Risk factors:

• Physical ill health

  • Chronic illness, dementia, stroke, Parkinson’s, chronic pain

• Social factors

  • Social isolation, being a carer, bereavements

• Prior history of depression

• Substance misuse may be either a cause or consequence of depression

 

 

Assesment :

• During the last month, have you often been bothered by feeling down, depressed or hopeless?

• During the last month, have you often been bothered by having little interest or pleasure in doing things?

 

If the answer to either of these questions is positive, further assessment of mental state, functional abilities and social situation should be undertaken by a trained person. 

 

 

Diagnosing depression in the presence of dementia :

 

This is a diagnostic challenge, and specialist referral is usually required.

Some symptoms of depression such as tiredness, weight loss and psychomotor retardation also occur in dementia. 

A history of the symptoms from an informant may be helpful. 

 

 

Risk of suicide in older people with depression :

 

Older adults with depression are at higher risk of completed suicide that younger people, so specific enquiry into suicidal thoughts should always be made.  Risk factors for suicide in older people include:

• Older age, male sex

• Social isolation

• Bereavement

• History of attempts

• Evidence of planning

• Chronic painful illness or disability

• Drug or alcohol use

• Sleep disorders

 

 

Management :

 

Any co-existing physical health problems should be optimised.  General advice should include good sleep hygiene, maintaining physical activity and limiting alcohol intake.

• For mild or subthreshold symptoms, psychosocial interventions such as increasing social contact and physical exercise may be sufficient.  Medication should not be offered as a first-line treatment but reserved for those who do not respond to initial measures.

• When drug treatment is required, selective serotonin re-uptake inhibitor (SSRI) should be the first-line therapy.   SSRIs may cause hyponatraemia, postural hypotension, and increase the risk of gastrointestinal bleeding.

•  Tricyclic antidepressants have anti-cholinergic side effects and should be avoided in older people.

• Psychological therapies are effective in older people, and in combination with drug treatment is more effective than either therapy alone.

• Those with moderate to severe symptoms are likely to require referral for specialist support.

• People who have responded to medication should continue is for at least six months after recovery to reduce the risk of relapse.