case study elderly depression

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A Case Study on Polypharmacy and Depression in a 75-Year-Old Woman with Visual Deficits and Charles Bonnet Syndrome

José caamaño-ponte.

1 Grupo de Investigación Dependencia, Gerontología, y Geriatría, Universidade Santiago de Compostela, 15782 Santiago de Compostela, Spain; moc.liamtoh@sojamaac

Martina Gómez Digón

2 Servicio Enfermería EOXI Lugo, 27003 Lugo, Spain; moc.liamg@42anittram

Mercedes Pereira Pía

3 Servicio Farmacia EOXI Lugo, 27003 Lugo, Spain; [email protected] (M.P.P.); [email protected] (A.d.l.I.C.)

Antonio de la Iglesia Cabezudo

Margarita echevarría canoura.

4 Sanitas Hospitales A Coruña, 15005 A Coruna, Spain; se.satinas@cairravehcem

David Facal

5 Departamento de Psicología Evolutiva y de la Educación, Universidade de Santiago de Compostela, 15782 Santiago de Compostela, Spain

Associated Data

The data presented in this study can be requested to the corresponding author. The data are not publicly available due to confidentiality and anonymity.

Depression is one of the most prevalent pathologies in older adults. Its diagnosis and treatment are complex due to different factors that intervene in its development and progression, including intercurrent organic diseases, perceptual deficits, use of drugs, and psycho-social conditions associated with the aging process. We present the case of a 75-year-old woman (who lives in the community) with a diagnosis of major depression with more than 10 years of history, analyzing her evolution and therapeutic approach.

1. Introduction

Depressive disorders are the most common psychiatric pathology in old adulthood. It is associated with various mental and biological stressors that affect the functional capacity and independence of old adults, reducing their quality of life. International studies show variable prevalences that range between 8.8% and 23.6% in Europe [ 1 , 2 ], could reach 60% in Latin America, and would exceed 38% in rural Asian populations. This geographical variability is due to methodological, clinical, and sociocultural differences. Recent studies in Spain inform that up to 36% of older people living in urban areas in the community suffer from depression [ 3 , 4 , 5 ]. Depression seems to be more frequent in the female sex. However, this observation could be biased because women present a greater longevity and/or a greater tendency to go to medical services than men, whereas men present a more severe somatic expression of psychiatric symptoms and/or a higher reluctance to express psychiatric symptoms than women [ 6 ].

Depressive symptoms include affective disorders such as sadness, apathy, emotional lability and crying, anhedonia, and nihilism; behavior modifications such as anxiety, irritability, insomnia, and hyporexia; and alterations in the course and content of thought, as well as cognitive and physical frailty. Among all the symptoms, autolytic ideation requires a specific comment, since depression is the main suicide risk factor in old age. Suicide constitutes one of the 10 main causes of death in the old adults, mainly in men aged 65 and over who use more lethal methods conditioned by loneliness and isolation [ 7 , 8 ]. In old populations, the etiology of depression is multifactorial: there are psychosocial causes derived from the aging process (family losses, work life, loneliness, environmental barriers, lack of resources, lack of social support) in addition to genetic and biological factors that contribute to the increase in frailty, geriatric syndromes, and dependency [ 9 , 10 ].

Its diagnosis is clinical, following the criteria included in the International Classification of Diseases (ICD-10) or the Diagnostic and Statistical Manual of Mental Disorders (DSM-5, APA 2014). In old adults, the diagnosis can be complex due to comorbidity and drugs that potentially induce psychiatric symptoms and iatrogenic complications, to adaptive disorders following age-related changes and/or to incipient cognitive impaiments. In any case, it can be an underdiagnosed disease due to circumstances related to its own nature, personality factors, and, also, because of the peculiarities of the healthcare systems [ 11 ].

To optimize its treatment, a transdisciplinary approach is required based on antidepressant drugs, such as selective serotonin reuptake inhibitors (SSRIs) or serotonin and norepinephrine reuptake inhibitors (SSNRIs), which have shown different therapeutic efficacy. It may also require, in many cases, mood stabilizers, anxiolytics, antipsychotics, tricyclic antidepressants (TCAs), or monoamine oxidase inhibitors (MAOIs) [ 12 , 13 , 14 ], plus psychosocial approaches (cognitive-behavioral psychotherapy, supportive psychotherapy), occupational techniques (re-education in activities of daily living, training in the use of technical aids), and physical training, which help to improve the prognosis and prevent relapses [ 15 ].

Within the different age-related conditions that can interfire with the diagnosis of depression in old age, Charles Bonnet syndrome is characterized by the presence of complex visual hallucinations, triggered by vision deprivation in the absence of neurological, psychiatric, and/or systemic disorders. The patient usually perceives the hallucinations as not real, which reduces anxiety, although the content, duration, and frequency are variable. Charles Bonnet syndrome can be associated with age-related entities such as enucleation, optic neuritis, diabetic retinopathy, macular degeneration, cataracts, and glaucoma, among others. Accordingly, its prevalence is relatively high in geriatric patients. In patients with major depression, a differential diagnosis with psychotic disorders is required [ 16 , 17 ].

The main objective of the study has been to facilitate deliberation on the frequent interrelation between organic pathologies, depressive symptomatology, and their overlap in time in old patients, as well as to present the heterodox therapeutic approach in this case, taking into account the complexity of the health care model of the Autonomous Community of Galicia (northwest Spain) and the patient’s therapeutic choices.

2.1. Personal History

A 75-year-old woman, who is right-handed, and a resident of the urban area of the province of A Coruña (Galicia, NW of Spain). She is married and has two children (one female and one male) and two male grandchildren. She lives with her husband (74 years old), who provides care support for the patient’s visual deficits. A medium education of schooling is possessed, along with an administrative profession and adequate social resources.

2.2. Ethical Standards

The study was conducted in accordance with the “Request for authorization for access and publication of health data as clinical case/case series” as provided in the General Data Protection Regulation (EU Regulation 2016/679 of the European Parliament and of the Council, 27 April 2016) and the Spanish regulations on personal data protection in force. Written informed consent was obtained from the participant. Due to visual deficits in the patient, the informed consent was read aloud and supervised by the caregiver.

2.3. Medical History

According to medical records, during this study the patient presented hypothyroidism, dyslipidemia, type II diabetes mellitus, macular degeneration, glaucoma, arterial hypertension, hypertensive heart disease, ChadsVasc4 persistent atrial fibrillation, extensive calcification of the mitral annulus, mild mitral regurgitation, moderate tricuspid regurgitation, lacunar stroke, vertigo, peripheral vascular disease, bronchial asthma, and acute bronchitis progressively diagnosed. The patient demonstrates no toxic habits.

The patient has been followed by the family medicine (FM) service of the center since the end of 2013, with the aim of carrying out a preventive approach, in coordination with doctors from other specialties such as cardiology, endocrinology, ophthalmology, neurology, and psychiatry.

In the initial clinical evaluation, previously diagnosed diseases were treated with levothyroxine sodium, Armolipid Plus, a nutraceutical based on berberine, red yeast, policosanols, coenzyme Q10, astaxanthin and folic acid, and Bimatoprost solution, to which clonazepam and duloxetine were added to treat anxiety-depression symptoms. The general physical examination showed no data of interest. A control analysis was requested, whose most significant results were glucose in serum/plasma 156 mg/dL, total cholesterol 300 mg/dL, HDL 48 mg/dL, LDL 232 mg/dL, TSH 0.93 mIU/L, and the need was emphasized for diet and physical exercise to adjust lipid levels, explaining that the patient ruled out lipid-lowering drug treatment due to fear of liver damage. The FM insisted on the convenience of carrying out a scheduled follow-up.

Between 2014 and 2018, the patient went to her FM and specialist doctors on different occasions to control her chronic diseases (mainly hypothyroidism, dyslipidaemia, Diabetes Mellitus, and Glaucoma). Acute diseases such as respiratory infection, viriasis, oral candidiasis, lump infectious breast, sciatica, or sacral-coccygeal trauma were successfully treated. She also received systematic immunization against the influenza virus. She underwent surgery for her visual pathology in 2016, with relative success and maintenance treatment consisting of Lutein, Bimatoprost, and Brinzolamide. Bronchial asthma with treated with Budesonide/Formoterol. Table 1 shows the main pharmacological treatment modifications made to date.

Evolutive drug adjustments.

Note: 2021-1 (February 2021). 2021-2 (October 2021). Boi-K: Potassium hydrogen carbonate 1001 mg and ascorbic acid 250 mg, with dose in mgs. c: capsule.

2.4. History of the Disease

The prevalent symptomatology referred to by the patient and her family throughout the depressive process consists of sadness, emotional lability and crying, low self-esteem, negativism, apathy, anxiety, insomnia, ruminant thinking, and occasional autolytic ideation. Regarding the loss of visual capacity and the secondary dependence to it, the diagnosis of glaucoma and macular degeneration has been subsequent to the onset of depressive symptoms.

Over the years, an evolution characterized by periods of emotional well-being with a significant reduction in symptoms and different relapses that required therapeutic adjustments has been observed. Monitoring of the depressive disorder is carried out by a psychiatrist outside the primary care center, who adjusts the psychotropic drugs periodically ( Table 1 ).

From a non-pharmacological perspective, she was treated in the center’s psychology department. Psychologists detected family problems, poor socialization, and a lack of acceptance of the disease with reactivity to support proposals, such as technical aids for ambulation or functional independence. She also attended therapeutic programs of the Spanish National Organization for the Blind (ONCE), where she currently receives supportive psychotherapy and participates in activities such as gymnastics and choir. Regarding physical activity, ONCE provides cardiorespiratory and muscular maintenance as well as psychomotor coordination training.

2.5. Supplementary Tests

The patient’s multiple pathologies and her evolution have required the performance of different complementary tests, the chronology and results of which are summarized in Table 2 and Table 3 . In August 2019, a routine electrocardiogram (ECG) was performed, showing atrial fibrillation (AF) at 120 bpm, initiating treatment with digoxin, diltiazen, and low molecular weight heparin (LMWH). Examined by the cardiology service, an echocardiogram was performed, which showed multiple valve disease, adjusting the treatment ( Table 1 ).

Control serum parameters.

Note: 2021-1 (February 2021). 2021-2 (October 2021). Parameters in mg/dl. Hgb A1c in %. Digoxinemia in nanograms/mL. niop: not included or provided.

Control cardiac and psychological paremeters.

Note: 2021-1 (February 2021). 2021-2 (October 2021). AF (Atrial Fiblilation). GADS: Goldberg Anxiety and Depression Scale. niop: not included or provided.

Assessed in August 2020, in neurology outpatient clinics in relation to a double episode of nocturnal disorientation, a cranial CT scan was requested that found a “small cerebellar hemorrhage” requiring hospitalization for neurological surveillance. Treatment with edobaxan is preventedly suspended due to its anticoagulant properties. A brain study is completed with MRI that does not clearly show the presence of hemorrhage, ruling out malformations or other lesions that cause bleeding. There was good evolution during the hospital stay. A control cranial CT scan was performed that showed a punctiform image in the right cerebellar hemisphere corresponding to calcification, so the patient was discharged and the edobaxan regimen was restarted.

During the COVID-19 pandemic, a SARS CoV-2 antigen screening was performed (November 2020) with a negative result.

2.6. Follow-Up during 2021

In December 2020, the patient went to the new FM service of the center showing a defective speech related to her visual difficulties, including a negativistic discourse with complaints as well as a nihilistic view of her circumstances and her future. She also maintained her heart disease, brain damage, anxiety-depressive symptoms, side effects of drug treatment, and secondary functional dependence. The clinical examination showed a temperature of 35.7 °C, heart rate of 70 bpm (atrial fibrillation), blood pressure of 150/75 mmHg, and O 2 saturation of 96%, resulting in normal physical and neurological examination. She reports complex visual hallucinations (people, animals, and objects) in the absence of cognitive impairment that appears to be Charles Bonnet syndrome.

During the months of January and June 2021, she attended four times for analytical control, assessment of the evolution and therapeutic adjustment (see Table 1 , Table 2 and Table 3 ), in coordination with her cardiologist and her psychiatrist. Different analytical parameters have been requested including hemogram, proteinogram, kidney function tests, and glomerular filtration. Hepatopancreatic, ionogram, markers of heart failure such as NT pro-BNP, iron metabolism, and anemias screening have shown data suggestive of normality.

The SARS-COVID-19 immunization is carried out between the months of March and April 2021.

In consultation with her FM and carried out in October 2021, the patient attends in the company of her husband; she is very cooperative, smiling, and showing emotional stability, with absence of parasuicidal ideation and Charles Bonnet syndrome, which she associates with increased physical activity and psychotherapeutic as well as to correct pharmacological control, despite the fact that anxiety levels remain high, referring to fear of loss of family support (the results are shown in Table 1 , Table 2 and Table 3 ).

3. Case Management from Family Medicine

Since it is a patient who lives in the community, the FM department of the health center has acted, coordinating the needs of monitoring of the different pathologies that she presents with the support of her family as a basic element of well-being. It is a classic FM strategy, implemented with the aim of achieving primary, secondary, and tertiary prevention.

4. Discussion

In the present case, the following areas of deliberation are raised: 1. Multifactorial etiology of the disease; 2. Diagnostic certainty; 3. Efficacy of psychopharmacological treatment; and 4. Role of the family in the patient’s care.

4.1. Multifactorial Etiology of the Disease

The main risk factors for depressive disorder in old adults have been frequently studied and include psychosocial circumstances of the aging process, personality factors, previous psychiatric pathology, intercurrent illnesses, and the interactions of associated treatments, although the level of influence of each factor is difficult to discriminate [ 18 , 19 ].

The present case could constitute a paradigm of the multicausality of depressive disorder in old adulthood, since, in a progressive and continuous way, several of the main factors associated with depressive symptoms that contribute to chronicity have been presented. In the psychosocial level, losses and grief, loneliness, environmental changes, and maladjustment stand out as potential etiological factors [ 20 ]. In this case, she is a person with a high cultural level, economic resources, comfortable habitat, and very stable social and family support. Regarding personality factors, some authors suggest that traits such as neuroticism increase the risk of presenting depressive symptoms in old adulthood [ 21 ]. It was not considered necessary to assess personality factors in a structured way, since an evolution of 10 years and the previous therapeutic approaches seem to be advisable, although it is true that the patient frequently refers to “a change in personality, from shyness to a certain disinhibition in the last years” associated with the general clinical picture that could be the result of antidepressant treatment. In the medical history, no references to previous psychiatric pathologies, consumption of toxic substances, or adjustment disorders were observed, with a stable work environment until her retirement.

Different studies associate metabolic diseases such as hypothyroidism and diabetes mellitus, or cardio and cerebrovascular disease, with an increased risk of suffering from depression, relating it to the multiple neuroimmunoendocrine changes in depressive patients. It has been observed that patients with depressive symptoms experience increased platelet activation that could predispose them to thromboembolic episodes. They also experience immune activation (NK cells and leukocytes) and hypercortisolemia, along with an increased adrenocorticotropic hormone (ACTH) and ACTH-releasing factor. In addition, they experience decreased insulin resistance, increased endogenous production of steroids, and the release of catecholamines, associated with an increase in arterial pressure and coronary vasoconstriction. Moreover, depressive symptoms constitute a poor prognostic factor in cardiovascular and metabolic diseases [ 22 , 23 , 24 , 25 ]. In this case, the protocol-based examinations showed no alteration justifying the role of physical factors in the depressive simptomatology. On the other hand, the polypharmacy used to control these diseases constitutes a known precipitating factor of depressive symptoms in old adults. Thus, drugs such as digoxin, diuretics, oral antidiabetics, and antihypertensives have been frequently associated with a greater risk of depression in these populations [ 26 ]. We cannot determine the level of influence of these drugs on the prognosis, but we can consider that their interactions with antidepressant drugs could make remission of the depressive symptomatology difficult.

In the clinical evolution of the patient, we consider the loss of vision to be key in the chronification of depressive symptoms due to the psychological repercussions as a factor of anxiety, insecurity, and fear; the functional repercussions for the instrumental and basic activities of daily life that limit self-care and potentiate iatrogenic risks; and the social repercussions related to leisure activities and increased consumption of resources, all of which favor frailty and limit self-perception of health status.

On the other hand, we consider the presence of a Charles Bonnet syndrome characterized by hallucinations to be of interest, which are commonly perceived as real by the patients and are related to visual deficits. Although the underlying mechanism is not well understood, it seems to be related to a brain’s continuous adjustment to significant vision loss. Old adults affected with Charlet Bonnet syndrome can avoid reporting to their doctor because of fear that the hallucinations could be related to a severe mental disorder. The clinical management consists of health education, explaining to the patient the nature of the disorder, the prevalent symptomatology, making them aware of the symptoms, and explaining that it is part of their visual deficit and not relevant to their depressive symptomatology. Eventually, pharmacological treatment with neuroleptics, benzodiazepines, antidepressants, and antiepileptics is required [ 16 , 17 ].

4.2. Diagnosis of Depression

As a complex diagnosis, major depression in old age involves assessing cognitive functions, behaviors, and the impact of any affective disorder on the functional capacity and quality of life of the patient. Following the DSM-5 criteria [ 11 ] facilitates the discrimination between a depressive disorder and a mixed adjustment disorder that could be better explained according to the current situation of the process. For the diagnosis of major depressive disorder, the criterion of temporality greater than two weeks, the presence of a depressed mood most of the day, and anhedonia, or a marked decrease in interest or a displeasure in almost all activities, are included; in addition, the presence of at least five additional symptoms are included, such as insomnia, hyporexia, loss of energy, inappropriate feelings of guilt and worthlessness, and self-destructive ideation, among others. In the case of mixed adjustment disorder, the diagnostic criteria include five groups (A–E), so that the anxiety-depressive symptoms occur in response to an identifiable stressor or factors that occur in the following three months. At the beginning of the stressor (A), the symptoms are clinically relevant with an intense and disproportionate discomfort in relation to the intensity of the stressor, generating a significant deterioration of social functioning or of other areas (B), other mental disorders are excluded (C), the symptoms do not represent a normal grief (D), and once the stressful event or its consequences have ended, the symptoms do not persist for more than another six months (E). In the case reported, it is not possible to fulfill criterion E because the most significant stress factors, those that generate the most discomfort and maladjustment, have become chronic so their resolution is not possible. Structured cognitive assessment has not been carried out because of the absence of progressive decline.

