Depression in older people: when we mistake it for age itself

“Mum is old, that’s all. What is there to enjoy at eighty?”

A daughter said that to me. She had come for advice for herself, not for her mother. And there was so much tiredness and so much resignation in that sentence that I thought of her first. Only afterwards of the mother, who had spent the last nine months in an armchair, had stopped going to the shop, had stopped ringing her cousin, and answered every question by saying that everything was fine.

The belief that dullness in old age is natural is one of the most stubborn errors I meet. It isn’t true. Ageing does bring losses, pain, a narrower world and a poorer body. What it does not bring is a state in which nothing interests you any more, in which you cannot get yourself upright in the morning, in which it makes no difference to you whether you see next year. That is not old age. That is often depression – and in late life it responds to treatment just as well as it does at forty.

Why it is so often missed in older people

Three reasons overlap, and any one of them would be enough.

The first is expectation. When a person is old, their low mood surprises nobody. If a thirty-year-old doesn’t leave the flat for three months, everyone is alarmed; in an eighty-year-old we call it “she has settled down”.

The second is language. A generation that grew up when mental health was not spoken about rarely says it is sad. It says the back hurts, there is no appetite, there is tiredness, there is no sleep. The doctor receives a physical complaint and treats it physically – which is understandable and often right, except that something occasionally hides underneath.

The third is crowding. An older person often has three or four diagnoses, twelve medicines and fifteen minutes with the doctor. In that time you check blood pressure, not the question of whether anything still gives them pleasure.

Here a fourth reason joins in, quieter than the rest: shame. People who grew up when any mental difficulty marked a whole family do not speak about it even to their own children. Several times I have heard someone in their seventies say for the first time that they had felt this way at thirty-five too, and had told nobody then. So they carried it alone for forty years.

What we hear, and what may lie beneath it

In my room I notice that older people almost always speak about depression indirectly. They don’t say “my soul is heavy”, they say something that sounds like a conclusion about life in general. And that is exactly why it is so easy to nod and move on.

The body is often an accomplice here

Now something we therapists skip over too quickly. In an older person, a state that looks like depression really can be partly or wholly fed by the body. Thyroid disorders, low vitamin B12 or iron, poorly controlled pain, heart failure, the aftermath of a stroke, sleep broken by apnoea, and also the side effects or interactions of medicines – all of these can produce fatigue, slowing and dullness.

I am not going to write about what points to what, because that is not my job and it would be irresponsible. I can write only this, and I think it is enough: when an older person’s mood, energy, sleep or appetite changes over a few months, a doctor is the first stop, not a therapist. Not because therapy wouldn’t help, but because it makes sense first to rule out what can be put right by treating the body. I have written about when that order really applies in the piece on when a doctor comes first.

And what about dementia

This is the question relatives ask most. Mum can’t recall names, loses the thread of a conversation, can’t find her keys – is this the beginning of dementia?

What I can say without stepping onto someone else’s ground is this: depression in later life really can affect memory, concentration and speed of thinking so markedly that the picture looks like cognitive decline. Older literature called it depressive pseudodementia. When the depression is treated, that decline often improves at least in part. This matters, because it means the answer “well, it’s dementia, nothing can be done” is not necessarily right.

What I will not do is hand you criteria for telling them apart. Distinguishing depression, mild cognitive impairment and early dementia is demanding even for specialists; it is done through examination, testing and time, and every attempt at judging it at the kitchen table does more harm than good. The right step is a referral to a memory clinic or a psychiatrist. I have written about what a diagnosis is and is not in the piece a diagnosis is a map, not a name.

The losses that come one after another

At seventy or eighty, events that at forty would have been experienced as an upheaval arrive in a queue. A partner dies. The friend she spoke to every Thursday dies. The driving licence ends. The flat becomes too much. A daughter moves to another town. Each of these is a loss – not only of a person, but of a role and of a self-evident place in the world.

Grieving over this is normal and is not an illness; I have written about grief being a process rather than a state in this piece. Depression appears when the process gets stuck: when the person no longer opens up even for visitors, when interest disappears in things that have nothing to do with the loss, when they begin withdrawing from every contact at once. I have set out the difference between sadness and depression in more detail in depression is not sadness.

