Anxiety and depression
Anxiety and depression are common in old age, they may coexist and they may be associated with neurological diseases such as stroke, dementia and Parkinson’s disease. Anxiety and depression significantly affect quality of life and wellbeing. Where anxiety and depression coexist, symptoms are more severe and are associated with poorer social functioning. 
Anxiety may be pre-existing, related to poor symptom control, management of care or fear of impending dying. Anxiety may present  as:
- generalised anxiety
- panic disorders
- social phobias
- agoraphobia (fear of open places).
Signs of anxiety in people with dementia may include:
- muscle tension, or
There is limited research into anxiety in the very old. Recognising anxiety is made more difficult because it is often associated with depression and / or dementia. Psychotherapies are recommended for anxiety, but may not be accessible to residents in aged care. Relaxation, touch and massage therapies may be helpful.
As residents with anxiety frequently have other health conditions the relative risks and benefits of medication need to be carefully assessed. Benzodiazepams are associated with increased risk of falls and are not recommended in the elderly. 
Depression is common in old age and is routinely screened for on admission to RAC and as part of all Aged Care Funding Instrument (ACFI) submissions. The ACFI requires depression to be assessed using the modified Cornell scale for depression; instructions for use are in the ACFI User Guide.
Older people with depression may experience the following:
- feeling emotionally empty, worthless
- increased irritability, worry and restlessness
- loss of interest in normal activities or interests
- persistent aches and pains that do not resolve with treatment
- difficulty concentrating or making decisions
- loss of hope for the future
- thoughts of suicide.
If a resident is taking several medications, a pharmacist review to identify medications that maybe contributing to depression is useful. Thyroid dysfunction and Vitamin B12 deficiency can cause depressive symptoms.
Current understanding of the relationship between depression and dementia
- The relationship between depression and dementia is very complex and is the subject of research. Depression may be a risk factor for dementia, and it may also be an early symptom of dementia. [4,5]
- Depression may be a risk factor for nursing home admission. Admission to a nursing home may be a cause depression in some residents. 
- There is support for the use of antidepressant medication to treat depression in people with dementia. The SSRI class of antidepressants is preferred over older medications as they are better tolerated. There is evidence that continuing treatment with antidepressants prevents relapses and recurrences of depression. 
- There is evidence that Rivastigmine may reduce symptoms of depression in people with dementia. 
- The way in which staff approach residents’ during activities may influence a resident’s mood. When staff show:
- direct positive engagement with the resident, the resident is more likely to actively engage with the activity and show pleasure
- the longer staff engage with the resident the longer they participate in the activity
- informal interactions from staff were shown to increase pleasure responses from residents. 
Existential distress is a term that refers to the emotional suffering of dying. It includes thoughts about the meaning of life, loneliness, loss of dignity and achieving life's goals.
Existential wellbeing may be seen as this “worldly” aspects of spirituality. Religious wellbeing represents the "other worldly” aspects of spirituality; the relationship between the person and a higher being. Existential distress may contribute to anxiety and depression whilst greater spiritual wellbeing is associated with greater psychosocial wellbeing. 
Dignity conserving therapy, person-centred care and respecting resident choices in care planning are all seen as ways of promoting emotional wellbeing. A number of psychotherapies have been shown to provide benefit in treating depression in the elderly. This includes Cognitive Behavioural Therapy (CBT) and reminiscence therapy though they may be less accessible to RAC residents. 
Pet therapy has been used in hospice and RAC and may provide an avenue for emotional connectivity for people with communication difficulties.  Studies on pet therapy have also been criticized for size, methodology and rigor. 
Groups with specific needs
Ageing holocaust survivors may experience high levels of anxiety around:
- normal ageing processes
- fear of the medical system
- reactivation of Post-Traumatic Stress Disorder with cognitive decline. 
Triggers that may reactivate distressing memories for holocaust survivors include:
- intravenous cannulae
- names and accents of health care workers.
It is suggested that other people who have survived genocide or torture and older Australian war veterans may also have late life emotional and psychological responses to previous trauma. Sensitively recording life history and being alert to indicators of exposure to past trauma are the keys to identifying needs.
There is little information published so far to inform the care of ageing survivors of later conflicts and genocide. CareSearch has information and resources that may be of use in an aged care context. A discussion of the current knowledge on caring for older people who may be affected by past traumas may be of interest. 
Sensitively asking “Is there anything else troubling you? Is there anything you would like to discuss?” when reviewing care needs allows the resident to explore these issues if he or she wishes to.