4.3. Efficacy of the Psychopharmacological Treatment

As has been reported, the pharmacological approach in this case is highly complex. Until the advent of SSRIs, the treatments of choice were TCA and tetracyclic (ATTC) antidepressants, but the potential induction of anticholinergic effects can cause cardiovascular alterations (orthostatic hypotension, arrhythmias, electrocardiographic alterations), changes in intestinal motility (constipation, paralytic ileus), urinary retention, and pupillary dilatation, among others, discouraging their use. Currently, SSRIs and SSNRIs are the dominant pharmacological approaches for depression in old adults, motivated by their ease of use, versatility, efficacy, and safety, in addition to their cost-effectiveness.

SSRIs (fluoxetine, fluvoxamine, paroxetine, sertraline, citalopram, escitalopram) work by blocking the reuptake of serotonin (5-HT) through inhibition of the adenosine triphosphatase (ATPase)-dependent sodium/potassium transporter (NA+/K+) in presynaptic neurons. With some differences between them, they have effects on other neurotransmission systems such as noradrenergic or dopaminergic. They are metabolized by liver enzymes, especially cytochrome P450 2D6, and have different pharmacokinetic characteristics. The main indication is major depression, although they are also useful in conditions such as obsessive-compulsive disorder or anxiety disorders. The most frequent side effects are gastrointestinal (nausea, burning, diarrhea), related to intestinal 5-HT receptors, which are minimized with a staggered dosage of medication. A variable percentage of patients treated with SSRIs manifest a sensation of activation of the central nervous system with agitation, nervousness, and insomnia that usually responds to moderate doses of benzodiazepines, such as alprazolam, lorazepam, or clonazepam. In general, they present a moderate risk of pharmacological interactions, and they are very safe drugs, as studies of lethal overdose show [ 27 , 28 , 29 , 30 , 31 , 32 ].

SSNRIs, such as duloxetine and venlafaxine, are a second group of drugs especially useful in the treatment of depression in old adulthood. SSNRIs may have a faster onset of action than other antidepressants by modulation of beta-adrenergic receptors. Duloxetine is a potent 5-HT and norepinephrine reuptake inhibitor with low affinity for muscarinic or histamine receptors, whereas venlafaxine shares 5-HT reuptake potency with moderate effects on norepinephrine reuptake and few effects on other neurotransmission systems. In addition, they present a low risk of pharmacokinetic interactions due to low potency in the inhibition of liver enzymes of cytochrome P450, a factor that facilitates their use. The FDA indications for this group of drugs are major depression, generalized anxiety disorder, and social anxiety disorder. Since they have a mechanism of action similar to that of tricyclic antidepressants, SSNRIs have shown their usefulness in some pain disorders, which makes them especially useful in older patients and in depression associated with neuropathic comorbidity. They share some of the gastrointestinal side effects with SSRIs, however, they differ from these in the moderate risk of increased blood pressure, somewhat less frequently in prolonged-release venlafaxine, which requires periodic monitoring in the first months of treatment and is solved by adjusting the dose. Other side effects described are syncope, ortostatic hypotension, and anticholinergic symptoms, such as dry mouth, urinary retention, and constipation, which in old patients must be monitored. Exceptional cases of fatal overdose have been described. Its level of efficacy compared to SSRIs seems somewhat higher, even though the data are discrepant [ 33 , 34 , 35 , 36 , 37 , 38 ].

In recent years, the approval of mirtazapine for the treatment of depression has led to its frequent use in old adults. It is an antagonist of alpha 2-adrenergic receptors that acts by increasing the release of norepinephrine that achieves a rapid increase in 5-HT levels, achieving modulation of the serotonergic system. Mirtazapine is metabolized through cytochrome P450 enzymes without being an inducer or inhibitor of these enzymes, so there are no interactions with other psychotropic agents, which facilitates the combination. Its main indication is major depression, used alone or in association with SSRIs/SSNRIs. Compared with paroxetine, it showed a faster response and fewer dropouts associated with adverse effects. Among the most frequent side effects are drowsiness (which advises its use at night) and increased appetite and weight. Furthermore, it seems to increase the levels of cholesterol and triglycerides secondarily, which, associated with its potential cardiovascular effect, makes it necessary to monitor blood pressure [ 39 , 40 , 41 ].

The therapeutic strategy is of great interest in this case. Since it is a highly complex case, the management of psychotropic drugs had to be careful, requiring consideration not only of the efficacy and probability of remission, but also of the minimization of secondary organic complications, to guarantee safety. In addition, the progressive appearance of comorbid, cardio, and cerebrovascular factors has required pharmacological adjustment. The potential interactions of the treatment must be considered, with the aim being its optimization. We consider the combined use of venlafaxine and mirtazapine to be successful due to its efficacy and safety, as evidenced by the adequate adherence of the patient to treatment and medical controls. In the case of duloxetine, its potential modification of blood pressure levels could question its use in this case [ 42 ]. The Goldberg Anxiety and Depression Scale (GADS) carried out in October 2021 suggests a remission of depressive symptoms and an improvement in the patient’s attitude. However, based on the results of the interview and the GADS (A7/D0), the use of benzodiazepines to control anxiety and insomnia symptoms does not seem clear.

4.4. Role of the Family in the Patient’s Care

This case presents many of the specific challenges in managing geriatric patients in the Galician health care model (northwest Spain). The guarantee of citizens’ health rights has been defined in the Spanish constitution since 1978. However, in 2002 there was a decentralization of competences in different areas, including health, according to the Law of Cohesion and Quality of the National Health System, which established a framework in the 17 autonomous communities of the Spanish State, but with peculiarities according to each territory. Regardless of this framework, the citizens, using their freedom, choose in each health situation whether to be treated in the public health system (in Galicia, the Servicio Galego de Saúde, or SERGAS) or in the free market system (private clinical services companies and/or consultations by private professionals), or both. The reality is that this mixed system can condition the efficiency of geriatric and psychiatric interventions in complex cases, hindering actions from primary health care because decision-making is dispersed. In this context, relevant information for therapeutic optimization is frequently lost.

The socioeconomic context of the patient allows clinical follow-up with good health resources, within a dual system (private and public) that contributes to effective health care, although its efficiency is limited by the heterogeneity of clinical opinions. As it has been mentioned above, the health care model in Galicia is based on a public, universal system in coexistence with private companies and entities of the social sector that provide health and care services, in addition to freelance professionals in health areas such as ophthalmology, psychiatry, internal medicine, or psychology, among many others. Between 2020 and 2021, the COVID-19 pandemic has required the adoption of restrictive measures in terms of prevention and mobility attitudes that seem to increase the incidence of psychiatric pathology in old populations [ 43 , 44 ], although in this case it does not seem to have conditioned the evolution of the patient.

We believe that a more intensive non-pharmacological approach would contribute to improving the prognosis; specifically, it would reduce anxiety-type symptoms and achieve a more objective self-perception of health. It would be an area for improvement using some of the usual techniques in similar cases, from cognitive behavioral to supportive or family therapy. In recent years, third generation behavioral therapies seem to contribute to intervention in psychogeriatrics. These include Acceptance and Commitment Therapy, Dialectical Behavioral Therapy, Mindfulness-Based Therapy, Behavioral Activation Therapy, Integral Behavioral Couple Therapy, or Functional Analytical Psychotherapy, which share an integrative vision of the psychological problems of old patients, considering their functional structure relevant, that is, the psychological functions of maladaptive behaviors in the context in which they occur [ 45 ]. These types of approaches may probably contribute to improve the quality of life and the health perception of the patient.

The evolution of the depressive disorder is linked to the role that her husband plays in psychological care and functional support for her activities of daily living. The long duration of the disease and the appearance of associated pathologies increase the intensity of care. The parallel aging of the husband and the incidence of medical and psychological problems could contribute to a potential claudication or the development of caregiver burnout [ 46 , 47 ].

5. Conclusions

The present work discusses the complexity of the diagnosis and treatment of depression in the geriatric patient. It is illustrated with the case of a patient (a 75-year-old woman) with depressive symptomatology with more than 10 years of evolution, also affected by different concomitant organic pathologies including visual deficits and Charles Bonnet syndrome. The interventions of different medical specialties are shown, and some psychopharmacological treatment options are discussed. The interactions of the different pharmacological treatments and the mixed care approaches are considered, with the aims of improving the case management and maximizing the quality of life of the patient in this type of complex clinical condition. The complexity of the healthcare system in Galicia (northwest Spain) and how difficult it is to handle complex geriatric cases in this context are discussed. In this regard, the most relevant limitation of this case in the lack of a specific approach, substituted for this patient by a mixed care model. Other limitations include the lack of a personality assessment using psychometrically valid tests, the lack of an explicit frailty assessment beyond the clinical observation of an increased bio-psycho-social vulnerability, and the lack of an objective assessment of the caregiver burden.

Author Contributions

J.C.-P. and M.G.D. conceived and designed the case report; J.C.-P., M.G.D., M.P.P., A.d.l.I.C. and M.E.C. collected the data and prepared the case report; D.F. critically reviewed the case report and prepared contributions regarding depression disorders and psycho-social care. All authors reviewed and revised the manuscript. All authors have read and agreed to the published version of the manuscript.

This research received no external funding.

Institutional Review Board Statement

This study was conducted in accordance with the Declaration of Helsinki. As a single case report, ethical review and approval was not applicable.

Informed Consent Statement

Informed consent, following the recommendation of the Galician Clinical Research Ethics Committee, was obtained from the participant.

Data Availability Statement

Conflicts of interest.

All authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

• Open access
• Published: 18 December 2021

Prevalence and determinants of depression among old age: a systematic review and meta-analysis

• Yosef Zenebe   ORCID: orcid.org/0000-0002-0138-6588 1 ,
• Baye Akele 2 ,
• Mulugeta W/Selassie 3 &
• Mogesie Necho 1  

Annals of General Psychiatry volume  20 , Article number:  55 ( 2021 ) Cite this article

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Depression is a leading cause of disability worldwide and is a major contributor to the overall global burden of disease. It is also one of the most common geriatric psychiatric disorders and a major risk factor for disability and mortality in elderly patients. Even though depression is a common mental health problem in the elderly population, it is undiagnosed in half of the cases. Several studies showed different and inconsistent prevalence rates in the world. Hence, this study aimed to fill the above gap by producing an average prevalence of depression and associated factors in old age.

This study aims to conduct a systematic review and meta-analysis to provide a precise estimate of the prevalence of depression and its determinants among old age.

A comprehensive search of PubMed, Scopus, Web of sciences, Google Scholar, and Psych-info from database inception to January 2020. Moreover, the reference list of selected articles was looked at manually to have further eligible articles. The random-effects model was employed during the analysis. Stata-11 was used to determine the average prevalence of depression among old age. A sub-group analysis and sensitivity analysis were also run. A graphical inspection of the funnel plots and Egger’s publication bias plot test were checked for the occurrence of publication bias.

A search of the electronic and manual system resulted in 1263 articles. Nevertheless, after the huge screening, 42 relevant studies were identified, including, for this meta-analysis, n  = 57,486 elderly populations. The average expected prevalence of depression among old age was 31.74% (95% CI 27.90, 35.59). In the sub-group analysis, the pooled prevalence was higher among developing countries; 40.78% than developed countries; 17.05%), studies utilized Geriatrics Depression Scale-30(GDS-30); 40.60% than studies that used GMS; 18.85%, study instrument, and studies having a lower sample size (40.12%) than studies with the higher sample; 20.19%.

A high prevalence rate of depression among the old population in the world was unraveled. This study can be considered as an early warning and advised health professionals, health policymakers, and other pertinent stakeholders to take effective control measures and periodic care for the elderly population.

The elderly people are matured and experienced persons of any community. Their experience, wisdom, and foresight can be useful for development and progress; they are a valuable asset for any nation [ 1 ]. Despite their invaluable wisdom and insight, the aging of the world's population is causing extensive economic and social consequences globally [ 2 ]. The aging population has increased rapidly over the last decades owing to two significant factors, namely, the reduction in mortality and fertility rates and improved quality of life, leading to an increase in life expectancy worldwide [ 3 , 4 , 5 ]. Globally, the number and proportion of people aged 60 years and older in the population are increasing. In 2019, the number of people aged 60 years and older was 1 billion. This number will increase to 1.4 billion by 2030 and 2.1 billion by 2050. By 2050, 80% of all older people will live in low- and middle-income countries [ 6 , 7 , 8 ].

A high geriatric population leads to high geriatric psychiatric problems [ 9 ]. The elderly, in general, face various challenges that are associated with physical and psychological changes commonly associated with the aging process [ 10 ]. The incidence of mental health problems is expected to increase among adults in general as well as in older populations in particular [ 11 ].

Depression is a leading cause of disability worldwide and is a major contributor to the overall global burden of disease [ 12 ]. It is also one of the most common geriatric psychiatric disorders [ 13 ] and a major risk factor for disability and mortality in older patients [ 14 ]. Even though depression is a common mental health problem in the elderly population, it is undiagnosed in about 50% of cases. The estimates for the prevalence of depression in the aging differ greatly [ 15 , 16 , 17 ]. WHO estimated that the global depressive disorder among older adults ranged between 10 and 20% [ 18 , 19 , 20 , 21 ]. Among all mentally ill individuals, 40% were diagnosed to have a depressive disorder [ 22 ]. People with depressive disorder have a 40% greater chance of premature death than their counterparts [ 20 ].

Most of the time, the clinical picture of depression in old age is masked by memory difficulties with distress and anxiety symptoms; however, these problems are secondary to depression [ 23 , 24 , 25 ]. Numerous community-based studies showed that older adults experienced depression-related complications [ 26 , 27 , 28 , 29 , 30 ]. Depression amplifies the functional disabilities caused by physical illness, interferes with treatment and rehabilitation, and further contributes to a decline in the physical functioning of a person [ 31 , 32 ]. It also has an economic impact on older adults due to its significant contribution to the rise of direct annual livelihood costs [ 33 ]. Hence, improvement of mental health among people in late life is considered to be medically urgent to prevent an increase in suicides in a progressively aging society.

Although real causes of depression remain not clear, psychological, social, and biological processes are thought to determine the etiology of depression and comorbid psychiatric diagnoses (e.g., anxiety and various personality disorders) [ 34 ]. Social scientists, postulating the psychosocial theory, posited that depression could be caused by a lack of interpersonal and communication skills, social support, and coping mechanisms [ 35 ]. Old biological theories stated depression is caused by a lack of monoamines in the brain. However, recent theories underscore the role of Brain-derived neurotrophic factor (BDNF) in the pathogenesis of depression [ 36 ]. In general, depression in the elderly is the result of a complex interaction of social, psychological, and biological factors [ 37 , 38 ].

Different factors associated with geriatric depression, such as female sex [ 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 ], increasing age [ 37 , 40 , 41 , 44 , 46 , 47 , 48 , 49 ], being single or divorced [ 42 ], religion [ 50 ], lower educational attainment [ 39 , 40 , 41 , 42 , 44 ], unemployment [ 38 , 42 ], low income [ 37 , 39 , 40 , 42 , 44 , 46 , 51 , 52 ], low self-esteem [ 53 ], childhood traumatic experiences [ 54 ], loneliness or living alone [ 40 , 50 , 51 , 55 ], social deprivation [ 45 , 46 , 56 ], bereavement [ 39 , 43 , 57 , 58 ], presence of chronic illness or poor health status [ 37 , 39 , 43 , 44 , 45 , 46 , 49 , 50 , 56 , 59 , 60 , 61 , 62 , 63 , 64 ], lack of health insurance [ 42 ], smoking habit [ 48 ], cognitive impairment [ 39 , 43 , 44 , 45 , 46 , 47 , 61 ] and a history of depression [ 43 , 44 , 47 ].

Compared with other health services, evidence of depressive disorders tends to be relatively poor. Therefore, the level of its burden among older adults is not well addressed in the world. Lack of adequate evidence about depression in older adults may be a factor that contributes to poor or inconsistent mental health care at the community level [ 21 , 65 ]. In addition to the poor setting for mental health care services, there are no up-to-date systematic reviews and meta-analysis studies conducted that could vividly show the global prevalence and determinants of depression among old age. Several studies also revealed different and inconsistent prevalence rates in the world. Therefore, this systematic review and meta-analysis aimed to summarize the existing evidence on the prevalence of depression among old age and to formulate possible suggestions for clinicians, the research community, and policymakers.

Search process

A systematic search of the literature in September 2020 using both international [PubMed, Scopus, Web of sciences, Google Scholar, Psych-info, and national scientific databases] was conducted to identify English language studies, published between August 1994 and January 2020, that examined the prevalence of depression among old age. We searched English keywords of “epidemiology” OR “prevalence” OR “magnitude” OR “incidence” AND “factor” OR “associated factor” OR “risk” OR “risk factor” OR “determinant”, “depression”, “depressive disorder” OR “major depressive disorder” AND “old age” OR “elderly” OR “geriatrics”, “community”, “hospital” and “global”. In addition, the reference lists of the studies were manually checked to obtain further studies.

Inclusion and exclusion criteria

Original quantitative studies that examined the prevalence and determinants of depression among old age were included. The included studies were randomized controlled trials, cohort, case–control, cross-sectional, articles written in English, full-text articles, and published between August 1994 and January 2020. The exclusion criteria were studies which published as review articles, qualitative studies, brief reports, letter to the editor or editorial comments, working papers articles published in a language other than English, researches conducted in non-human subjects, and studies having duplicate data with other studies. The literature search was conducted based on the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guideline [ 66 ]. All articles were independently reviewed by four researchers against inclusion and exclusion criteria. Any initial disagreement was resolved.

Data extraction and appraisal of study quality

After eliminating the duplicates, four investigators reviewed study titles and abstracts for eligibility. If at least one of them considered an article as potentially eligible, the full texts were assessed by the same reviewers. Any disagreements were resolved by discussion. Detailed information on the country, data source, study population, and results were extracted from each included study into a standardized spreadsheet by two authors and checked by the other two authors. EndNote X7.3.1 was used to organize the identified articles. Two investigators independently assessed the risk of bias of each of the included studies. The quality of studies included in the final analysis was evaluated with the Newcastle Ottawa quality assessment checklist [ 67 ]. The components of the quality assessment checklist include study participants and setting, research design, recruitment strategy, response rate, representativeness of the sample, the convention of valid measurement, reliability of measurement, and appropriate statistical analyses.

Statistical analysis

The data were analyzed with STATA 12.0 [ 68 ]. Prevalence standard errors were calculated using the standard formula for proportions: sqrt [ p *(1 – p )/ n ]; The heterogeneity across the studies in proportion of depression in the elderly population and the contribution of studies attributing to total heterogeneity was estimated by the I 2 statistic. The point estimates from each study were combined using a random-effects meta-analysis model to obtain the overall estimate with the DerSimonian–Laird method. Sources of heterogeneity across studies were examined with meta-regression. Publication bias and small study effects were assessed with the Egger test.

