Synopsis
Recognise later-life depression and anxiety behind cognitive, physical and functional presentations, assess suicide and safeguarding directly, distinguish loneliness without medicalising it, and combine accessible psychological, social and medicine care with physical-comorbidity safeguards.
- Later-life depression may present as loss of interest, fatigue, pain, poor appetite, sleep change, memory complaint, irritability or functional withdrawal rather than stated sadness.
- First-line assessment combines direct interview, collateral and a validated tool such as PHQ-9 or GDS; a score neither diagnoses nor assesses suicide alone.
- Ask directly about suicide at initial and follow-up review. Do not assume older age, faith, family presence or bereavement makes risk low.
- Use 4AT for acute change and assess cognition, physical disease, pain, sleep, alcohol, medicines, hearing, vision, grief, abuse and practical adversity.
- Loneliness is subjective disconnection; living alone is an objective arrangement. Neither automatically means depression, and social contact must match the person's preference.
- For less severe depression, first-line options include guided self-help, behavioural activation, structured exercise and psychological treatment chosen with the person.
- For more severe depression, NICE supports individual CBT plus an antidepressant when acceptable, with urgent specialist care for psychosis, catatonia or life-threatening intake failure.
- A cautious frail-adult sertraline regimen may start 25 mg daily and increase to 50 mg after about one week, with sodium, bleeding and falls review.
- Mirtazapine may suit selected insomnia or low-appetite phenotypes but sedation and posture can worsen falls; it is an antidepressant, not a social treatment for loneliness.
- Address hearing, transport, digital exclusion, bereavement, carer role and meaningful group or one-to-one connection alongside clinical therapy.
Key red flags
Ask directly about thoughts of death, self-harm, intent, plan, means, previous attempts, substance use, protective factors and current ability to remain safe.
New confusion, altered arousal or abrupt withdrawal is delirium until assessed and cannot be diagnosed as depression from a questionnaire.
Psychotic guilt, nihilistic delusion, starvation, stupor or severe psychomotor change requires urgent old-age psychiatry assessment.
Anxiety with chest pain, syncope, focal neurology, hypoxia, hypoglycaemia or thyroid symptoms needs parallel medical evaluation.
Bereavement does not protect against major depression or suicide; assess duration, pervasive symptoms, function, guilt and hopelessness.
Financial control, isolation by others, neglect or fear at home raises safeguarding concern rather than uncomplicated loneliness.
Intent, plan, means, psychosis, severe hopelessness or inability to maintain safety requires immediate action.
Nihilistic guilt, hallucination, stupor, mutism or refusal of intake requires urgent specialist treatment.
Investigation priorities
Establish syndrome, chronology and function.
Management branches
Persistent low mood, anxiety, withdrawal, somatic or cognitive complaint occurs.
- Optimise communication and assess suicide, psychosis, mania, delirium and immediate medical danger.
- Use clinical interview, collateral and validated screening with functional, medicine, physical and social assessment.
- Agree severity, goals and a psychological, social and if appropriate medicine plan with early review.