Geriatric depression is underdiagnosed. What can we do about it?

Written by Billing Dynamix

“Old and Sad” Isn’t Normal

BY Megan Cheng, SPT
UNM School of Medicine
Division of Physical Therapy

It made sense for her to feel down.

My great-grandmother was an adventurer. She flew small planes. She took a boat around Cape Horn and found it disappointingly calm. She ran a bank on a secretary’s salary. She was sharp

Her body declined faster than her mind. And so she stayed inside. She played bridge, but complained that the group played “so slow, just talking about their grandkids”. She watched the news “to see who got shot today”. 

It made sense, to me, that she seemed sad and frustrated. She missed her husband, and she couldn’t get out and experience what her active mind desired. But now I wonder if she was depressed, and if we could have helped her.

Depression in older adults is significantly underdiagnosed, and even when it is recognized it often goes untreated – or not treated in the best way.1 Older adults may be given anti-depressive medications but are less likely to be referred to counseling, despite the fact that a majority of older adults prefer counseling to medication.2 Evidence shows that a combination of these methods is most likely to reduce depression. And medication must be used cautiously, especially sedatives that may increase risk of orthostatic hypotension and falls.1 According to Beer’s Criteria3, many anti-depressive medications should be strongly avoided in this population. 

One factor that may lead to under-diagnosis is the fact that older people tend to have events in their lives that warrant grief. They may have lost spouses and friends. They may have moved to assisted living or to a nursing home. They may be struggling with other health conditions. But persistent sadness that extends beyond the normal bounds of grief is not normal, and there are ways to mitigate it. 

Another factor may be that patients are hesitant to admit that they struggle with mental health.

Since physical therapists spend extended time with patients, they have the opportunity to watch for signs of geriatric depression, and to screen for it in older patients. If a physical therapist suspects that a patient may be depressed, they can then advocate for referral to counseling and other treatment. Evidence-based screenings for depression include the 2-question PHQ-2:

During the past month, have you been bothered by:

  • feeling down, depressed or hopeless? or
  • little interest or pleasure in doing things?

 The 5-question Geriatric Depression Scale and the Cornell Scale for Depression in Dementia are among other screeners. However, a practitioner cannot depend on these questionnaires alone – they must also be on the look-out for signs of depression during patient interactions.

Here are some signs to look for, from UptoDate1:

  • A person has poor motivation to participate in treatment
  • A person’s mood or somatic symptoms are out of proportion to what is expected for their condition
  • A person has a poor response to standard medical treatment
  • A person does not engage with care providers

In the oldest old (>85 y/o), dysphoric mood may be a less reliable indicator of depression. Concern is merited when:

  • There is a change in mood or interest within at least two weeks
  • A physical comorbidity results in non-physical symptoms
  • A comorbidity results in social regression or incapacity
  • Physical symptoms of depression occur with or after mood symptoms, and are disproportional to those expected from a comorbidity and treatment

Depression is less likely to be present if a patient responds to affection from family and caregivers, retains humor, looks forward to visits, and accepts assistance and care.

Covid isolation has increased discussions of geriatric mental health. Let’s use the momentum of this tragedy to increase awareness of geriatric depression, advocate for patients, and improve the way we provide holistic care for the elder generations. 

  1. Espinoza RT, Unützer J. Diagnosis and management of late-life unipolar depression. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on May 2, 2021.)
  2. Gum AM, Areán PA, Hunkeler E et al. Depression treatment preferences in older primary care patients. Gerontologist. 2006;46(1):14-22. doi: 10.1093/geront/46.1.14.
  3. 2019 American Geriatrics Society Beers Criteria® Update Expert Panel, Fick DM, Semla TP, Steinman M, et al. American Geriatrics Society 2019 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2019; 67: 674‐ 694.