Search result

The search procedure primarily obtained n  = 1263 results, which after reading the title and abstract, full-text, and the application of the inclusion and exclusion criteria were reduced to n  = 42. The selection process is shown in Fig.  1 .

Articles search flow diagram

Characteristics of the study subjects

A total of 42 studies [ 38 , 42 , 50 , 57 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 99 , 100 , 101 , 102 , 103 , 104 , 105 ] studied our outcome of interest; A total sample size of fifty-seven thousand four hundred and eighty-six (57,486) elderly populations were included in the present study. The geographical province of studies was assessed. We found: Six studies in India [ 72 , 86 , 94 , 95 , 98 , 102 ], five studies in China [ 50 , 77 , 84 , 89 ], three studies in Turkey [ 71 , 82 , 105 ], three studies in Nepal [ 76 , 90 , 97 ], three studies in Thailand [ 70 , 75 , 83 ], two studies in the USA [ 91 , 100 ], two studies in Australia [ 57 , 99 ], two studies in Malaysia [ 42 , 96 ], two studies in Ethiopia [ 81 , 93 ], one study in German [ 103 ], one study in the UK [ 104 ], one study in Norway [ 85 ], one study in Italy [ 79 ], one study in Japan [ 87 ], one study in Mexico [ 78 ], one study in Brazil [ 92 ], one study in Finland [ 74 ], one study in Singapore [ 101 ], one study in Saudi Arabia [ 69 ], one study in the United Arab Emirates [ 80 ], one study in Ghana [ 88 ], one study in Sudan [ 73 ] and one study in Egypt [ 38 ]. Most of the studies in the present analysis were cross-sectional [ 38 , 42 , 50 , 57 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 81 , 82 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 92 , 93 , 95 , 96 , 97 , 98 , 101 , 102 , 103 , 105 ] and four studies were Cohort [ 85 , 94 , 99 , 104 ].

Sixteen studies [ 70 , 73 , 74 , 81 , 86 , 88 , 90 , 92 , 93 , 94 , 97 , 98 , 102 , 103 , 104 , 105 ] used Geriatric Depression Scale-15 (GDS-15), 12 studies [ 38 , 69 , 71 , 72 , 75 , 76 , 77 , 82 , 84 , 89 , 96 ] used Geriatric Depression Scale-30 (GDS-30), four studies [ 50 , 80 , 83 , 101 ] used Geriatric Mental State Schedule (GMS) and ten studies [ 42 , 57 , 78 , 79 , 85 , 87 , 91 , 95 , 99 , 100 ] used others (ICD-10, CIDI, DASS-21, KICA, CES-D, Euro-D, DSM-III, MCS and HADS) tools to measure depression in old age (Table 1 ).

Quality of included studies

The quality of 42 studies [ 38 , 42 , 50 , 57 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 99 , 100 , 101 , 102 , 103 , 104 , 105 ] was assessed with the modified Newcastle Ottawa quality assessment scale. This scale divides the total quality score into 3 ranges; a score of 7 to 10 as very good/good, a score of 5 to 6 as having satisfactory quality, and a quality score less than 5 as unsatisfactory. The majority (28 from the 42 studies) had scored good quality, nine had a satisfactory quality, and four of the studies had unsatisfactory quality .

The prevalence of depression among old age

The reported prevalence of elderly depression among 42 studies [ 38 , 42 , 50 , 57 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 99 , 100 , 101 , 102 , 103 , 104 , 105 ] included in this study ranges from 7.7% in a study from Malaysia and Australia [ 57 , 96 ] to 81.1% in India [ 72 ]. The average prevalence of depression among old age using the random effect model was found to be 31.74% (95% CI 27.90, 35.59). This average prevalence of depression was with the heterogeneity of ( I 2  = 100%, p value = 0.000) from the difference between the 42 studies (Fig.  2 ).

Forest plot for the prevalence of depression

Subgroup analysis of the prevalence of depression among old age

A subgroup analysis was done considering the economic status of countries, the study instrument and the sample size of each study. The cumulative prevalence of depression in elderly population among developing countries; 40.78% [ 38 , 42 , 69 , 70 , 71 , 72 , 73 , 75 , 76 , 78 , 81 , 82 , 83 , 86 , 88 , 90 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 101 , 102 , 105 ] was higher than the prevalence in developed countries; 17.05% [ 50 , 57 , 74 , 77 , 79 , 80 , 84 , 85 , 87 , 89 , 91 , 99 , 100 , 103 , 104 ] (Fig.  3 ). The average prevalence of depression was 40.60% in studies that used GDS-30 [ 38 , 69 , 71 , 72 , 75 , 76 , 77 , 82 , 84 , 89 , 96 ] which is higher than the prevalence in studies that utilized GDS-15;35.72% [ 70 , 73 , 74 , 81 , 86 , 88 , 90 , 92 , 93 , 94 , 97 , 98 , 102 , 103 , 104 , 105 ], GMS;18.85% [ 50 , 80 , 83 , 101 ] and other tools;19.91% [ 42 , 57 , 78 , 79 , 85 , 87 , 91 , 95 , 99 , 100 ] (Fig.  4 ). Moreover, studies which had a sample size of below 450 [ 38 , 42 , 57 , 70 , 71 , 72 , 73 , 75 , 76 , 79 , 81 , 86 , 88 , 90 , 92 , 94 , 96 , 97 , 98 , 99 , 102 , 104 ] provided higher prevalence of depression; 40.12% than those who had a sample size ranges from 450 to 999 [ 74 , 80 , 82 , 84 , 85 , 91 , 93 , 95 , 100 , 105 ]; 25.38% and above 1000 [ 50 , 69 , 74 , 77 , 78 , 83 , 87 , 89 , 101 , 103 ]; 20.19% (Fig.  5 ).

Sub-group analysis of depression based on economic status of countries

Sub-group analysis of depression based on study instruments

Sub-group analysis of depression based on sample size of studies

Sensitivity analysis

The sensitivity analysis was performed to identify whether one or more of the 42 studies had out-weighted the average prevalence of depression among old age. However, the result showed that there was no single influential study, since the 95% CI interval result was obtained when each of the 42 studies was excluded at a time (Fig.  6 ).

Sensitivity analysis for the prevalence of depression among old age

Publication bias

There was no significant publication bias detected and Egger's test p value was ( p  = 0.644) showing the absence of publication bias for the prevalence of depression among old age. This was also supported by asymmetrical distribution on the funnel plot for a Logit event rate of prevalence of depression among old age against its standard error (Fig.  7 ).

Funnel plot for publication bias for depression

Factors associated with depression among old age

Among 42 studies [ 38 , 42 , 50 , 57 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 99 , 100 , 101 , 102 , 103 , 104 , 105 ] included in the present meta-analysis, only 32 [ 38 , 42 , 50 , 57 , 69 , 72 , 73 , 75 , 77 , 78 , 79 , 80 , 81 , 83 , 84 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 101 , 102 , 103 , 104 , 105 ] reported about the associated factors for depression among old age. Our qualitative synthesis for the sociodemographic factors associated with depression in elderly populations showed that female gender [ 38 , 69 , 72 , 75 , 80 , 86 , 89 , 93 , 98 , 102 , 105 ], age older than 75 years [ 38 , 69 , 101 , 102 ], being single, divorced or widowed [ 38 , 42 , 69 , 80 , 81 , 87 , 89 , 98 , 105 ], being unemployed [ 69 , 86 , 96 , 105 ], retired [ 95 ], no educational background [ 75 , 81 , 86 , 89 , 90 , 97 , 102 ] OR low level of education [ 69 , 81 , 84 , 91 , 92 , 105 ], low level of income [ 69 , 72 , 78 , 80 , 94 , 95 , 105 ], substance use [ 75 , 81 , 103 ], poverty [ 95 , 102 ], cognitive impairment [ 81 , 103 ], presence of physical illness, such as diabetes, heart diseases, stroke and head injury [ 42 , 50 , 57 , 72 , 77 , 81 , 83 , 84 , 86 , 87 , 88 , 89 , 95 , 97 , 106 ], living alone [ 88 , 102 , 104 ], disturbed sleep [ 77 , 89 ], lack of social support [ 73 , 77 , 87 ], dependent totally for the activities of daily living [ 50 , 79 , 91 , 92 , 97 , 102 , 103 ], living with family [ 42 , 93 ], history of a serious life events, such as death in family members, conflict in family, chronic illness in family members and those who had 3 or more serious life events [ 72 , 83 , 96 ], poor daily physical exercise [ 89 ] and exposure to verbal and/or physical abuse were strongly and positively associated with depression [ 90 ] (Table 2 ).

As to the researcher’s knowledge, this review and meta-analysis on the prevalence and determinants of depression among old age are the first of their kind in the world. Therefore, the knowledge generated from this meta-analysis on the pooled prevalence and associated factors for depression among old age could be important evidence to different stakeholders aiming to plan policy in the area. The average prevalence of depression among old age using the random effect model was found to be 31.74%. A subgroup analysis was done considering the economic status of countries, the study instrument, and the sample size of each study.

In the present systematic review and meta-analysis, the existing available information varies by the region, where the study was conducted, data collection tools used to screen depression, and the sample size assimilated in the study. Sixty-two percent ( n  = 26) of the studies were found in developing countries. About 38% ( n  = 16) of the incorporated studies utilized GDS-15 to screen depression, around 28% ( n  = 12) studies used GDS-30 to screen depression, ten percent ( n  = 4) studies used GMS to screen depression, whereas the rest utilized other tools. More than half ( n  = 22) of the included studies utilized a sample size of below 450.

The result of this meta-analysis revealed that depression in the elderly populations in the world was high (31.74%). This pooled prevalence of depression among old age in the world (31.74%; 95% CI 27.90 to 35.59%) was higher than a global systematic review and meta-analysis study on 95,073 elderly populations aged > 75 years and 24 articles in which a pooled prevalence of depression was 17.1% (95% CI 9.7 to 26.1%) [ 107 ], a global systematic review and meta-analysis study on 41 344 outpatients and 83 articles in which a pooled prevalence of depression was 27.0% (95% CI: 24.0% to 29.0%) [ 108 ], WHO reports on mental health of older adults over 60 years old with 7% prevalence of depression in the general older population [ 106 ], a Brazilian systematic review and meta-analysis study on 15,491 community-dwelling elderly people average age 66.5 to 84.0 years and 17 articles with a pooled prevalence rates of 7.0% for major depression, 26.0% for CSDS (clinically significant depressive symptoms), and 3.3% for dysthymia [ 109 ] and an Iranian meta-analysis study on 3948 individuals aged 50 to 90 years and 13 articles with a pooled prevalence of severe depression was 8.2% (95% CI 4.14 to 6.3%) [ 110 ]. The reason for such a high prevalence of depression in the globe would be due to the difference in sample size, study subjects, the severity of depression, study area, study instruments, and the means of administration of the tools employed in the studies [ 111 ].

In contrast to our current systematic review and meta-analysis study, the pooled prevalence of depression was lower than a Chinese Meta-Analysis of Observational Studies on 36,791 subjects and 46 articles with a pooled prevalence of depression was 38.6% (95% CI 31.5–46.3%) [ 112 ], and an Indian systematic review and meta-analysis study on 22,005 study subjects aged 60 years and above, and 51 articles with a pooled prevalence of depression was 34.4% (95% CI 29.3 to 39.6) [ 113 ]. The reason for the discrepancy might be due to the wide coverage of the study and the higher sample size utilized in the present study. Furthermore, differences could be due to the poor health care coverage and significant population makes a destitute life both in China and India. In addition, both China and India have a rapidly aging population. Old age causes enforced retirement which may lead to marginalizing older people. Elders are regarded as incompetent and less valuable by potential employers. This attitude serves as a social stratification between the young and old and can prevent older men and women from fully participating in social, political, economic, cultural, spiritual, civic, and other activities [ 114 , 115 , 116 ].

A significant regional variation on the pooled prevalence of depression in the elder population was observed in this review and meta-analysis study. The aggregate prevalence of depression in elderly population among developing countries; 40.78% [ 38 , 42 , 69 , 70 , 71 , 72 , 73 , 75 , 76 , 78 , 81 , 82 , 83 , 86 , 88 , 90 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 101 , 102 , 105 ] was higher than the prevalence in developed countries; 17.05% [ 50 , 57 , 74 , 77 , 79 , 80 , 84 , 85 , 87 , 89 , 91 , 99 , 100 , 103 , 104 ]. The huge variation might be due to absolute poverty, economic reform programs, limited public health services, civil unrest, and sex inequality are very common in developing countries [ 117 ].

Likewise, the greater pooled prevalence of depression in elderly population was observed in studies using a sample size below 450 study subjects (40.12%) [ 38 , 42 , 57 , 70 , 71 , 72 , 73 , 75 , 76 , 79 , 81 , 86 , 88 , 90 , 92 , 94 , 96 , 97 , 98 , 99 , 102 , 104 ] than the pooled prevalence of depression in elders that used a sample size of 450–999 (25.38%) [ 74 , 80 , 82 , 84 , 85 , 91 , 93 , 95 , 100 , 105 ], and above 1000 (20.19%) [ 50 , 69 , 74 , 77 , 78 , 83 , 87 , 89 , 101 , 103 ]. The reason could be a smaller sample size increases the probability of a standard error thus providing a less precise and reliable result with weak power.

Regarding the associated factors; being female, age older than 75 years, being single, divorced or widowed, being unemployed, retired, no educational background, low level of education, low level of income, lack of social support, living with family, current smoker, presence of physical illness, such as diabetes, heart diseases, stroke, and head injury, poor sleep quality, physical immobility and a history of serious life events, such as a death in family members, conflict in the family, chronic illness in family members and those who had 3 or more serious life events were found to have a strong and positive association with depression among old age.

Difference between included studies in the meta-analysis

This meta-analysis study was obtained to have a high degree of heterogeneity between the studies incorporated in pooling the prevalence of depression in the elderly population of the world. The analysis of subgroups for detection of sources of heterogeneity was done and the economic status of the country, where the study was done, data collection instruments, and sample size were identified to contribute to the existing variation between the studies incorporated in the analysis. Besides, a sensitivity analysis was performed using the random-effects model to identify the effect of individual studies on the pooled estimate. No significant changes in the pooled prevalence were found on the removal of a single study.

Limitations should be considered when interpreting the results of this study. Screening tools cannot take the place of a comprehensive clinical interview for confirmatory diagnosis of depression. Nevertheless, it is a useful tool for public health programs. Screening provides optimum results when linked with confirmation by mental health experts, treatment, and follow-up. As this meta-analysis included studies done using screening tools, a further meta-analysis done with diagnostic tools will help to assess the true burden of depression and to determine the need for pharmacological and non-pharmacological interventions. Furthermore, because of the lack of access to the full text of some studies, the researchers failed to include these research findings.

This review and meta-analysis study obtained a pooled prevalence of depression in the elderly population in the world to be very high, 31.74% (95% CI 27.90, 35.59). This pooled effect size of depression in the elderly population in the world obtained is very important as it showed aggregated evidence of the burden of depression in the targeted population. Since the high prevalence of depression among the old population in the world, this study can be considered as an early warning and advice to health professionals, health policymakers, and other pertinent stakeholders to take effective control measures and periodic assessment for the elderly population.

Availability of data and materials

The data sets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Activities of daily living

Adjusted odds ratio

Community-dwelling elderly people

Center for Epidemiologic Studies Depression Scale

Confidence interval

Composite International Diagnostic Interview Short Form

Clinically significant depressive symptoms

Cross-sectional

Depression, Anxiety, and Stress Scale

Diagnostic and Statistical Manual of Mental Disorders

Elderly medical inpatients

Geriatrics depression

Geriatric Depression Scale

Geriatric Mental State Schedule

Hospital Anxiety and Depression Scale

Kimberley Indigenous Cognitive Assessment of Depression

Mental Component Summary

Not reported

Preferred Reporting Items for Systematic Reviews and Meta-analysis

United Kingdom

United States of America

World Health Organization

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Zenebe, Y., Akele, B., W/Selassie, M. et al. Prevalence and determinants of depression among old age: a systematic review and meta-analysis. Ann Gen Psychiatry 20 , 55 (2021). https://doi.org/10.1186/s12991-021-00375-x

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G. DAVID SPOELHOF, MD, GARY L. DAVIS, PhD, AND ADDIE LICARI, MD

Am Fam Physician. 2011;84(10):1149-1154

Patient information: See related handout on caring for older family members with depression , written by the authors of this article.

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The diagnosis of depression in older patients is often complicated by comorbid conditions, such as cerebrovascular disease or dementia. Tools specific for this age group, such as the Geriatric Depression Scale or the Cornell Scale for Depression in Dementia, may assist in making the diagnosis. Treatment decisions should consider risks associated with medications, such as serotonin syndrome, hyponatremia, falls, fractures, and gastrointestinal bleeding. Older white men with depression are at high risk of suicide. Depression is common after stroke or myocardial infarction, and response to antidepressant treatment has been linked to vascular outcomes. Depression care management is an important adjunct to the use of antidepressant medications. Structured psychotherapy and exercise programs are useful treatments for select patients.

The epidemiology of geriatric major depression is similar to that of younger adults, affecting 5 to 10 percent of older patients in primary care outpatient settings and occurring more often in women. 1 Depression in older persons may represent a relapse of depression from earlier in life rather than a new depressive disorder presenting late in life. Persons with late-onset depressive symptoms are more likely to have underlying cerebrovascular disease or incipient dementia. This may explain why response to psychological and pharmacologic treatment approaches is lower in older populations. Psychotic depression, which causes delusions or hallucinations, is more common in late-life depression. 1 The following illustrative cases highlight challenges presented by older patients with depression.

Case 1 . An 85-year-old nursing home patient with dementia has been withdrawn and eating poorly. The staff thinks that she may be depressed and asks you about prescribing an antidepressant .

Major depression in older patients is diagnosed using the same criteria as in younger adults. It is based on the persistence of the core symptoms of anhedonia or depressed mood for two weeks, with four or more of the following: feelings of worthlessness or guilt, decreased ability to concentrate or make decisions, fatigue, psychomotor agitation or retardation, insomnia or hypersomnia, significant changes in weight or appetite, and recurrent thoughts of suicide or death. 2

The diagnosis can be more difficult in older persons, because they may have somatic symptoms related to comorbid illnesses and are less likely to report certain symptoms, such as guilt. Depressive symptoms such as fatigue and hypersomnia may be a consequence of illness. 3 The diagnosis may be further obscured by dementia, limiting the patient's ability to provide a thorough history. Table 1 shows a comparison of the symptoms and signs of depression and dementia. 4 Depression is more common in patients in nursing homes and is often manifested by weight loss. 5

The Geriatric Depression Scale is a useful screening tool that has been validated for use in patients with dementia who have Mini-Mental State Examination scores as low as 15 ( Table 2 6 ) . 7 The Cornell Scale for Depression in Dementia is a caregiver-based evaluation tool that can be used to diagnose depression that accompanies more severe dementia. 8 It can be accessed at http://www.amda.com/resources/2005_updates_ltc_teaching_kits/dementia.pdf . Other causes of depressive symptoms should be considered, such as delirium, adverse effects from medication, or metabolic disorders ( Table 3 9 , 10 ) .

