Depression is not a part of normal aging and may present atypically. Feelings of sadness may not be the primary symptom of depression in older adults, leaving medical providers less likely to recognize its presence. Depression may present as general complaints, fatigue, insomnia or increased irritability. Correct diagnosis may be challenging as comorbid conditions, such as heart disease, stroke, or cancer, may be intertwined with depressive symptoms. Additionally, some older adults may be taking medications with side effects that contribute to depression or cause symptoms such as fatigue. The diagnosis of depression may be overlooked while focusing on the patient's acute or other chronic medical conditions.

Strategies to improve care for older adults with depression:

1. Take a careful history.

• Note the onset of the depression and the time course of symptoms.  Contact a caregiver or family member, if possible and with patient consent, to gather additional information.

2. Learn more about the person. 

• What matters most at this point in their life?  How is he/she coping and who is helping?  Are there recent stressors such as loss or illness of a loved one, serious diagnosis, caregiver or financial stress, loss of independence, or a recent move?

3. Determine the need for emergency behavioral health services.

• Is there suicidal or homicidal ideation?  Is there inability to perform self-care due to psychiatric symptoms?

4. Assess depression using a screening tool.

• These include the Patient Health Questionnaire (PHQ2 and PHQ 9) and Geriatric Depression Scale (Short Form).

5. Identify cognitive impairment as this increases the risk of depression and anxiety.

6. Identify additional behavioral and psychiatric health needs

• These may include substance use disorders, anxiety, post-traumatic stress disorder, social isolation, or loneliness.  Access other health care team members to gather information and help guide care.

7. Address concurrent medical problems. 

• Identify medical illnesses which may increase the chance of depression (e.g. cerebrovascular disease, Parkinson's disease, hypothyroidism, pain).  Identify concurrent geriatric syndromes such as falls, sensory deficits, delirium, incontinence, weight loss, malnutrition, and fatigue as these syndromes may worsen mood disorders.

8. Review the medication list and understand patient adherence to taking medication.

9. Determine if there are losses in function which need to be supported. 

• Involve a social worker, if available, to identify helpful community resources (e.g. mobile meals, home health care, community day sites).