How to identify & support older clients with depression

What is depression? 

While it is common to feel sad from time to time, depression is a constant feeling of sadness and loss of interest, which stops you doing your normal activities. There are a range of different types of depression that exist and symptoms can be relatively minor to severe. The most common type of depression seen in older people is non-melancholic depression, which is often linked to either psychological factors, stressful life events or personality characteristics. However, if there has been a history of depression throughout a person’s life then there are likely to be genetic factors contributing to a depressive illness. Typically, depression does not result from a single event but is often seen as a result of a number of events or factors. To learn more about these insights, head here. 

What are the causes of depression in older people? 

Physical ill health:  

• There is a complex relationship between physical and mental wellbeing with many physical illnesses, such as cancer, thyroid disease, vitamin deficiencies and infections also causing depression via complex biological mechanisms. There is also increasing evidence that cerebrovascular disease is linked to later life depression.  
• Many chronic disease conditions can impact mobility and self-care, which often results in frustration, a sense of burden on others and fears of being institutionalised. 
• Several medications that are used to treat many physical conditions have been linked to depression, particularly some antihypertensives, steroids and pain medication.  

Social isolation and loneliness: 

• Many older people experience loneliness and social isolation, usually as a result of having to live alone, reduced close contact with family, and a lack of connection with their culture of origin or an inability to actively participate in the local community through lack of transport options. 
• When this occurs in combination with mobility issues or chronic disease it increases the risk of depression. 

Loss in older age: 

• Depression is commonly associated with both real and symbolic loss. As we age, it tends to be a period where our losses are cumulative and frequent.  
• While most older people are able to cope with the death of their partner, friends, pets, loss of independence, their health and impacts on their quality of life; for some, these cumulative losses can trigger depression.  

What are the typical signs of depression in older people? 

Unexplained physical symptoms: 

• If there are physical symptoms that cannot be adequately explained, then you need to consider depression, which may become more apparent on questioning. 
• Common symptoms can include insomnia, weight loss, dizziness, chronic pain or constipation. 
• It’s important to understand that older people may deny that there could be a psychosocial element to their presenting symptoms. 

Memory loss: 

• Depression can be commonly associated with memory loss, which sometimes ends up being the focus of the treatment rather than the depression itself.  
• In the absence of a diagnosis of dementia related pathology, memory loss can improve if the underlying depression is well managed.  

Behavioural changes: 

• Behavioural changes can be a warning sign that things aren’t right and should be considered as part of an overall assessment of an older person’s health and wellbeing. 
• Changes commonly associated with depression can include avoiding leaving home, refusal to eat, alcohol abuse, and hoarding behaviours. Preoccupations on changing their will, talking about death, giving away personal effects or taking an interest in firearms also indicate there may be mental health concerns.  

Why is it important to recognise older people with depressive symptoms? 

Depression is commonly not recognised and can go on for months or years if left untreated. Untreated depression can have many negative effects on a person’s life, including their engagement with podiatric treatment and management of their overall health, particularly if they have a number of chronic conditions.  Early identification and treatment of depression in older people can also reduce functional decline, prevent hospitalisations and improve overall quality of life.  

Many older people also perceive there is stigma associated with depression and are often unwilling to admit or talk about their feelings. Some older people believe that depression is a sign of weakness rather than appreciating that it is a medical condition. Therefore, it is really important that we identify potential symptoms early and actively encourage our older clients to seek support so that interventions can be implemented.  

What can podiatrists do to support our older clients who may be experiencing depression? 

We need to be aware that some older people find it difficult to talk about personal matters and they may never have really talked about how they are feeling, as this was not common practice when they were growing up. While others really worry what will happen to them as a result of sharing what is going on for them, they don’t want to be perceived as a burden or be treated differently. Some older people also worry that asking for help will be seen as a sign of weakness. 

It is important that we are regularly checking in with our older clients on how they are feeling and coping in general and make note of any changes that may be occurring. By beginning the conversation, you may be able to make a real difference in someone’s life by reducing the stigma associated with depression and providing them with the encouragement to seek professional support. If an older client does open up to you and share that they are struggling, then some useful conversation starters can include: 

• “I can see this is a really hard time for you.” 
• “I know it doesn’t feel like it now but there is hope that things can get better.” 
• “Have you thought about seeing your doctor about this?” 

Other strategies can include: 

• Incorporating and encouraging lifestyle changes such as diet, exercise and social activities into your management plans, and reinforcing positive actions. 
• Actively encouraging life-style changes from mid-life to prevent the risk of older age depression through reducing hypertension, cessation of smoking, and reducing cholesterol and lipid levels. 
• Referring for a medication review if clients are on medications known to increase the risk of depression. 
• Encourage strategies to reduce anxiety such as relaxation and mindfulness techniques.
• Encourage clients to regularly talk about their mood as part of your overall assessment and respond with respect but gently challenge negative thoughts by providing alternative perspectives. It is important to avoid dismissive statements such as, “It can’t be that bad”. 
• Having further resources and information about the causes of depression, range of treatment options and where to access help, readily available in your practice.