Treating depression in patients living in a nursing home may be problematic because polypharmacy makes medication interactions and adverse effects more likely. Compromised renal or hepatic function also may contribute to adverse reactions. Tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors, and other second-generation antidepressants have similar effectiveness. Based on their adverse effect profiles, SSRIs are the preferred medications for treating depression in older adults. Based on expert opinion, citalopram (Celexa), escitalopram (Lexapro), and sertraline (Zoloft) may be preferred because of fewer drug interactions or cognitive risks. 11

Frail older patients are more likely to be taking other medications with serotonergic properties ( Table 4 12 ) . Therefore, care should be taken to avoid serotonin syndrome, which is manifested as autonomic (e.g., hyperthermia, hypertension, tachycardia), neuromotor (e.g., hyperreflexia, myoclonus, tremors) or cognitive/behavioral (e.g., confusion, anxiety, hallucinations) symptoms. 12

Because hyponatremia has been linked to the use of SSRIs, serum sodium levels should be checked if a patient exhibits lethargy or delirium after starting therapy. 13 SSRI use also increases the risk of falls, fractures, gastrointestinal bleeding, and sleep disturbances. 14 – 17 The duration of therapy required to maintain remission is uncertain. 18 , 19 Based on principles of geriatric pharmacotherapy, patients should have periodic assessments for continuing medication or tapering to a minimal effective dose.

Case 2 . Three weeks ago, a 75-year-old man presented with a viral-sounding illness. The patient seemed apathetic, but commented that he needed to recover in time for hunting season. He later died of a self-inflicted gunshot wound .

White men older than 65 years account for a disproportionate number of completed suicides. 1 Depression is a major risk factor for suicidal ideation ( Table 5 ) . 20 Suicidal patients may present to their physician with seemingly unrelated symptoms shortly before making an attempt. A mood change, especially when means for self-harm (e.g., firearms) are readily available, should prompt a careful evaluation for suicidal ideation. Suicidal intent, the presence of a plan, and the means available to carry out the plan should be addressed directly in the interview.

Management of suicidal ideation in older patients requires hospitalization, unless there is a reliable source of psychosocial support, and good follow-up is assured. Although SSRI therapy has been shown to reduce suicidal ideation, it has been difficult to demonstrate that it reduces the rate of suicide attempts. 21 , 22 Medications more likely to be lethal in overdose (e.g., tricyclic antidepressants) should be avoided. Persisting suicidal ideation is one of the indications for electroconvulsive therapy, which may be safely administered to older patients. Other indications for electroconvulsive therapy are lack of response to medication, psychosis, and previous good response to this modality. 23

Case 3 . A 72-year-old woman had a myocardial infarction and underwent coronary artery bypass grafting four weeks ago. She has been participating in an outpatient cardiac rehabilitation program. Her therapist is concerned about her lack of progress and apparent apathy. The patient's son comments that she seems uninterested in participating in family activities and looks depressed .

About 20 percent of patients who have a stroke or myocardial infarction develop major depression. 24 , 25 Depression persisting after an acute coronary event increases the risk of future cardiovascular events and death. 26 In one study, response to treatment for depression was associated with a 7.4 percent risk of recurrent cardiac events, compared with a 25.6 percent risk in those whose depression did not respond to treatment. 27

The American College of Cardiology and the American Heart Association recommend screening for and treating depression for secondary prevention in patients with ST-segment elevation myocardial infarction. Assessment is recommended during hospitalization, one month after discharge, and annually thereafter. 28 Cognitive behavior therapy (CBT) or antidepressant medication is recommended for treatment. SSRIs are generally well tolerated by patients with cardiac conditions. Whether treatment of depression prevents future cardiovascular events is uncertain. A study of patients with acute coronary syndrome showed treatment of depression to be associated with greater patient satisfaction and a reduction of depressive symptoms, with a trend toward improved cardiac prognosis. 29

Case 4 . An 82-year-old woman comes to the office for a checkup three months after the death of her husband. The patient says her daughter asked her to make the appointment because she had not seemed like herself lately. The patient expresses anhedonia, and her 10-item Geriatric Depression Scale score is 7 out of 10. Her physical examination and laboratory tests are otherwise unremarkable. You prescribe a 30-day supply of an SSRI with three refills. Six weeks later, she says she discontinued the medication after the 30-day supply ran out and did not understand that she needed to get a refill. She is uncertain whether the medication was helpful .

Depressive symptoms may be a normal part of bereavement. Symptoms causing functional impairment and persisting without improvement for more than two months after the loss of a loved one should result in consideration for treatment. 30 After a diagnosis of depression is established, pharmacotherapy is one of several treatment options ( Table 6 ) . 11

If medication is chosen, there is increasing evidence that a prescription with office-based follow-up is inferior to an organized program of depression care management or collaborative care. 31 , 32 Depression care management involves the designation of an allied health professional to assist treatment by providing education and close follow-up, and monitoring response to treatment. 33 A randomized study compared usual care with pharmacotherapy augmented by depression care management. It found improved remission rates and medication adherence over the 12-month intervention (number needed to treat = 4), and the results were sustained for another 12 months after intervention had ended (number needed to treat = 9). 34 The evidence in favor of depression care management is strong enough that the U.S. Preventive Services Task Force (USPSTF) recommends screening for depression in adults (including older adults) only when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up. The USPSTF notes that the evidence demonstrating a benefit of screening in the absence of depression care support is small. 35

Structured psychotherapy yields depression remission rates similar to medication, and may be preferred in patients at higher risk of adverse drug reactions. 36 CBT is the most widely studied form of psychotherapy and has been shown to be effective in geriatric depression, particularly in mild to moderately severe cases. CBT involves replacing negative distortions of events and situations with more positive and rational cognitive responses. 37 , 38 There is some evidence that the effects of CBT may be longer lasting than drug therapy following discontinuation of treatment. Older persons do well with CBT, but need special attention because of memory impairment and sensory deficits, primarily hearing loss. 39

There is some evidence that aerobic and anaerobic exercise programs are helpful for treating depression. A meta-analysis specific to older patients found evidence of benefit for major depression but the effects were not sustained unless the exercise program continued. 40 A Cochrane review on exercise for adult depression found evidence of benefit comparable to cognitive therapy. 41 Both reviews noted inconsistencies in the quality of the studies and the need for further research.

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Loneliness is strongly linked to depression among older adults, a long-term study suggests

Mental Health

doi: 10.3310/alert_46882

This is a plain English summary of an original research article . The views expressed are those of the author(s) and reviewer(s) at the time of publication.

Depression is a major public health problem that is growing worldwide. The causes are complex and vary from person to person. However, new research estimates that up to one in five cases of depression among older adults could be prevented by reducing loneliness. The study therefore has important public health implications, highlighting the need for comprehensive action across society to combat loneliness. 

This is the first large, long-term study to investigate the link between loneliness and depression in people aged 50 or older. It confirms that feeling lonely is associated with an increased risk of future depression. The link exists irrespective of other related social experiences and exists even among people who are not socially isolated or who feel socially supported. After experiencing loneliness, the risk of depression persists for up to 12 years.

Loneliness can be changed or controlled, unlike other risk factors for depression, such as our genes. But previous studies looking at the relationship between loneliness and depression have so far been inconclusive.

This research supports the implementation of the Government’s strategy for tackling loneliness in England, which launched in 2018 and has become particularly relevant following lockdowns and social distancing during the pandemic .  

What’s the issue?

Depression among older adults is common, affecting four to nine out of every 100 people worldwide. Recent data suggest that these figures are increasing. Depression is associated with other conditions and in severe cases, can be life-threatening because it can lead to suicidal feelings.

Understanding the causes could help to identify people most at risk and inform strategies for prevention at a population level.

One in three people aged 50 years and over in the UK report feeling lonely. It may partly be due to retirement, bereavement, reduced social networks and physical and cognitive decline. Loneliness is a painful emotional experience that occurs when a person’s social relationships do not fulfil their needs. It can be related to, but distinct from, other aspects of relationships such as social isolation and social support. 

Previous research has investigated the relationship between loneliness and depression, but has not been conclusive. For example, many studies did not follow people for more than two to three years – and few adjusted for other potential causes of depression such as genetics.

An improved understanding of the impact of loneliness on mental health could lead to new interventions to help prevent or reduce the burden of depression in older adults. 

What’s new?

In this study, the researchers analysed data on 4,211 people included in the English Longitudinal Study of Ageing (ELSA). They were all aged 50 and above. Two-thirds (2785 or 66%) were unemployed or retired. 

Participants had answered questions every two years for 12 years. They had described their experiences of loneliness, social engagement and social support, as well as symptoms of depression.

Their answers to questions about lacking companionship, feeling left out, and feeling isolated were combined into a loneliness score on a seven-point scale. The results were adjusted to take account of social experiences (such as perceived social support). and other factors such as age, sex, marital status, mobility, education and wealth.

The higher the loneliness score, the more severe the symptoms of depression. The researchers found that:

• each one-point increase on the loneliness scale was linked with a 16% increase in average depressive symptom severity score
• loneliness was linked to nearly one in five (18%) cases of depression one year later
• the effect of loneliness decreased with time but was still associated with one in ten (11%) cases after 12 years 
• depressive symptoms increased over time among people with greater loneliness scores, indicating that loneliness was causing future depression.

The researchers had taken account of depression and loneliness at the start of the study. This reduces the possibility that depression was leading to loneliness. They concluded that it was the other way round, and that loneliness was increasing the risk of depression.

Why is this important?

The researchers discuss how loneliness might impact on mental health. It could be that p eople who are lonely are extra-vigilant in social settings and anticipate rejection. They may disproportionately recall negative social memories and develop negative beliefs about themselves. Ways of thinking like this are associated with depression. 

The results suggest that tackling loneliness has the potential to reduce or even prevent future depressive symptoms among adults aged 50 or over. 

Health professionals working with older people who report feeling lonely should be aware that they have an increased risk of depression. They may need interventions to reduce loneliness to support their mental health. Psychological therapies have been shown to reduce loneliness, especially those that target ways of thinking.

Interventions could include:

• social prescribing (a link worker takes a holistic view of someone's health and wellbeing and gives people time to focus on what matters to them)
• psychological therapies that target negative feelings of loneliness
• social skills training 
• psychoeducation (teaching specific skills to improve mental health such as problem-solving and other forms of coping, good sleeping habits and collaborative working)
• supported socialisation (offering people support and guidance to select and attend activities).

Community-based approaches designed to reduce loneliness could be an effective way to prevent or reduce depressive symptoms in older adults. These interventions might involve building community resources, strengthening networks within neighbourhoods, community connectors in primary care, or arts and sports-based approaches embedded in communities. Improving the quality of relationships and increasing companionship, meaningful connections, and providing a sense of belonging, should be a key part of these strategies. It is not sufficient just to increase the time spent with others.

What’s next?

The next steps will involve increasing awareness about the link between loneliness and depressive symptoms in older adults - and influencing health and social care guidelines to reduce loneliness in the community. 

The people included in this study are all White British. Further research could explore the effect of loneliness in more diverse populations. Research is also needed to evaluate the effectiveness of specific interventions designed to combat loneliness among older people. 

You may be interested to read

The full paper: Lee SL, and others. The association between loneliness and depressive symptoms among adults aged 50 years and older: a 12-year population-based cohort study . The Lancet Psychiatry 2021;8:1 

A Connected Society: A strategy for tackling loneliness - a  policy paper setting out the Government’s approach to tackling loneliness in England.  

The Campaign to End Loneliness gives i nformation on loneliness .  

The NHS website gives information on depression . 

Funding:  The English Longitudinal Study of Ageing (ELSA) is funded by the NIHR. This research was supported by the NIHR University College London Hospitals Biomedical Research Centre.

Conflicts of Interest:  The study authors declare no conflicts of interest.

Disclaimer:  NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Privacy Overview

• Guides & Competencies
• Try This:® Series
• Geriatric Nursing Protocols
• ConsultGeri
• BHPC: Depressive Disorders Case Study: Older Adult

By: Karina Santibanez, DNP, PMHNP-BC

Interactive Module

Target Audience

• Interprofessionals
• Registered Nurses

Description

This Behavioral Health in Primary Care (BHPC) case study aids in assessing and developing a care plan for an older adult presenting with a depressive disorder in primary care.

About the Series

NURSING IMPROVING MENTAL HEALTH IN THE COMMUNITY is an NYU Meyers Initiative to maximize the potential of the nursing workforce as a vital part of the primary care team to address behavioral health concerns, including substance use and mental health, and mitigate social determinants that serve as barriers to good health.

This project is supported by the New York Community Trust. 

Learning Outcomes

• Apply knowledge about the risks of geriatric depression in the assessment and treatment planning of patients.
• Apply a non-judgmental perspective to engage patients, normalizing, and validating their symptoms.
• Utilize assessment tools in a therapeutic manner during course of a patient's treatment.
• Integrate knowledge from this case study into providing future education and support for patients. 

Karina Santibanez, DNP, PMHNP-BC

Adjunct Clinical Professor

NYU Rory Meyers College of Nursing

Connect with our team

[email protected]

Related Resources

• The Geriatric Depression Scale (GDS)
• The Impact of Event Scale - Revised (IES-R)
• Integrating the Geriatric Surgery Verification (GSV) Program with the 4Ms: Discharge Case Study
• Behavioral Health in Long-Term Care: Primary Care Providers
• Behavioral Health in Long-Term Care: RNs/Interprofessionals
• BHPC: Depressive Disorders
• BHPC: Depressive Disorders Case Study: Adolescent
• BHPC: Depressive Disorders Case Study: Adult
• Care of Older Adults in Long-Term Care: RN/IP Series
• Care of Older Adults in Rural America (COA-RA) Series
• Care of Older Adults in the Long-Term Care Setting (COA-LTC) Series

• Open access
• Published: 13 November 2020

Neighbourhood environment and depressive symptoms among the elderly in Hong Kong and Singapore

• Winnie W. Y. Lam 1 ,
• Becky P. Y. Loo   ORCID: orcid.org/0000-0003-0822-5354 1 &
• Rathi Mahendran 2  

International Journal of Health Geographics volume  19 , Article number:  48 ( 2020 ) Cite this article

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Geriatric depression is a growing public health issue worldwide. This study aims at identifying the relevant neighbourhood attributes, separate from the individual-level characteristics, that are related to the onset of depressive disorders among the geriatric population.

This study adopts a structural equation modelling (SEM) approach to understand the effect of the neighbourhood environment on geriatric depression, as identified by data collected from community-dwelling elderly living in Hong Kong and Singapore. Using network buffers as the unit of analysis, different features of the neighbourhood environment are captured and analysed. SEM also examines the strength and direction of the relationships using different parameters at both the individual and neighbourhood levels, as well as the prevalence of depressive symptoms among the elderly.

The total sample size is 347, with 173 and 174 elderly people in Hong Kong and Singapore respectively. The results show that in addition to one’s physical health status, both objective and subjective neighbourhood factors including the size of parks, land use mix, walkability, and connectivity are all statistically significant influential factors in geriatric depression. In particular, enhancing walkability and providing more parks at the neighbourhood level can bring mental health benefits.

Conclusions

Public health policy initiatives aimed at tackling geriatric depression can be achieved by adopting a holistic and integrative approach to better prepare the neighbourhood environment in an ageing society.

Introduction

Depression in later life is an important public health issue due to the increased risk of morbidity and suicide, as well as decreased physical, social, and cognitive functioning [ 5 ]. In two of the most rapidly ageing cities in Asia, elderly depression is one of the most common psychiatric disorders. In Hong Kong, the prevalence rate is 13.7% for females and 8.9% for males; while in Singapore it is estimated at 5.5% [ 20 , 44 ]. Therefore, to be effective and relevant, age-related policies and programmes in Asian cities need to keep pace with the rapidly ageing population [ 37 ]. In particular, the identification of factors that exacerbate or alleviate depression have important implications in promoting healthy ageing-in-place, a concept that allows the elderly to live in their existing communities with familiar family and/or social support, rather than to move to institutionalized homes for the elderly [ 32 ].

In cities, multiple factors contribute to the risk of depression ranging from genetic vulnerabilities, neurobiological changes, and environmental factors such as social and psychological issues, and often the neighbourhood environment [ 47 ]. For governments, a holistic ageing policy that considers not only individual demographic, medical, and socio-economic factors but also their neighbourhood environment is needed to safeguard the physical and mental health of the elderly. In particular, the integrative conceptual framework developed by Billings and Moos [ 4 ] suggests that personal resources interact with environmental resources such as physical and architectural features of community settings which could lead to environmental stressors and affect appraisal and coping responses to cause depression. This research focusing on the neighbourhood environment and elderly depressive symptoms is grounded in this theoretical background.

Figure  1 is a schematic diagram of the integrative framework. A recent review summarises that neighbourhood environmental resources including high walkability, connectivity, and accessibility are expected to contribute to the elderly’s physical and mental health, and hence their quality of life [ 33 ]. The elderly tend to spend more time in their neighbourhood environment because their activities are significantly curtailed by physical decline and frailty, retirement, reduced mobility, decreased access to transport, shrinking social support and networks, and cognitive decline [ 12 ]. Hence, satisfaction with the availability and proximity of key resources, such as retail and healthcare services, is also found to reduce depressive symptoms [ 24 ]. Good connectivity, while reducing trip distance between locations, enhances walkability and encourages outdoor mobility in older adults [ 42 ]. Similarly, open spaces can improve living conditions and enhance the overall quality of life [ 23 ]. A geographical neighbourhood which is not supportive to walking, and with limited access to services and resources, poses further significant barriers for older people seeking full participation in society, with deleterious effects predisposing the development of geriatric depressive symptoms [ 13 , 41 ]. Moreover, several studies have shown that certain neighbourhood factors were consistently associated with depression [ 14 , 35 , 51 , 52 ]. Indeed, it is found that seniors facing severe mobility impairment have a lower level of social engagement and life satisfaction [ 29 ], suggesting that poor accessibility can create environmental stressors to the elderly.

