the last menses. If it is clinically unclear if a patient is in perimenopause, one can measure FSH and estrogen levels during the early follicular phase. During perimenopause, vasomotor symptoms (VMS) and mood lability may worsen. Vasomotor symptoms include hot flashes and night sweats. Other physical symptoms of menopause include: forgetfulness, insomnia, sexual changes (decreased desire, vaginal atrophy), vaginal dryness, joint pains, bladder discomfort, breast pain, and headaches.

Menopausal patients with vasomotor symptoms are more likely to have mood symptoms as well, which can include: irritability, insomnia, mood lability, and anxiety. Both the mood changes associated with menopause as well as the vasomotor symptoms are linked to dysregulation of monoaminergic neurotransmitter systems caused by fluctuating estrogen levels.

Treatment is based on where the patient is in the course of perimenopause/ menopause and on the severity of the mood symptoms. The other factor is the appropriateness of hormone replacement therapy (HRT). While there has been much controversy about HRT since the Women’s Health Initiative study in 2002 showed concerns about possible increased risk of breast cancer and limited cardiac protection of HRT, more recent evaluation of the study results has reduced many of these concerns. As a result estrogen is the only FDA approved treatment for VMS, and since mood symptoms of menopause are so intimately linked to VMS, theoretically estrogen would be a good treatment for depression linked to menopause as well.

If the patient is in perimenopause and HRT is an option, studies have shown that HRT can be helpful for both the mood symptoms of perimenopause as well as VMS, so it can be an appropriate treatment for women presenting with mild-moderate mood symptoms related to perimenopause. If HRT is not an option or if the mood symptoms are more severe, treatment with an antidepressant is an option. Studies have shown that the selective norepinephrine reuptake inhibitors (venlafaxine, duloxetine) are more helpful for VMS than the selective serotonin reuptake inhibitors (SSRIs), so if HRT is not an option, one might consider starting with an SNRI to treat both the mood symptoms as well as the VMS. If HRT is an option, one might consider a combination of HRT and an SSRI as an alternative