20th July 2023

Assessment and Diagnosis

Diagnosis in older adults may be more challenging, and it is thought that depression is underdiagnosed in this population. In addition, depression is associated with increased morbidity.

Depression presents with a variety of symptoms which can be psychological, physical, and social. Psychological symptoms include low mood, diminished interest or pleasure in activities, loss of energy or motivation and feelings of worthlessness. Physical symptoms include weight loss, significant changes in appetite and sleep disturbance. Social symptoms include withdrawing from friends and family and difficulties at home or work. In severe depression, there may also be features of psychosis.

The current NICE guidance refers to both DSM-IV and ICD-10 classification systems which are used to aid formal diagnosis, with its preferred system as DSM-IV. These systems have now been upgraded to DSM-V and ICD-11, respectively, though the NICE guideline has not yet been updated to reflect this.

Shared criteria of both systems are that they require one symptom to be either low mood or anhedonia, symptoms should be present for most of the day for at least two weeks and symptoms have a significant impact on function. They differ in the threshold number of symptoms and the ICD-11 includes hopelessness as a characteristic symptom, whereas it does not feature in the DSM-V. It is also worth noting that the updated DSM-V has removed bereavement as an exclusion and instead recommends clinical judgement, however the ICD-11 still includes it, with a certain threshold that must be met to diagnose a depressive episode superimposed on normal grief.

The classification criteria help determine the severity of depression (mild, moderate, and severe), based on the number of symptoms, along with the degree of functional impairment.

These diagnostic criteria are the same for older adults, as they are for younger patients. However, there are other tools that can help recognise and diagnose depression in older people. These include the Geriatric Depression Scale, Cornell Scale for Depression in Dementia, Patient Health Questionnaire-9.

The British Geriatric Society (BGS) gives guidance on Comprehensive Geriatric Assessment which includes reviewing the person’s mood and mental health. The BGS highlight the importance of exploring if the patient has any suicidal thoughts, as older adults with depression are at higher risk of completed (fatal) suicide than younger adults.