An integrative framework of people-environment factors in analysing adaptive processes and depression [ 4 ]

In terms of the interactions of personal and environmental resources, the prevalence of depression has been found to be affected by the number of rooms in the home, as well as housing quality [ 14 ]. A higher satisfaction with housing was associated with fewer depressive symptoms [ 28 ]. Several self-reported measures of the geographical neighbourhood, such as neighbourhood collective efficacy, neighbourhood problems, and neighbourhood quality, were also important. Generally, living in a low-income neighbourhood appears to be strongly related to poorer mental health and depression [ 16 ]. The extent, strength, and quality of social connections with each other in their neighbourhoods affect their appraisal and coping responses and, hence, is also a social determinant of health [ 19 ]. ‘Non-material’ aspects of life, such as support and love, are necessary for good mental health [ 3 ]. Hence, the emotional support older people receive within their local neighbourhood is particularly relevant. Studies suggest that the concentration of older people living close together could have a favourable effect on alleviating geriatric depression [ 35 ]. There is also a body of evidence showing that social capital—the degree to which older people see themselves as involved with, and are able to rely on, other members in their neighbourhood [ 40 ]—buffers against stressful life events, improves coping responses, and helps prevent the onset of depression [ 26 ]. Social capital has important moderating or mediating effects on depression in different population-based cohort studies [ 3 ], including a sampled Chinese population [ 6 ].

Despite the growing interest in understanding the environmental influences on people’s health, research studies have mainly focused on the West. Much is still unknown about the importance of the neighbourhood environment on depression in Asian communities, which tend to be of higher density and diversity [ 9 , 51 , 52 ]. The study by Chen et al. focused on the neighbourhood characteristics of elderly people living in low-income communities in Hong Kong. By assessing perceived measures using linear regression, they found that at-ease walking proximity to medical facilities was influential [ 9 ]. The work by Chen’s team adds to the knowledge about particular aspects of neighbourhood environmental resources on geriatric mental health in Asian communities. Moreover, the empirical evidence in three Asian cities (i.e., Hong Kong, Singapore, and Tokyo) indicates that the home environment of the elderly, especially neighbourhood walkability, is interconnected with the formation of social capital and the elderly’s physical and mental health conditions [ 34 ]. The research team of Zhang et al. [ 51 , 52 ] further explored the environment-depressive symptoms associations and found that the “ultra-dense, well-connected, pedestrian-friendly, destination-rich neighbourhoods may contribute to lowering the risk of depressive symptoms in Hong Kong older adults by enabling them to frequently walk to local destinations of daily living and, thus, maintain their independence and bond with the community” (Zhang et al. [ 52 ]: 96). Yet, exposure to extreme levels of public transport density and associated traffic volumes may create environmental stress and increase the risk of depressive symptoms [ 51 ].

Our study aims to complement and expand the existing literature by revisiting the definition of geographical neighbourhood, incorporating both objective and subjective measures of the neighbourhood, and by extending the study area to include both Hong Kong and Singapore—two cosmopolitan Asian cities—to elucidate effective strategies ahead. It is increasingly recognized that a combination of objective and subjective measures is necessary in understanding complex public health issues [ 22 ]. By employing structural equation modelling (SEM), we examine the possible mechanisms by which depressive symptoms may be related to the neighbourhood environment in which a person resides. Hong Kong and Singapore were selected in view of their many common characteristics, physically, economically, historically, and culturally. The contrast between the two societies may well serve to inform the debate on geriatric depression, which thus far has centred primarily on Western countries.

Methodology

Sample population and study area.

This cross-sectional study involved community-dwelling senior citizens in Hong Kong and Singapore with support from local senior citizen community centres. Due to the lack of comprehensive sampling frames, convenience sampling was used. The survey altogether included 228 seniors in Hong Kong and 250 seniors in Singapore. Written consent was obtained from all participants before the interviews, which were conducted during May and June, 2013. More details about the survey design and sample recruitment are provided in Loo et al. [ 33 ]. The neighbourhoods in Hong Kong were selected based on the comprehensive list of senior community centres from the Social Welfare Department. All senior community centres were approached for participation. Upon initial agreement to participate, site visits were done to establish the suitability of the venue, time schedule, and membership size. The samples eventually came from four neighbourhoods in Sai Ying Pung on Hong Kong island, Hung Hom and Lai Chi Kok in Kowloon, and Tai Po in the New Territories. In Singapore, the seniors were recruited at an established training and research centre in the Jurong town area. This is the same large scale satellite housing development that is seen across the country; each is self-contained with public housing units, a town centre, amenities for shopping, employment in industrial estates, schools, medical care and recreational facilities. Based on the respondents’ home locations, the three neighbourhoods are Jurong West Central, Boon Lay, and Hong Kah. Major road networks generally do not run through these townships which are however linked to these major highways. In both cities, our target population were healthy community-dwelling elderly who are not experiencing any acute life event known to the elderly community or research training staff.

Based on the samples, further inclusion criteria for the study population were people who (a) were aged 65 years or older in the study period; (b) scored 20/22 or above in MMSE during the screening of cognitive abilities (see below); and (c) completeness of the questionnaires. This resulted in a total sample size of 347, with 173 and 174 elderly people in Hong Kong and Singapore respectively. More specifically, 26, 47, and 58 samples were excluded because of the above three inclusion criteria, respectively.

Demographic data collection

The gathered demographic and socioeconomic information of the respondents included: gender, age, educational level, living arrangements and accommodation, household car-ownership, and number of chronic diseases. The body mass index (BMI) for all respondents—as an indicator of general obesity—was also recorded.

Assessments

The Mini-Mental State Examination (MMSE) was used to measure cognitive impairment. This 30-point questionnaire tests various cognitive functions, including orientation to time and place, repetition, verbal recall, attention and calculation, language, and visual construction. The total test score ranges from 0 (impaired) to 30 (normal). Cut-off points for cognitive impairment of 22 for those who are literate and 20 for those who are illiterate were based on a previously validated study in the Chinese population which yielded a sensitivity of 83.87% and a specificity of 84.48% [ 49 ].

The 15-item Geriatric Depression Scale (GDS-15) was used to assess depression. Each item was scored on a dichotomous ‘Yes’ or ‘No’ response, and the scale was the sum of the recoded 15 items, ranging from 0 to 15. Higher scores on the GDS indicate higher levels of depressive symptoms. The prevalence of depression was indicated by a cut-off point of 8 [ 11 ]. For Cantonese speakers, the validated Chinese version of the GDS was used. Cronbach’s alpha in the present sample is 0.83, suggesting a reasonably reliable measure for further analysis.

Health-related variables were obtained using the SF-36v2 Health Survey—a multipurpose, short-form health survey. It has 36 questions that yield an eight-scale profile of functional health and well-being, two psychometrically based physical and mental health summary measures, and a preference-based health utility index. The physical component score (PSC) and mental component score (MCS) are two variables used to reflect the general physical and mental health status respectively [ 33 ]. Both have a range of 0 to 100 with higher scores suggesting better health [ 46 ]. For easy reference, they can be interpreted as summary physical and mental health scores, respectively.

The International Physical Activity Questionnaire—Short Form (IPAQ-SF) was used, which measures health-related participation in physical activity (PA) in populations. The specific types of activity assessed are: walking, moderate-intensity activities, and vigorous intensity activities. Frequency (measured in days per week) and duration (time per day) are collected separately for each specific type of activity. Items are structured to provide separate scores for walking, moderate-intensity, and vigorous-intensity activity, as well as a combined total score to describe overall level of activity. Volume of activity is computed by weighting each type of activity by its energy requirements as defined in the Metabolic Equivalent of Tasks (METs), which are multiples of the resting metabolic rate. Multiplying the MET score with the number of minutes the activity is performed yields a score in MET-minutes. MET-minutes per week were used to classify older people into three categories: low, moderate, and high level of physical activity [ 21 ].

Geographical neighbourhood variables

Indicators of two sets of geographical neighbourhood variables, based on immediacy and breadth of impact, were constructed. Level-1 local factors or individual-specific immediate neighbourhood factors refer to parameters at a micro scale of influence, while those at a meso-level are termed level-2 local factors or wider shared neighbourhood factors. This study advocates the concept of people-based neighbourhoods, which are identified based on the actual activity space or space–time movements of individuals [ 33 ] rather than district-based neighbourhoods, which are fixed for administrative purposes. To achieve this, the home addresses of all participants were geocoded using a geographic information system (GIS). To analyse level-1 local factors, a 500-m network buffer was drawn around each participant’s residential location using network distance to reflect walkable distance for the participants [ 7 ]. Neighbourhood factors were gaugfed on a pro-rata basis.

The first dimension of level-1 local factors captures the spatial distribution of opportunities near their homes as this plays a key role in defining social in/exclusion [ 41 ]. By calculating the shortest physical distance to key facilities around the participants’ homes [ 50 ], this study considers the network distance to places such as the nearest medical facility (DIS1) or entrance to an open space (DIS2). Network distance here refers to the length of walking path on the pedestrian network, which is more realistic than the shortest direct line/Euclidian distance, between two places [ 32 ]. The second dimension of level-1 local factors captures various key principles in urban planning, including connectivity (CON) and the 3D, that is, density (DEN), diversity (DIV), and design (DES) [ 8 ]. CON is measured by the road junction density within the buffer area. For DEN, this study considers overall and elderly population density, where higher density implies an advantage of having more population to support a vibrant neighbourhood. DIV, refers to the mix of land use in contributing to a balanced development. It is calculated using the Simpson’s Diversity Index [ 43 ] as an entropy measure by considering five categories of land use: residential, commercial, institutional, recreational, and others [ 32 ]. Finally, good DES relates to the attractiveness of the neighbourhood environment. It includes connectivity as expressed in the number of intersections per square kilometre (DES1), the percentage of open space in one’s neighbourhood (DES2a), and the area (km 2 ) of parks contained within the network buffer.

The third dimension relates to one’s perception of how walkable is the neighbourhood. Eighteen subjective walkability variables under the dimensions of comfort, convenience and safety were gathered from the face-to-face questionnaire survey. These variables are summarized in Table 1 . The different parameters of the neighbourhood walking environment were rated on a Likert scale from one to five, ranging from very poor to very good condition. In addition, participants were also asked to rate the overall walkability of their neighbourhood subjectively on a scale of 0 to 100.

To measure social capital, four statements were used. Three statements required a response on a five-point Likert scale from strongly disagree to strongly agree: “People in my neighbourhood get along with each other well”; “People are willing to help each other”; and “Living in this neighbourhood gives me a sense of community”. The fourth statement, “Do you have someone to accompany you outside?”, required a yes or no answer.

The above neighbourhood factors are individual-specific. This poses a challenge to the operationalization of the shared space, which can enhance the relationship between people, places, and the surrounding traffic [ 17 , 18 ]. Spatial aggregation was then performed in the study by overlapping individual neighbourhood buffers with common boundaries and within a walkable distance roughly double the immediate neighbourhood buffer of 500 m (that is, a radius of roughly 1 km). Level-2 local factors or the wider shared community factors capture the general or average condition of people living there. The first dimension of level-2 local factors captures the average or mean value of all parameters included in the level-1 local factors. The second dimension covers some additional demographic variables. These include the percentage of oldest-old of 85 years or above and females. The third dimension includes an objective walkability assessment, which is a composite score of the walking conditions of the neighbourhood based on the research protocols developed by Loo and Lam [ 32 ]. There are altogether twelve variables, covering the pavement (pavement surface, shelter, pedestrian guardrail, directional signs, road works and street furniture) and crossing facilities (dropped kerb, audible pedestrian signals, number of vehicular lanes, refuge island for wide roads, traffic light cycle, and crossing time).

Research framework

SEM is used to establish relationship strength and direction among the different individual and neighbourhood environment parameters in the occurrence of depressive symptoms among the elderly. It is also used to test the mediating relationship, elucidating the potential pathways in which neighbourhood factors and individual attributes affect depression in the elderly. SEM is particularly suitable to this research because it allows for the building of complex models (including relationships among observed and latent-variables) and corrects for measurement errors, thereby allowing for a more accurate test of the mediational effect [ 25 ]. Based on our theoretical framework, we have selected different factors related to personal resources and environmental resources as exogenous variables The latter are further classified as individual-specific immediate neighbourhood characteristics (hereafter referred to as level 1 local factors) and wider shared neighbourhood characteristics (hereafter referred to as level 2 local factors). Depressive symptoms were treated as endogenous. Thus, it is hypothesized that the exogenous variables interact with and mediate the development of depressive symptoms. The dependent variable in this study is the occurrence of depressive symptoms among the elderly population.

The characteristics of the sample population are shown in Table 2 . The overall prevalence of depression using the GDS cut-off point of 8 was 7.8% in Hong Kong and 15.6% in Singapore. It should be noted that convenience sampling was adopted in this research work. In all of the 347 older people, a large proportion (77.2%) were female ( n  = 268). The higher percentage of females in the sample reflects a gender difference in attitudes towards involvement in community and volunteer activities in the two cities [ 38 ]. Despite this, the present multi-centre study is an effective method of recruiting sufficient number of community-based subjects. The mean age of the elderly respondents was 73.82 years (SD = 6.04), ranging from 65 to 95 years. 4.9% of the samples belong to the oldest-old age, who were aged 85 or above during the study year. Around 23.3% ( n  = 81) of respondents lived alone and 77.5% were part of non-car owning households ( n  = 269). About 70% of the respondents ( n  = 243) only received primary education or lower level. Following the guidelines of the World Health Organization [ 48 ], around two third of respondents were normal-weight individuals (a BMI of 18.5 to 24.99). Nevertheless, 32.6% of the elderly people in this study were overweight and 4.9% were obese. Approximately 23.6% had more than three chronic diseases, of which the top three were high blood pressure (51.8%), knee osteoarthritis (31.1%), and diabetes (18.6%). Despite these constraints, many respondents in Hong Kong remained physically active (45.1%) based on the score in MET-minutes. The share of being physically active was lower in Singapore (6.9%). Moreover, as seen from Table 2 , our subject individuals generally enjoyed reasonably good physical and mental health as community-dwelling elderly of over 65 years old. Overall, less than 20% of the respondents have their physical and mental health scores below 50. However, as shown above, these average figures hide problems of depression in the ageing population.

Following the SEM approach, we have tested different models and the final model with accompanying path coefficients is presented in Fig.  2 . Only statistically significant variables are kept. Examining the factors that characterize older people’s neighbourhoods may help provide evidence as to the extent to which neighbourhood factors are related to the development of depressive symptoms. Firstly, the model shows that better physical conditions, as reflected by a higher physical health score, are linked to a lower risk in depressive symptoms (coefficient = − 0.01, p < 0.05). While overweight or obese elderly people (coefficient = − 4.35; p < 0.05), and the oldest-old (coefficient = − 9.98; p < 0.05), are less likely to maintain a good physical health status. Among the immediate neighbourhood factors (Level 1), abundant park area (coefficient = − 2.68; p < 0.05) help to counteract depression. The park area is, in turn, affected by land use mix (coefficient = 0.02; p < 0.05), suggesting that higher land use mix is positively associated with the park area. Among the wider shared neighbourhood factors (Level 2), good objective walkability score (coefficient = − 0.38; p < 0.05) is negatively associated with depressive. In addition, the good objective walkability score is positively associated with connectivity (coefficient = − 0.00; p < 0.05), though the variable itself is also directly associated with geriatric depression (coefficient = − 0.00; p < 0.05). Generally, this suggests and reconfirms that higher road junction density (CON or connectivity) can create smaller street blocks to encourage walking but heavy vehicular traffic may also create environmental stress.

Path diagram showing the relationships between individual and neighbourhood factors

In addition, some other variables that we have tested are also generating results that are worth mentioning, though their statistical significance levels are not below 0.05 to be reported in Fig.  2 . They are subjective variables. Two are individual-specific immediate neighbourhood (level-1) factors, that is, the subjective sense of community (coefficient = − 0.02) and subjective perception of poor neighbourhood air quality (coefficient = 0.01),and two are wider shared neighbourhood (level-2) factors, that is, having companions to walk together (coefficient = − 0.89), and getting along well with neighbours (coefficient = − 0.30). We believe that the limited sample size may be a contributory factor and these subjective neighbourhood factors are worth closer examination in future larger-scale research.

Referring to the integrative framework of Billings and Moos [ 4 ], our work indicates that personal resources, such as physical health and body weight, are closely linked to the elderly’s mental health. This is contrary to previous studies which have showed that there is either no apparent association observed between BMI and depressive symptoms [ 27 ], or that there is even a negative relationship [ 30 ]. This present study suggests that maintaining a healthy weight allows one to be in better physical health condition and, in turn, has better mental health. Fitness programmes for the elderly, such as outdoor walking activities, could be further promoted at a community-wide level, in order to keep them active and physically fit.

In terms of environmental resources, we found that having larger areas of parks near one’s home is linked to fewer depressive symptoms. In Hong Kong and Singapore, parks represent open green space and leisure facilities such as playground, basketball courts and sports complex. One can conceptualize the impact in two ways. First, parks has been found to be important to people whether or not they use it often and actively [ 36 ]. Parks seen at a distance from one’s home can also be viewed as an environmental resource of importance to public mental health [ 1 ]. Second, being able to be directly immersed in the leisure environment provides opportunities for morning exercises, after-dinner walks, and social contacts, which are beneficial to older people’s health and well-being. Particularly in high-rise compact urban areas such as Hong Kong and Singapore, daily contact with the natural environment can have measurable mental benefits [ 10 ]. An earlier study indicated that once access is considered, size is more important than attractiveness in determining use [ 15 ]. This echoes the study result where the size of parks near to one’s home matters.

Another significant and powerful environmental resource that helps to reduce the risk of geriatric depression in Hong Kong and Singapore is promoting walkability within one’s neighbourhood. Walking is a popular, inexpensive, and convenient activity for older adults that is vital to maintaining their physical and mental health [ 32 , 45 ]. A supportive neighbourhood environment helps promote walking as a mode of active transport that can be incorporated into the daily routine of older people, which often involves making medical trips [ 31 ]. By adopting an objectively measured micro-scale walkability assessment to evaluate different dimensions of the walking environment, this study found that promoting a more walking-friendly neighbourhood can be a core component of the public health policy. The composite score suggests that pavement width, surface condition, availability of street seats, ease of finding assistance, pedestrian crossing width, and whether or not the overpasses/underpasses are equipped with lifts, are important contributing factors in a walkable environment that decreases the risks of geriatric depression. A previous study discovered that, in a Western context, a more walking-friendly neighborhood decreases the risk among the elderly of becoming depressed [ 2 ].