Suicide in old age is spoken about too little

Something that surprises the public: in most European countries, Slovenia included, the highest suicide rates are among older men, not among the young. These are often people who saw their own doctor a few weeks earlier – and there they said that they were in pain and were not sleeping, but not what they were thinking.

So: if an old person says that they are no longer needed, that it would be easier for everyone, that they would like it to end – that is not a philosophical remark about mortality and it is not a reason to change the subject. Ask directly and calmly. And find help the same day, even if you are told you are overreacting.

What helps

Psychotherapy works with older people. That is not a polite sentence. Reviews of the research show that effects in people over sixty are comparable to those in younger adults, both in cognitive behavioural therapy and in other structured approaches. The belief that at this age “nothing can be changed any more” does not come from the data; it comes from prejudice.

In my own work with families, I deal mostly with what has quietly rearranged itself between them. When a parent weakens, roles invert: the daughter becomes the one who decides, the father the one who obeys. This is painful for both, and both stay silent about it, because it seems ungrateful to speak. When it finally is spoken, something that had been stifling everyone often loosens in the house.

Very concretely, three things also help: a steady daily rhythm with a fixed waking time, at least a short trip out into daylight, and at least one reliable weekly contact that does not have to be arranged afresh each time. Loneliness in older people is not merely unpleasant – it is linked to a measurably higher risk of poorer health and shorter survival.

Where my argument does not hold

Now the part I would like to stay with you. I argue that dullness in old age should not be put down to the years. But the opposite error exists and is just as harmful.

First: some people really do settle in later life, narrow their circle and want less happening – and are content with that. A ninety-year-old who most enjoys sitting by the window watching the garden is not depressed, if she feels well doing it and brightens when someone visits. Withdrawal is not in itself a symptom. The symptom is the loss of pleasure, not the loss of pace.

Second: in a person with several illnesses, pain and poor mobility, some fatigue and low mood is a realistic response to genuinely hard circumstances. If we offer such a person only a psychological explanation, we are telling them their troubles are in their head. They are not.

And third: therapy cannot replace what is missing from a life. If an old person sees nobody five days a week, a weekly conversation with me will help less than a neighbour who comes for coffee. Sometimes the right answer is a day centre, a volunteer or a lift to the shop, not therapy. I say this to families too, when they would like me to sort out something that can only be sorted out by someone being there.

How to start the conversation

Not with the question “are you depressed?”. For many of that generation the word means madness or weakness, and it will close the conversation before it starts.

Better to begin with an observation and with time. “I’ve noticed you haven’t rung Milena for a long while. You used to speak every week.” Then silence. If an answer comes, don’t correct it and don’t argue: an old person who says they are no use to anyone doesn’t need a list of evidence to the contrary, but someone who acknowledges that this is a dreadful feeling and stays beside them. Persuasion is almost always quick and almost always unsuccessful.

And then a concrete step, a small one: an appointment with the doctor that you go to together. For many people that step is not accomplished by motivation but by company.

One more thing is worth knowing: the first conversation is often not the one in which anything moves. An old person who spent decades being the one who held the family together will not admit on a Friday afternoon that they can no longer manage. But three weeks later, in a second similar conversation, they may say something they hadn’t said before. Persistence without pressure is more effective here than a single serious talk that everyone prepares for and that ends in resentment.

What to remember

Dullness, loss of pleasure and a sense of uselessness are not part of ageing. Ageing brings losses, not an emptiness that lasts for months and responds to nothing.

In an older person, depression often announces itself through the body and through memory, not through the word “sad”. That is why the road almost always begins with a doctor – so that whatever the body and the medicines may be contributing can be looked at.

A change in memory and concentration is not necessarily dementia; depression can produce a similar picture and, unlike dementia, often improves. But telling them apart is not a matter for judgement at home.

Therapy works about as well in older people as in younger ones. And sometimes the most useful thing is not therapy at all: someone who comes on Wednesday at ten, because they come every Wednesday at ten.