This study offers an integrated analysis of neighbourhood effects on geriatric depression; and provides empirical evidence suggesting that an older person’s neighbourhood of residence contributes to geriatric mental health. A walkable environment with abundant parks are favourable environmental settings for older people in Hong Kong and Singapore. To date, knowledge is very limited regarding the variability of neighbourhood effects among Asian cities on a person’s mental health. By exploring the effects of neighbourhood environment on geriatric depression, the results have paved the way for further studies on inter-city or regional comparison of mental health in an ageing population globally. The present study also adds to the diversity of available population-based literature on geriatric depression in Asia. Theoretically, the study stresses that the concept of geographical neighbourhood that goes beyond the immediate nearby areas but also the wider community. The first set of neighbourhood factors, which we referred to as level-1 local factors, can be individual-specific. It reflects one’s perceptions of his/her neighbourhood. The second set of neighbourhood characteristics, referred to as level-2 local factors, is related to certain general or common conditions that people share in a local area. The advantages at the different levels that the assessment revealed can provide a more robust understanding of the issues, while also underlining the challenges that exist in defining neighbourhoods; which is rather a complex concept to define and measure.

This study is not without its limitations. First, the sampling strategy could be improved by trying to reach community-dwelling elderly directly. Given the difficulties of getting a better sampling frame, convenience sampling was used. Moreover, the sample size is limited. As SEM with multiple explanatory factors perform better with bigger samples [ 29 ], increasing the sample size will allow us to model more variables and further explore the complex relationships of subjective variables with depression. Furthermore, respondents in Hong Kong and Singapore are pooled for the analysis, differences among communities and between cities are not examined in this study. Further research should address variations at different spatial scales. Second, the research investigated the presence of clinically relevant levels of depressive symptoms using GDS rather than the clinical diagnosis of depression. However, GDS is one of the most commonly used depressive symptoms measures in geriatric studies and has been shown to have good reliability for clinical diagnosis. Third, the dependent variable for the analytical data analysis is binary in nature. This can lead to concerns over the prevalence and incidence of depressive symptoms, and reduce the predictive power of the model. Though the binary approach adopted is sufficient in addressing the manifold question at hand, it does place constraints on a better understanding of geriatric depression. Fourth, the cross-sectional design adopted poses a number of challenges. It is not possible to unequivocally determine the direction of causation using the present cross-sectional data. For instance, depression at any given time might be influenced by current neighbourhood features. On the other hand, it can also be the result of cumulative exposure to neighbourhood features over many years. The effects of the neighbourhood environment on the development of depression is likely to have a time lag. This calls for further, preferably longitudinal, research to adequately explain the causal pathways by which a neighbourhood might affect health. Very often, depression is best viewed across a longitudinal time series which transects through the invasion history of depression into a person’s mind [ 39 ]. Besides, as our research did not collect the elderly residential history and decision-making information, we cannot conduct meaningful analysis about the residential self-selection issue. We recognize that focused research may further explore its relationship with depression.

On the way forward, the findings of this research have political implications for both Hong Kong and Singapore, as they are faced with rapidly ageing populations and socio-cultural changes. Overall, the high prevalence rates of geriatric depression in many ageing societies has led to public concerns. So far, the ageing policy has put much attention on the financial, healthcare and housing aspects. Nonetheless, this paper finds that the geographical neighbourhood in which an older person lives has a significant impact on his/her mental health, even after accounting for individual-level determinants. Even though depression is an individually experienced phenomenon, external factors including the neighbourhood environment are linked to its development. The development, evaluation, and dissemination of a new generation of programmes and structural interventions, especially on how to improve the neighbourhood environment, can be targeted towards improving the mental health of this population. Above all, understanding depression requires an analysis of the complex web of variables that gave rise to these specific individual circumstances. The expanding body of research on the effect of the neighbourhood environment on depression holds great promise, not only for achieving a more complete aetiological picture of the conditions, but also for delineating ways to understand and promote health and well-being in an ageing population. The findings of this study suggest that psychological health and the environment require greater age-specific policies if the elderly are to age well and successfully with good quality of life and life satisfaction.

Availability of data and materials

The datasets collected in the current study are available from the corresponding author on reasonable requests.

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This research project was funded by the National University of Singapore (NUS) Initiative to Improve Health in Asia (NIHA) Research Grant on “Promoting Active Transportation for the Elderly: A Comparative Study of Three Asian Cities” (NIHA-2011-1-010). It was also partially funded by the Sixth Government Matching Grant Scheme on “Health and Active Ageing: What is the Role of the Urban Environment” of the Hong Kong Special Administrative Region Government and the 27th Round Post-doctoral Fellowship/Research Assistant Professorship Scheme on “Healthy Aging and Sustainable Transport” of the University of Hong Kong.

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WWYL led the research fieldwork, conducted the data analysis, and drafted this paper. BPYL conceptualized the project, obtained the research funding, guided the data analysis, and edited the manuscript. RM obtained the research funding, led the research fieldwork in Singapore, and guided the data analysis. All authors read and approved the final manuscript.

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Dr Winnie W. Y. Lam obtained her PhD degree at the Department of Geography of the University of Hong Kong. Her research interests are socially sustainable transport, especially in relation to the transport disadvantaged such as the elderly, women and children.

Professor Becky P. Y. Loo is Professor and Head of Department of Geography Head of Department at the University of Hong Kong. She is a Fellow of the Academy of Social Sciences, UK. She is also the Director of the Institute of Transport Studies, and Founding Co-Director of the Joint Laboratory on Future Cities. Her core research interests are transportation, smart technologies and cities. In particular, she is interested in applying spatial analysis, surveys and statistical methods in analysing pertinent issues related to the relationships of the environment and the well-being of people living in cities.

Dr Rathi Mahendran is Associate Professor & Senior Consultant Psychiatrist, Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore. She graduated from the National University of Singapore in 1980 and completed the Specialist Training in Psychiatry in 1998. She subsequently trained in the UK and the US under Health Manpower Development Plan programmes in 1989 and 1996 respectively. She was awarded Master of Medical Education from the University of Dundee (UK) in 2013. Her interests are in psychopharmacology and medical education. She also provides psychosocial care for ambulatory patients at the National University Cancer Institute, Singapore (NCIS). Some of Dr Rathi’s notable achievements include the Distinguished Psychiatrist Award by Singapore Psychiatric Association, awarded in 2016.

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Lam, W.W.Y., Loo, B.P.Y. & Mahendran, R. Neighbourhood environment and depressive symptoms among the elderly in Hong Kong and Singapore. Int J Health Geogr 19 , 48 (2020). https://doi.org/10.1186/s12942-020-00238-w

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Case Study 5 – Older Adults

The following case vignette provides key concepts that could be considered when developing a plan of care for a patient who may require a controlled substance to manage their health concerns. As with any clinical situation, there are many patient variables that must be considered, including comorbid conditions, social determinants of health and their personal choices. You may choose to include different or additional health history and physical examination points, diagnostic tests, differential diagnoses and treatments depending on your patient’s context however this case vignette focuses on the aspects relevant to controlled substances.

June is a 73 year old woman who is a new patient recently referred to the primary care clinic and seeing Matt, the NP. She is seeking a refill for her lorazepam, which she has been taking for anxiety/poor sleep since her husband’s death 10 years ago. Her prescribed dose is 1 mg at bedtime, but she has been taking 2 mg at bedtime for the last 2 to 3 months due to poor sleep. She also takes a tablet during the day with glass of scotch for anxiety. Her other medications include candesartan and paroxetine for depression.  June is a patient in the clinic so Matt has her health history available on the EMR. Matt takes a full health history. Pertinent findings in relation to this CDS use vignette is reported here.

She tells Matt that she had an ED visit 2 months ago after a motor vehicle accident where she crashed car into a parked car while driving home from the grocery store. She received a refill for her lorazepam at that time. Finally, she fell at home 3 weeks ago after tripping while taking out the garbage. She did not present for assessment but thinks she sprained her wrist. She has been taking ibuprofen 2 to 3 times daily for pain and wants Tylenol with codeine (T3).  Matt attempts to open discussion of benzodiazepine use and falls/accidents.  She is surprised and says “this has never been an issue, no one ever told me this before”.

Clinical office – including a desk, two chairs, an exam table, an EMR on computer, a BP cuff/machine, and a stethoscope.

Matt is wearing shirt and slacks, with a lab coat. Brown short hair.

Matt: So I understand you need a refill on your medication today June. June: Yes…I am almost out of my lorazepam prescription because I’ve needed to take an extra one at night for the last couple of months to help me sleep. Sometimes I need one through the day too because I get anxious. I tried having a shot of Scotch but that doesn’t help at all. I also want a few of those Tylenol with Codeine to help with the pain in my wrist. I fell a couple of weeks ago and the ibuprofen isn’t helping. My daughter gave me a couple of T3’s and they really worked! Matt: OK…let’s talk about the wrist injury first. How did it happen? June: I tripped on a mat while I was taking out the garbage. I was feeling a little dizzy that day like I get sometimes. I didn’t think it was anything so I didn’t get it checked. I don’t want people to think I’m sick all the time. I was in the ED a couple of months ago after a little car accident but everything was OK.

Matt is thinking about history questions for the wrist injury:

Matt: Now that you mention it, I do see a report here about the ED visit. So you weren’t hurt. What can you tell me about the accident? Were you feeling dizzy that day? June: As a matter of fact, I think I was feeling a little dizzy that morning. I figured it’s because I haven’t been sleeping all that great…the anniversary of my husband’s death always makes me unsettled. Matt: Do you remember if you took any extra lorazepam that day or the night before? June: I’m not sure but I probably did because I hadn’t been sleeping well for a while before that. Matt: What about any alcohol…did you have anything to drink that day before you went out? June: Oh no…I’d never to that! I only have a drink if I know I don’t have to drive anywhere…usually in the afternoon while I’m watching my shows. Matt: OK…what about the day that you fell and hurt your wrist…do you remember if you’d taken any extra pills or if you had anything to drink?” June: Wow…that’s hard to remember…I’m not sure.

Matt thinks about the additional assessments for the wrist injury, falls risk and use of alcohol along with her benzodiazepines.

Matt: I have to tell you that I’m a little worried about a couple of things June. You tell me that you are taking more lorazepam than what was initially prescribed and that you are also using alcohol. When you use this medication and along with your blood pressure medicine and the pill for your depression, they can work together to make you dizzy and disoriented. That could be the reason for your fall and even the car accident. Do you remember any other falls?” June: I trip every once in a while but I figure that’s because I’m getting old and I’m not in shape like I used to be when I exercised a lot. Wow…this has never been an issue…no one ever told me this before!

Matt thinking about other tools her could use to assess June today. As Matt is discussing this with June he is thinking about the other tools he would use to confirm his diagnosis.

Matt: From what you’ve told me, your depression score hasn’t changed since the last time it was recorded on your health record and you tell me you’re feeling anxious but your score only shows this as mild right now. I’m not saying that this isn’t something that we need to talk about but I think your paroxetine is still at a good dose for you. I am concerned that you are drinking alcohol while taking the lorazepam.

Matt: OK June, here’s the plan I propose. I will give you a 30-day supply of your lorazepam as it was originally prescribed which is once daily at bedtime. I’m going to order an X-ray of your wrist to see if there are any broken bones. I’d like to suggest that you get some counseling to help with the anxiety because taking extra lorazepam is not safe when added to the other medications you take and I’m really worried about you getting hurt from a fall. Finally, I’d like to book an appointment to see you again in a week to look at the X-ray and talk some more about your symptoms. June: You mean you aren’t going to give me something for this pain in my wrist? Matt: No June…not until we see if there are any broken bones. I think we’d be better getting you in to see the clinic physiotherapist who can help you with some treatments for the pain and exercises to get it strong again. In the meantime, you can keep using your wrist support and take plain Tylenol for pain.

Matt: Do you have any other questions? June: No…I’m not happy that I can’t have any T3s but at least I might be able to sleep now that I’ll have enough of my other pills. I guess I have to come back in a week then. Matt: I’d like to see you again after you’ve had your X-ray…yes but you can always call back if anything changes.

Learning Outcome

By the end of this learning outcome, the participant should be able to:

• Recognize misuse of prescription controlled substances through history, physical and diagnostic tests in an older adult.
• Predict risk for falls, depression, anxiety and substance misuse in an older adult.
• Manage safe prescribing of benzodiazepines in the older adult
• Examine the use of treatment agreements in the older adult.
• Recognize the impact of prescribed control drug substances on patient safety in the elderly population.

Resources and Links

• FROP-com screen
• Benzodiazepine Use and Taper
• Geriatric Depression Scale
• Brief Pain Inventory
• CAGE questionnaire
• CAGE-AID questionnaire

Exercise can help treat depression, but what works best depends on age and gender: study

Health Exercise can help treat depression, but what works best depends on age and gender: study

Treating depression can be complicated and financially draining.

Seeing a psychologist can leave a big hole in your wallet, and anti-depressants can have such  debilitating withdrawal symptoms  that some people have to take them indefinitely.

But what if there was one more treatment option you could consider?

There is; it's exercise. And a new study suggests it can actually be more beneficial than antidepressant medication alone.

But the type you do, and how you do it, matters.

Australian researchers recently completed a major review of 200 randomised trials  on exercising to treat depression. It meant analysing over 14,000 people with clinical depression, which is characterised by at least two weeks of feeling low.

After concluding exercise was an effective treatment, they went further and compared specific types of exercise.

So let's unpack what they found.

And just quickly, before we do that, it's important to note anti-depressants and cognitive behavioural therapy are effective for some people and anyone changing their treatment plan should talk to their doctor.

Which activities are most beneficial?

Walking or jogging , yoga and strength training are about as effective as cognitive behavioural therapy and more effective than anti-depressant medication alone.

But we can narrow it down further.

The review found yoga and qigong (a Chinese system of physical exercises and breathing control) are likely to be more effective for men , and strength training is best for women .

Yoga is somewhat more effective for older adults and strength training can lead to greater improvements among younger patients.

Dance is also great at lowering depressive symptoms.

"I think that's because it has that social interaction, vigorous exercise, uplifting music and so it seems a really promising avenue for research," says Michael Noetel, lead researcher and senior psychology lecturer at the University of Queensland.

However, most studies on dance are on young women so Dr Noetel says there needs to be more varied research before it's recommended more widely.

Interestingly, the review found stretching to be the least helpful type of exercise for treating depression.

How often do I need to exercise?

The Australian guidelines suggest supervised group exercise for 30 to 40 minutes three times a week for a minimum of nine weeks.

But this new review found it didn't matter how many minutes or sessions of exercise people did per week (as long as they did some).

The effect of exercise was also the same whether you had mild or severe depression.

However, the intensity of the activity does matter; so the more vigorous, the better.

The benefits are also greater if you participate in exercise with other people as opposed to going at it alone.

What if I don't like any of these exercises?

There's no point trying to pursue yoga or weight training if you really hate it.

In fact, pushing yourself to do something you get no sense of satisfaction from can actually have a negative effect, says Rhiannon White, senior lecturer at the University of Western Sydney, who was not involved in the review. 

She's been studying the link between physical activity and mental health for 10 years and says it can be unhelpful to be overly prescriptive about what exercise people with depression should do.

"If we say 'this is the best type' and someone doesn't feel competent doing it or can't access that activity due to cost then exercise doesn't feel like an option to them," Dr White says.

"It's good to know what types are more beneficial but then we need to guide people to find the one that gives them the biggest sense of accomplishment ... that might not be resistance training, it might be a walk to the park with their dog or a friend."

Context matters, she says, and e ven the time of day you exercise can alter the mental health benefits you receive.

So why is exercise good for depression?

Experts believe there are a few reasons.

When someone is depressed they can get stuck in a cycle of isolation — they withdraw socially and then find it hard to re-integrate — but exercising with others can break that cycle.

Depression can also make you feel hopeless, making it difficult to get out of bed and do the things that are important to you. This can create a loop of guilt, but exercise can break this by providing a sense of accomplishment, Dr Noetel says.

That's why resistance training can be so effective as it's based on the number of repetitions and it's easy to set small goals and see progress.

There's also a lot to be said for novel experiences. If you are learning something new, there's a greater sense of satisfaction when you master it.

Dr Noetel suggests this could be the reason why yoga is more effective for men.

"If I think of my dad, he would not have done a downward dog in his whole lifetime ... so it's about learning something new, it's the cognitive aspect."

On top of that, when we exercise we get a surge of neurotransmitters like dopamine (ever had runners high?) which could be why more vigorous exercise has stronger effects.

How can I get started?

Those experiencing depression might meet the criteria for a chronic disease management (CDM) plan, which could get them  up to five subsidised sessions under Medicare  with an exercise physiologist.

Accredited exercise physiologists often design programs for people with anxiety, depression and post-traumatic stress disorder.

"They could support you as you start exercising and although five appointments isn't a lot, it's a start and starting is often the biggest hurdle," Dr Noetel says.

CDM plans can be arranged by a GP but Dr Noetel says not many doctors use them to refer people to exercise physiologists, perhaps because the field is relatively new.

Dr White says unfortunately many GPs don't go further than giving their patient a nudge to get moving, which isn't much help. 

Both experts say it's important exercise isn't considered an "add-on" treatment and research shows patients do a lot better when they are given a structured exercise program, rather than just encouragement.

How can I stay motivated?

Depression is often characterised by days where leaving the house is an impossibility, so getting to a gym or a group class won't be realistic.

Dr White says this is why it might be more helpful to have a support person, like a family member or friend, who can be on standby to come around and accompany you on a walk around the block on bad days.

She says online exercise videos might be preferable when symptoms are worse, as they can be done at home.

"It might not be the best exercise you'll ever do but it's the small steps that build a bit of confidence."

She suggests keeping in mind three factors that determine whether we feel motivated to exercise:

• who we're exercising with and whether we feel supported by them
• a sense of competence
• value and enjoyment from the activity

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• Exercise and Fitness
• Mental Health

• Open access
• Published: 20 September 2023

Older adults’ experiences during the COVID-19 pandemic: a qualitative systematic literature review

• Elfriede Derrer-Merk   ORCID: orcid.org/0000-0001-7241-0808 1 ,
• Maria-Fernanda Reyes-Rodriguez   ORCID: orcid.org/0000-0002-2645-5092 2 ,
• Laura K. Soulsby   ORCID: orcid.org/0000-0001-9071-8654 1 ,
• Louise Roper   ORCID: orcid.org/0000-0002-2918-7628 3 &
• Kate M. Bennett   ORCID: orcid.org/0000-0003-3164-6894 1  

BMC Geriatrics volume  23 , Article number:  580 ( 2023 ) Cite this article

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Relatively little is known about the lived experiences of older adults during the COVID-19 pandemic. We systematically review the international literature to understand the lived experiences of older adult’s experiences during the pandemic.

Design and methodology

This study uses a meta-ethnographical approach to investigate the included studies. The analyses were undertaken with constructivist grounded theory.

Thirty-two studies met the inclusion criteria and only five papers were of low quality. Most, but not all studies, were from the global north. We identified three themes: desired and challenged wellbeing; coping and adaptation; and discrimination and intersectionality.

Overall, the studies’ findings were varied and reflected different times during the pandemic. Studies reported the impact of mass media messaging and its mostly negative impact on older adults. Many studies highlighted the impact of the COVID-19 pandemic on participants' social connectivity and well-being including missing the proximity of loved ones and in consequence experienced an increase in anxiety, feeling of depression, or loneliness. However, many studies reported how participants adapted to the change of lifestyle including new ways of communication, and social distancing. Some studies focused on discrimination and the experiences of sexual and gender minority and ethnic minority participants. Studies found that the pandemic impacted the participants’ well-being including suicidal risk behaviour, friendship loss, and increased mental health issues.

The COVID-19 pandemic disrupted and impacted older adults’ well-being worldwide. Despite the cultural and socio-economic differences many commonalities were found. Studies described the impact of mass media reporting, social connectivity, impact of confinement on well-being, coping, and on discrimination. The authors suggest that these findings need to be acknowledged for future pandemic strategies. Additionally, policy-making processes need to include older adults to address their needs. PROSPERO record [CRD42022331714], (Derrer-Merk et al., Older adults’ lived experiences during the COVID-19 pandemic: a systematic review, 2022).

Peer Review reports

Introduction

In March 2020 the World Health Organisation declared a pandemic caused by the virus SARS-CoV2 (COVID-19) [ 1 ]. At this time 118,000 cases in 114 countries were identified and 4,291 people had already lost their lives [ 2 ]. By July 2022, there were over 5.7 million active cases and over 6.4 million deaths [ 2 ]. Despite the effort to combat and eliminate the virus globally, new variants of the virus are still a concern. At the start of the pandemic, little was known about who would be most at risk, but emerging data suggested that both people with underlying health conditions and older people had a higher risk of becoming seriously ill [ 3 ]. Thus, countries worldwide imposed health and safety measures aimed at reducing viral transmission and protecting people at higher risk of contracting the virus [ 4 ]. These measures included: national lockdowns with different lengths and frequencies; targeted shopping times for older people; hygiene procedures (wearing masks, washing hands regularly, disinfecting hands); restricting or prohibiting social gatherings; working from home, school closure, and home-schooling.

Research suggests that lockdowns and protective measures impacted on people’s lives, and had a particular impact on older people. They were at higher risk from COVID-19, with greater disease severity and higher mortality compared to younger people [ 5 ]. Older adults were identified as at higher risk as they are more likely to have pre-existing conditions including heart disease, diabetes, and severe respiratory conditions [ 5 ]. Additionally, recent research highlights that COVID-19 and its safety measures led to increased mental health problems, including increased feelings of depression, anxiety, social isolation, and loneliness, potentially cognitive decline [ 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 ]. Other studies reported the consequences of only age-based protective health measures including self-isolation for people older people (e.g. feeling old, losing out the time with family) [ 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 ].

Over the past decade, the World Health Organisation (WHO) has recognised the importance of risk communication within public health emergency preparedness and response, especially in the context of epidemics and pandemics. Risk communication is defined as “the real-time exchange of information, advice and opinions between experts or officials, and people who face a threat (hazard) to their survival, health or economic or social well-being” ([ 31 ], p5). This includes reporting the risk and health protection measurements through media and governmental bodies. Constructing awareness and building trust in society are essential components of risk communication [ 32 ]. In the context of the pandemic, the WHO noted that individual risk perception helped to prompt problem-solving activities (such as wearing face masks, social distancing, and self-isolation). However, the prolonged perception of pandemic-related uncertainty and risk could also lead to heightened feelings of distress and anxiety [ 31 , 33 ], see also [ 34 , 35 , 36 , 37 ].

This new and unprecedented disease provided the ground for researchers worldwide to investigate the COVID-19 pandemic. To date (August 2022), approximately 8072 studies have been recorded on the U.S. National Library of Medicine ClinicalTrials.gov [ 38 ] and 12002 systematic reviews have been registered at PROSPERO, concerning COVID-19. However, to our knowledge, there is little known about qualitative research as a response to the COVID-19 pandemic and how it impacted older adults’ well-being [ 39 ]. In particular, little is known about how older people experienced the pandemic. Thus, our research question considers: How did older adults experience the COVID-19 pandemic worldwide?

We use a qualitative evidence synthesis (QES) recommended by Cochrane Qualitative and Implementation Methods Group to identify peer-reviewed articles [ 40 ]. This provides an overview of existing research, identifies potential research gaps, and develops new cumulative knowledge concerning the COVID-19 pandemic and older adults’ experiences. QES is a valuable method for its potential to contribute to research and policy [ 41 ]. Flemming and Noyes [ 40 ] argue that the evidence synthesis from qualitative research provides a richer interpretation compared to single primary research. They identified an increasing demand for qualitative evidence synthesis from a wide range of “health and social professionals, policymakers, guideline developers and educationalists” (p.1).

Methodology

A systematic literature review requires a specific approach compared to other reviews. Although there is no consensus on how it is conducted, recent systematic literature reviews have agreed the following reporting criteria are addressed [ 42 , 43 ]: (a) a research question; (b) reporting database, and search strategy; (c) inclusion and exclusion criteria; (d) reporting selection methods; (e) critically appraisal tools; (f) data analysis and synthesis. We applied these criteria in our study and began by registering the research protocol with Prospero [ 44 ].

The study is registered at Prospero [ 44 ]. This systematic literature review incorporates qualitative studies concerning older adults’ experiences during the COVID-19 pandemic.

Search strategy

The primary qualitative articles were identified via a systematic search as per the qualitative-specific SPIDER approach [ 45 ]. The SPIDER tool is designed to structure qualitative research questions, focusing less on interventions and more on study design, and ‘samples’ rather than populations, encompassing:

S-Sample. This includes all articles concerning older adults aged 60 +  [ 1 ].

P-Phenomena of Interest. How did older adults experience the COVID-19 pandemic?

D-Design. We aim to investigate qualitative studies concerning the experiences of older adults during the COVID-19 pandemic.

E-Evaluation. The evaluation of studies will be evaluated with the amended Critical Appraisal Skills Programme CASP [ 46 ].

R-Research type Qualitative

Information source

The following databases were searched: PsychInfo, Medline, CINAHL, Web of Science, Annual Review, Annual Review of Gerontology, and Geriatrics. A hand search was conducted on Google Scholar and additional searches examined the reference lists of the included papers. The keyword search included the following terms: (older adults or elderly) AND (COVID-19 or SARS or pandemic) AND (experiences); (older adults) AND (experience) AND (covid-19) OR (coronavirus); (older adults) AND (experience) AND (covid-19 OR coronavirus) AND (Qualitative). Additional hand search terms included e.g. senior, senior citizen, or old age.

Inclusion and exclusion criteria

Articles were included when they met the following criteria: primary research using qualitative methods related to the lived experience of older adults aged 60 + (i.e. the experiences of individuals during the COVID-19 pandemic); peer-reviewed journal articles published in English; related to the COVID-19 pandemic; empirical research; published from 2020 till August 2022.

Articles were excluded when: papers discussed health professionals’ experiences; diagnostics; medical studies; interventions; day-care; home care; or carers; experiences with dementia; studies including hospitals; quantitative studies; mixed-method studies; single-case studies; people under the age of 60; grey literature; scoping reviews, and systematic reviews. We excluded clinical/care-related studies as we wanted to explore the everyday experiences of people aged 60 + . Mixed-method studies were excluded as we were interested in what was represented in solely qualitative studies. However, we acknowledge, that mixed-method studies are valuable for future systematic reviews.

Meta-ethnography

The qualitative synthesis was undertaken by using meta-ethnography. The authors have chosen meta-ethnography over other methodologies as it is an inductive and interpretive synthesis analysis and is uniquely “suited to developing new conceptual models and theories” ([ 47 ], p 2), see also [ 48 ]. Therefore, it combines well with constructivist grounded theory methodology. Meta-ethnography also examines and identifies areas of disagreements between studies [ 48 ].

This is of particular interest as the lived experiences of older adults during the COVID-19 pandemic were likely to be diverse. The method enables the researcher to synthesise the findings (e.g. themes, concepts) from primary studies, acknowledging primary data (quotes) by “using a unique translation synthesis method to transcend the findings of individual study accounts and create higher order” constructs ([ 47 ], p. 2). The following seven steps were applied:

Getting started (identify area of interest). We were interested in the lived experiences of older adults worldwide.

Deciding what was relevant to the initial interest (defining the focus, locating relevant studies, decision to include studies, quality appraisal). We decided on the inclusion and exclusion criteria and an appropriate quality appraisal.

Reading the studies. We used the screening process described below (title, abstract, full text)

Determining how the studies were related (extracting first-order constructs- participants’ quotes and second-order construct- primary author interpretation, clustering the themes from the studies into new categories (Table 3 ).

Translating the studies into one another (comparing and contrasting the studies, checking commonalities or differences of each article) to organise and develop higher-order constructs by using constant comparison (Table 3 ). Translating is the process of finding commonalities between studies [ 48 ].

Synthesising the translation (reciprocal and refutational synthesis, a lines of argument synthesis (interpretation of the relationship between the themes- leads to key themes and constructs of higher order; creating new meaning, Tables 2 , 3 ),

Expressing the synthesis (writing up the findings) [ 47 , 48 ].

Screening and Study Selection

A 4-stage screening protocol was followed (Fig.  1 Prisma). First, all selected studies were screened for duplicates, which were deleted. Second, all remaining studies were screened for eligibility, and non-relevant studies were excluded at the preliminary stage. These screening steps were as follows: 1. title screening; 2. abstract screening, by the first and senior authors independently; and 3. full-text screening which was undertaken for almost all papers by the first author. However, 2 papers [ 9 , 23 ] were assessed independently by LS, LR, and LMM to avoid a conflict of interest. The other co-authors also screened independently a portion of the papers each, to ensure that each paper had two independent screens to determine inclusion in the review [ 49 ]. This avoided bias and confirmed the eligibility of the included papers (Fig.  1 ). Endnote reference management was used to store the articles and aid the screening process.

Prisma flow diagram adapted from Page et al. [ 50 ]. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ, 372, n71. https://doi.org/10.1136/bmj.n71 )

Data extraction

After title and abstract screening, 39 papers were selected for reading the full article. 7 papers were excluded after the full-text assessment (1 study was conducted in 2017, but published in 2021; 2 papers were not fully available in English, 2 papers did not address the research question, 1 article was based on a conference abstract only, 1 article had only one participant age 65 +).

The full-text screening included 32 studies. All the included studies, alongside the CASP template, data extraction table, the draft of this article, and translation for synthesising the findings [ 47 , 48 ] were available and accessible on google drive for all co-authors. All authors discussed the findings in regular meetings.

Quality appraisal

A critical appraisal tool assesses a study for its trustworthiness, methodological rigor, and biases and ensures “transparency in the assessment of primary research” ([ 51 ], p. 5); see also [ 48 , 49 , 50 , 51 , 52 , 53 ]. There is currently no gold standard for assessing primary qualitative studies, but different authors agreed that the amended CASPS checklist was appropriate to assess qualitative studies [ 46 , 54 ]. Thus, we use the amended CASP appraisal tool [ 42 ]. The amended CASP appraisal tool aims to improve qualitative evidence synthesis by assessing ontology and epistemology (Table 1 CASP appraisal tool).

A numerical score was assigned to each question to indicate whether the criteria had been met (= 2), partially met (= 1), or not met (= 0) [ 54 ]; see also [ 55 ]. The score 16 – 22 are considered to be moderate and high-quality studies. The studies scored 15 and below were identified as low-quality papers. Although we focus on higher-quality papers, we did not exclude papers to avoid the exclusion of insightful and meaningful data [ 42 , 48 , 52 , 53 , 54 , 55 , 56 , 57 ]. The quality of the paper was considered in developing the evidence synthesis.

We followed the appraisal questions applied for each included study and answered the criteria either ‘Yes’, ‘Cannot tell’, or ‘No’. (Table 1 CASP appraisal criteria). The tenth question asking the value of the article was answered with ‘high’ of importance, ‘middle’, or low of importance. The new eleventh question in the CASP tool concerning ontology and epistemology was answered with yes, no, or partly (Table 1 ).

Data synthesis

The data synthesis followed the seven steps of Meta-Ethnography developed by Noblit & Hare [ 58 ], starting the data synthesis at step 3, described in detail by [ 47 ]. This encompasses: reading the studies; determining how the studies are related; translating the studies into one another; synthesis the translations; and expressing synthesis. This review provides a synthesis of the findings from studies related to the experiences of older adults during the COVID-19 pandemic. The qualitative analyses are based on constructivist grounded theory [ 59 ] to identify the experiences of older adults during the COVID-19 pandemic (non-clinical) populations. The analysis is inductive and iterative, uses constant comparison, and aims to develop a theory. The qualitative synthesis encompasses all text labelled as ‘results’ or ‘findings’ and uses this as raw data. The raw data includes participant’s quotes; thus, the synthesis is grounded in the participant's experience [ 47 , 48 , 60 , 61 ]. The initial coding was undertaken for each eligible article line by line. Please see Table 2 Themes per author and country. Focused coding was applied using constant comparison, which is a widely used approach in grounded theory [ 61 ]. In particular, common and recurring as well as contradicting concepts within the studies were identified, clustered into categories, and overarching higher order constructs were developed [ 47 , 48 , 60 ] (Tables 2 , 3 , 4 ).

We identified twenty-seven out of thirty-two studies as moderate-high quality; they met most of the criteria (scoring 16/22 or above on the CASP; [ 54 ]. Only five papers were identified as low qualitative papers scoring 15 and below [ 71 , 73 , 74 , 86 , 91 ]. Please see the scores provided for each paper in Table 4 . The low-quality papers did not provide sufficient details regarding the researcher’s relationship with the participants, sampling and recruitment, data collection, rigor in the analysis, or epistemological or ontological reasoning. For example, Yildirim [ 91 ] used verbatim notes as data without recording or transcribing them. This article described the analytical process briefly but was missing a discussion of the applied reflexivity of using verbatim notes and its limitations [ 92 ].

This systematic review found that many studies did not mention the relationship between the authors and the participant. The CASP critical appraisal tool asks: Has the relationship between the researcher and participants been adequately considered? (reflecting on own role, potential bias). Many studies reported that the recruitment was drawn from larger studies and that the qualitative study was a sub-study. Others reported that participants contacted the researcher after advertising the study. One study Goins et al., [ 72 ] reported that students recruited family members, but did not discuss how this potential bias impacted the results.

Our review brings new insights into older adults’ experiences during the pandemic worldwide. The studies were conducted on almost all continents. The majority of the articles were written in Europe followed by North America and Canada (4: USA; 3: Canada, UK; 2: Brazil, India, Netherlands, Sweden, Turkey 2; 1: Austria, China, Finland, India/Iran, Mauritius, New Zealand, Serbia, Spain, Switzerland, Uganda, UK/Ireland, UK/Colombia) (see Fig.  2 ). Note, as the review focuses on English language publications, we are unable to comment on qualitative research conducted in other languages see [ 72 ].

Numbers of publications by country

The characteristics of the included studies and the presence of analytical themes can be found in Table 4 . We used the following characteristics: Author and year of publication, research aims, the country conducted, Participant’s age, number of participants, analytical methodology, CASP score, and themes.

We identified three themes: desired and challenged wellbeing; coping and adaptation; discrimination and intersectionality. We will discuss the themes in turn.

Desired and challenged wellbeing

Most of the studies reported the impact of the COVID-19 pandemic on the well-being of older adults. Factors which influenced wellbeing included: risk communication and risk perception; social connectivity; confinement (at home); and means of coping and adapting. In this context, well-being refers to the evidence reported about participants' physical and mental health, and social connectivity.

Risk perception and risk communication

Politicians and media transmitted messages about the response to the pandemic to the public worldwide. These included mortality and morbidity reports, and details of health and safety regulations like social distancing, shielding- self-isolation, or wearing masks [ 34 , 35 , 36 , 37 ]. As this risk communication is crucial to combat the spread of the virus, it is also important to understand how people perceived the reporting during the pandemic.

Seven studies reported on how the mass media impacted participants' well-being [ 23 , 67 , 68 , 70 , 72 , 81 , 85 ]. Sangrar et al. [ 68 ] investigated how older adults responded to COVID-19 messaging: “My reaction was to try to make sure that I listen to everything and [I] made sure I was aware of all the suggestions and the precautions that were being expressed by various agencies …”. (p. 4). Other studies reported the negative impact on participants' well-being of constant messaging and as a consequence stopped watching the news to maintain emotional well-being [ 3 , 67 , 68 , 70 , 72 , 81 , 85 ]. Derrer-Merk et al. [ 23 ] reported one participant said that “At first, watching the news every day is depressing and getting more and more depressing by the day, so I’ve had to stop watching it for my own peace of mind” (p. 13). In addition, news reporting impacted participants’ risk perception. For example, “Sometimes we are scared to hear the huge coverage of COVID-19 news, in particular the repeated message ‘older is risky’, although the message is useful.” ([ 81 ], p5).

• Social connectivity

Social connectivity and support from family and community were found in fourteen of the studies as important themes [ 9 , 62 , 66 , 67 , 68 , 75 , 76 , 77 , 78 , 79 , 80 , 83 , 84 , 90 ].

The impact of COVID-19 on social networks highlighted the diverse experiences of participants. Some participants reported that the size of social contact was reduced: “We have been quite isolated during this corona time” ?([ 80 ], p. 3). Whilst other participants reported that the network was stable except that the method of contact was different: “These friends and relatives, they visited and called as often as before, but of course, we needed to use the telephone when it was not possible to meet” ([ 77 ], p. 5). Many participants in this study did not want to expand their social network see also [ 9 , 77 , 78 , 79 ]. Hafford-Letchfield et al. [ 76 ] reported that established social networks and relationships were beneficial for the participants: “Covid has affected our relationship (with partner), we spend some really positive close time together and support each other a lot” (p. 7).

On the other hand, other studies reported decreases of, and gaps in, social connectedness: “I couldn’t do a lot of things that I’ve been doing for years. That was playing competitive badminton three times a week, I couldn’t do that. I couldn’t get up early and go volunteer in Seattle” [ 9 , 67 , 75 ]. A loss of social connection with children and grandchildren was often mentioned: “We cannot see our grandchildren up close and personal because, well because they [the parents] don’t want us, they don’t want to risk our being with the kids … it’s been an emotional loss exacerbated by the COVID thing” ([ 68 ] p.10); see also [ 9 , 67 , 78 ]. On the contrary, Chemen & Gopalla [ 66 ] note that those older adults who were living with other family members reported that they were more valued: “Last night my daughter-in-law thanked me for helping with my granddaughter” (p.4).

Despite reports of social disconnectedness, some studies highlighted the importance of support from family members and how support changed during the COVID-19 pandemic [ 9 , 62 , 81 , 83 , 90 ]. Yang et al. [ 90 ] argued that social support was essential during the Lockdown in China: “N6 said: ‘I asked my son-in-law to take me to the hospital” (p. 4810). Mahapatra et al. [ 81 ] found, in an Indian study, that the complex interplay of support on different levels (individual, family, and community) helped participants to adapt to the new situation. For example, this participant reported that: “The local police are very helpful. When I rang them for something and asked them to find out about it, they responded immediately” (p. 5).

Impact of confinement on well being

Most articles highlighted the impact of confinement on older adults’ well-being [ 9 , 62 , 63 , 65 , 67 , 69 , 70 , 72 , 75 , 77 , 78 , 79 , 81 , 82 , 83 , 85 , 89 , 90 ].

Some studies found that participants maintained emotional well-being during the pandemic and it did not change their lifestyle [ 79 , 80 , 82 , 83 , 89 , 92 ]: “Actually, I used this crisis period to clean my house. Bookcases are completely cleaned and I discarded old books. Well, we have actually been very busy with those kind of jobs. So, we were not bored at all” ([ 79 ], p. 5). In McKinlay et al. [ 82 ]’s study, nearly half of the participants found that having a sense of purpose helped to maintain their well-being: “You have to have a purpose you see. I think mental resilience is all about having a sense of purpose” (p. 6).

However, at the same time, the majority of the articles (12 out of 18) highlighted the negative impact of confinement and social distancing. Participants talked of increased depressive feelings and anxiety. For example, one of Akkus et al.’s [ 62 ] participants said: “... I am depressed; people died. Terrible disease does not give up, it always kills, I am afraid of it …” (p. 549). Similarly, one of Falvo et al.’s [ 67 ] participants remarked: “I am locked inside my house and I am afraid to go out” (p. 7).

Many of the studies reported the negative impact of loneliness as a result of confinement on participants’ well-being including [ 69 , 70 , 72 , 78 , 79 , 90 , 93 ]. Falvo et al. [ 67 ] reported that many participants experienced loneliness: “What sense does it make when you are not even able to see a family member? I mean, it is the saddest thing not to have the comfort of having your family next to you, to be really alone” (p. 8).

Not all studies found a negative impact on loneliness. For example, a “loner advantage” was found by Xie et al. ([ 82 ], p. 386). In this study participants found benefits in already being alone “It’s just a part of who I am, and I think that helps—if you can be alone, it really is an asset when you have to be alone” ([ 82 ], p. 386).

Bundy et al. [ 80 ] investigated loneliness from already lonely older adults and found that many participants did not attribute the loneliness to the pandemic: “It’s not been a whole lot, because I was already sitting around the house a whole lot anyway ( …). It’s basically the same, pretty well … I’d pretty well be like this anyway with COVID or without COVID” (p. 873) (see also [ 83 ]).

A study from Serbia investigated how the curfew was perceived 15 months afterward. Some participants were calm: “I realized that … well … it was simply necessary. For that reason, we accepted it as a measure that is for the common good” ([ 70 ], p.634). Others were shocked: “Above all, it was a huge surprise and sort of a shock, a complete shock because I have never, ever seen it in my life and I felt horrible, because I thought that something even worse is coming, that I even could not fathom” ([ 70 ], p. 634).

The lockdowns brought not only mental health issues to the fore but impacted the physical health of participants. Some reported they were fearful of the COVID-19 pandemic: “... For a little while I was afraid to leave, to go outside. I didn’t know if you got it from the air” ([ 75 ]. p. 6). Another study reported: “It’s been important for me to walk heartily so that I get a bit sweaty and that I breathe properly so that I fill my lungs—so that I can be prepared—and be as strong as possible, in case I should catch that coronavirus” ([ 77 ], p. 9); see also [ 70 , 78 , 82 , 85 ].

Coping and adaptation

Many studies mentioned older adults’ processes of coping and adaptation during the pandemic [ 63 , 64 , 68 , 69 , 72 , 75 , 79 , 81 , 85 , 87 , 88 , 89 , 90 ].

A variety of coping processes were reported including: acceptance; behavioural adaptation; emotional regulation; creating new routines; or using new technology. Kremers et al. [ 79 ] reported: “We are very realistic about the situation and we all have to go through it. Better days will come” (p. e71). Behavioural adaptation was reported: “Because I’m asthmatic, I was wearing the disposable masks, I really had trouble breathing. But I was determined to find a mask I could wear” ([ 68 ], p. 14). New routines with protective hygiene helped some participants at the beginning of the pandemic to cope with the health threat: “I am washing my hands all the time, my hands are raw from washing them all the time, I don't think I need to wash them as much as I do but I do it just in case, I don’t have anybody coming in, so there is nobody contaminating me, but I keep washing” ([ 69 ], p. 4391); see also [ 72 ]. Verhage et al. [ 87 ] reported strategies of coping including self-enhancing comparisons, distraction, and temporary acceptance: “There are so many people in worse circumstances …” (p. e294). Other studies reported how participants used a new technology: “I have recently learned to use WhatsApp, where I can make video phone calls.” ([ 88 ], p. 163); see also [ 89 ].

Discrimination -intersectionality (age and race/gender identity)

Seven studies reported ageism, racism, and gender discrimination experienced by older adults during the pandemic [ 23 , 63 , 67 , 70 , 76 , 84 , 88 ].

Prigent et al. [ 84 ], conducted in a New Zealand study, found that ageism was reciprocal. Younger people spoke against older adults: “why don’t you do everyone a favour and drop dead you f******g b**** it’s all because of ones like you that people are losing jobs” (p. 11). On the other hand, older adults spoke against the younger generation: “Shame to see the much younger generations often flout the rules and generally risk the gains made by the team. Sheer arrogance on their part and no sanctions applied” (p.11). Although one study reported benevolent ageism [ 23 ] most studies found hostile ageism [ 23 , 63 , 67 , 70 , 76 , 84 ]. One study from Canada exploring 15 older adult’s Chinese immigrants’ experiences reported racism as people around them thought they would bring the virus into the country. The negative impact on existing friendships was told by a Chinese man aged 69 “I can tell some people are blatantly despising us. I can feel it. When I talked with my Caucasian friends verbally, they would indirectly blame us for the problem. Eventually, many of our friendships ended because of this issue” ([ 88 ], p161). In addition, this study reported ageism when participants in nursing homes felt neglected by the Canadian government.

Two papers reported experiences of sexual and gender minorities (SGM) (e.g. transgender, queer, lesbian or gay) and found additional burdens during the pandemic [ 63 , 76 ]. People experienced marginalisation, stereotypes, and discrimination, as well as financial crisis: “I have faced this throughout life. Now people look at me in a way as if I am responsible for the virus.” ([ 63 ], p. 6). The consequence of marginalisation and ignorance of people with different gender identities was also noted by Hafford- Letchfield et al. [ 76 ]: “People have been moved out of their accommodation into hotels with people they don't know …. a gay man committed suicide, community members know of several that have attempted suicide. They are feeling pretty marginalised and vulnerable and you see what people are writing on the chat pages” (p.4). The intersection of ageism, racism, and heterosexism and its negative impact on people’s well-being during the pandemic reflects additional burden and stressors for older adults.

This systematic literature review is important as it provides new insights into the lived experiences of older adults during the COVID-19 pandemic, worldwide. Our study highlights that the COVID-19 pandemic brought an increase in English-written qualitative articles to the fore. We found that 32 articles met the inclusion criteria but 5 were low quality. A lack of transparency reduces the trustworthiness of the study for the reader and the scientific community. This is particularly relevant as qualitative research is often criticised for its bias or lack of rigor [ 94 ]. However, their findings are additional evidence for our study.

Our aim was to explore, in a systematic literature review, the lived experiences of older adults during the COVID-19 pandemic worldwide. The evidence highlights the themes of desired and challenged wellbeing, coping and adaptation, and discrimination and intersectionality, on wellbeing.

Perceived risk communication was experienced by many participants as overwhelming and anxiety-provoking. This finding supports Anwar et al.’s [ 37 ] study from the beginning of the pandemic which found, in addition to circulating information, that mass media influenced the public's behaviour and in consequence the spread of disease. The impact can be positive but has also been revealed to be negative as well. They suggest evaluating the role of the mass media in relation to what and how it has been conveyed and perceived. The disrupted social connectivity found in our review supports earlier studies that reported the negative impact of people’s well-being [ 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 ] at the beginning of the pandemic. This finding is important for future health crisis management, as the protective health measures such as confinement or self-isolation had a negative impact on many of the participants’ emotional wellbeing including increased anxiety, feelings of depression, and loneliness during the lockdowns. As a result of our review, future protective health measures should support people’s desire to maintain proximity with their loved ones and friends. However, we want to stress that our findings are mixed.

The ability of older adults to adapt and cope with the health crisis is important: many of the reported studies noted the diverse strategies used by older people to adapt to new circumstances. These included learning new technologies or changing daily routines. Politicians and the media and politicians should recognise both older adults' risk of disease and its consequences, but also their adaptability in the face of fast-changing health measures. This analysis supports studies conducted over the past decades on lifespan development, which found that people learn and adapt livelong to changing circumstances [ 95 , 96 , 97 ].

We found that discrimination against age, race, and gender identity was reported in some studies, in particular exploring participants’ experiences with immigration backgrounds and sexual and gender minorities. These studies highlighted the intersection of age and gender or race and were additional stressors for older adults and support the findings from Ramirez et al. [ 98 ] This review suggests that more research should be conducted to investigate the experiences of minority groups to develop relevant policies for future health crises.

Our review was undertaken two years after the pandemic started. At the cut-off point of our search strategy, no longitudinal studies had been found. However, in December 2022 a longitudinal study conducted in the USA explored older adult’s advice given to others [ 99 ]. They found that fostering and maintaining well-being, having a positive life perspective, and being connected to others were coping strategies during the pandemic [ 100 ]. This study supports the results of the higher order constructs of coping and adaptation in this study. Thus, more longitudinal studies are needed to enhance our understanding of the long-term consequences of the COVID-19 pandemic. The impact of the COVID-19 restrictions on older adults’ lives is evident. We suggest that future strategies and policies, which aim to protect older adults, should not only focus on the physical health threat but also acknowledge older adults' needs including psychological support, social connectedness, and instrumental support. The policies regarding older adult’s protections changed quickly but little is known about older adults’ involvement in decision making [ 100 ]. We suggest including older adults as consultants in policymaking decisions to ensure that their own self-determinism and independence are taken into consideration.

There are some limitations to this study. It did not include the lived experiences of older adults in care facilities or hospitals. The studies were undertaken during the COVID-19 pandemic and therefore data collection was not generally undertaken face-to-face. Thus, many studies included participants who had access to a phone, internet, or email, others could not be contacted. Additionally, we did not include published papers after August 2022. Even after capturing the most commonly used terms and performing additional hand searches, the search terms used might not be comprehensive. The authors found the quality of the papers to be variable, and their credibility was in question. We acknowledge that more qualitative studies might have been published in other languages than English and were not considered in this analysis.

To conclude, this systematic literature review found many similarities in the experiences of older adults during the Covid-19 pandemic despite cultural and socio-economic differences. However, we stress to acknowledge the heterogeneity of the experiences. This study highlights that the interplay of mass media reports of the COVID-19 pandemic and the policies to protect older adults had a direct impact on older adults’ well-being. The intersection of ‘isms’ (ageism, racism, and heterosexism) brought an additional burden for some older adults [ 98 ]. These results and knowledge about the drawbacks of health-protecting measures need to be included in future policies to maintain older adults’ well-being during a health crisis.

Availability of data and materials

The systematic literature review is based on already published articles. And all data analysed during this study are included in this manuscript. No additional data was used.

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Elfriede Derrer-Merk contributed to the design, analysis, and writing the draft. Maria-Fernanda Rodriguez-Reyes contributed to the analysis, revised the draft, and approved the submission. Laura K. Soulsby contributed to the analysis, revised the draft, and approved the submission. Louise Roper contributed to the analysis, revised the draft, and approved the submission. Kate M. Bennett contributed to the design, analysis, writing the draft, and approved the submission.

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Derrer-Merk, E., Reyes-Rodriguez, MF., Soulsby, L.K. et al. Older adults’ experiences during the COVID-19 pandemic: a qualitative systematic literature review. BMC Geriatr 23 , 580 (2023). https://doi.org/10.1186/s12877-023-04282-6

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10 of the most common signs of depression in older adults

Posted: July 27, 2023 | Last updated: July 27, 2023

Depression is not an inherent part of aging: Here are 10 of the most common signs in older adults

The American Psychiatric Association defines depression as "a common and serious medical illness that negatively affects how you feel, the way you think, and how you act," resulting in, among other symptoms, "feelings of sadness and/or a loss of interest in activities you once enjoyed."

Mental illnesses should be approached with the same seriousness and urgency as any physical disease. Unfortunately, depression in older adults is frequently misdiagnosed, undertreated, or mistaken as a natural sign of a person's "slowing down" with age or enduring chronic age-related physical ailments , of which an estimated 80% of older adults have at least one.

Stacker compiled a list of 10 of the most common signs of depression in older adults using information from the National Institute on Aging and other scientific and medical sources. Identifying these symptoms and seeking timely professional help can significantly improve the quality of life of older adults.

While depression rates among older adults are lower than among younger people, a lack of access to accurate information greatly increases the likelihood that older adults do not understand what is happening to them or how to ask for help. Depression in older people is often tied to cognitive changes, changes in sleep patterns, and a general loss of interest , all of which can contribute to a significantly higher risk of isolation. Family members, friends, caregivers, and health professionals in contact with seniors must therefore be aware of the warning signs in order to offer support and treatment options.

According to the Centers for Disease Control and Prevention, most older adults do not report feeling depressed , though living conditions and a person's degree of social interaction play a major role. While cases of depression among the elderly living within a community range from less than 1% to 5%, 11.5% of hospitalized patients and 13.5% of those who receive home health care have reported depressive symptoms.

Most elderly patients suffering from depression do respond to anti-depressive drugs, psychotherapy, or a combination thereof. Symptoms are usually different in seniors than in younger adults—they are less likely to develop cognitive-affective symptoms, such as dysphoria, worthlessness, or guilt than younger patients, while insomnia, fatigue, psychomotor lethargy, loss of interest in living, and hopelessness tend to be more prevalent.

Extended periods of feeling sad, anxious, or 'empty'

Grief and sadness due to the loss of a loved one or other life events are normal at all ages, but can become especially acute among seniors who outlive their siblings and friends. If the older adult is sad, anxious, or mentions feeling empty for a long period of time—more than a few months—they might be experiencing dysthymia or depression.

Consistent feelings of hopelessness, helplessness, worthlessness, or guilt

According to a study published by the National Library of Medicine, "self-worthlessness [or] inadequacy is a distinctive and consistent symptom of major depression across all cultures." The onset of these feelings is also a distinct reproducible predictor of a person's risk of recurrence after overcoming an initial bout of depression.

Restlessness or irritability

Seniors may show signs of being agitated, busy, or short-tempered by manifesting consistent nervous behaviors. They can repeatedly tap their fingers against a table, fidget, or repeat movements. They may also fixate on specific daily tasks such as cleaning and organizing, moving objects from one place to another, or making up excuses to try to leave the house. These and other demonstrations of restlessness, while a common symptom in Alzheimer's patients, can also be a sign of depression, especially when combined with episodes of irritability.

Loss of interest in hobbies and other pleasurable activities

Social withdrawal and a loss of interest in hobbies and other activities previously found pleasurable is called anhedonia, a core symptom of depression. Anhedonia can present as a social or physical symptom; social anhedonia is a progressive disinterest in interpersonal relationships and a lack of comfort in social situations, while physical anhedonia is the inability to feel tangible pleasures such as eating or touching.

Loss of energy or fatigue

Fatigue can make simple daily activities, such as getting out of bed or getting dressed, too hard to perform. It can be a consequence of suffering one or several other symptoms of depression, such as sleeping problems, indigestion due to bad food choices, or stress. It can also be a symptom on its own. One 2018 study found that more than 90% of patients with depression report feeling fatigued .

Sluggishness or moving and talking more slowly

While fatigue is the feeling of being exhausted even after sleeping or resting, sluggishness or lethargy can be a mental condition that compromises the capacity to move nimbly, even if the patient is physically able and healthy. It can affect speech, movement, and reflexes.

Memory and decision-making issues

In older adults, the loss of executive functions, memory, and the ability to make decisions can be symptoms of different diseases or just a normal part of the aging process. A health professional must accurately diagnose the patient to discard brain conditions such as dementia, infectious diseases, and chronic illnesses before attributing these symptoms to depression .

Sleep irregularity, including waking up too early or sleeping too late

According to the Sleep Foundation : "People with depression may find it difficult to fall asleep and stay asleep during the night or experience periods of excessive daytime sleepiness." The organization states that sleep problems and vice versa can exacerbate depression; sleep problems can bring on depression. Either way, there is an undeniable link between depression and sleeping. The sleeping habits of seniors must be closely supervised to prevent mental and physical health problems.

Change in appetite, especially with unintentional weight gain or loss

It is common for older adults to have less appetite since they have lower energy requirements due to less physical activity. There are several reasons for the elderly to lose their appetite: dental issues, difficulty chewing and swallowing, side effects of prescription medications, and depression. A mental health exam is recommended if a senior loses their appetite and weight for no apparent reason. On the other hand, if the person starts eating excessively, it might be a sign of stress or anxiety, conditions often linked to depression as well.

Suicide ideation or suicide attempts

A 2021 primer on the relationship between suicide ideation and suicide attempts pointed to, among other sources, a study by the World Health Organization that found "two‐thirds of individuals with suicidal ideation never make a suicide attempt." Mental conditions, such as depression, are strongly linked to suicidal ideation, but are not necessarily associated with suicide attempts. Constantly monitoring the elderly and providing them with adequate care and medical help is critical, especially if they have ever expressed suicidal thoughts.

Additional research by Emilia Ruzicka. Story editing by Brian Budzynski. Copy editing by Kristen Wegrzyn. Photo selection by Clarese Moller.

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