Dealing with Depression in Later Life

By Mary Ellen Copeland

Depression is the most common psychiatric disturbance in the elderly.

15-25% of the elderly are depressed. The number increases if there is chronic illness or the person is in a nursing homes-it far exceeds the frequency of Alzheimer's Disease.

Since 12% of the population is now over 65 and that number is expected to double in the next 50 years, attention need to be focused on how to improve the quality of life for this important segment of the population.

Depression in the elderly has not been studied intensively. It is often masked by organic disease.

There is a need for improvement in identification of depression in the elderly.

It is life threatening. It may be the precursor of suicide. 10-15% of people with major depression commit suicide. The risk of suicide increases with age.

Social issues that contribute to depression in the elderly and keep them from getting appropriate treatment:

• Our society focuses on and values youthfulness--the capacities and attributes of the elderly are consistently underrated and undervalued in our society.
• Older people may feel that their life is meaningless-that they no longer have value.
• They were taught to be independent and feel they should be able to take care of themselves and their own problems.
• They are not comfortable talking about, and tend to minimize, symptoms that have emotional or psychological components. Stigma worsens this problem.
• They fear of hospitalization, particularly psychiatric hospitalization.
• Loss related to age--family, friends, work, physical loss of abilities, appearance, home, self esteem, role, social status, support network--is a strong contributing factor.
• There are no longer have extended families that provide meaning, support and care.
• Depression may be worsened by poor health, poor diet, lack of exercise, light, money and social support.
• Elder abuse is sometimes a factor.

These issues are compounded because:

• The diagnostic procedure is complex, especially if there are medical problems which are common in the elderly.
• It's difficult to draw the line between what is depression and what is sadness connected to disappointment and loss.
• Symptoms such as apathy, asthenia, memory disorders and deterioration are viewed as part of the aging process when it is in fact depression.
• The elderly are afraid to talk about the confusion and memory loss of depression because they think it might be Alzheimer's.

Consequently, it is estimated that only 25% of the depressed elderly receive appropriate care.

The positive side of this picture is:

There is lots of hope. Many older people who have had short or long and even repeated episodes of depression have gotten well and stayed well for long periods of time. They are happy, healthy and enjoy being alive.

When is treatment necessary?

Treatment is necessary if:

• pain and sadness connected to a specific event last too long
• sadness, disappointment and loss persistently affect daily activities of work, study, family, leisure activities, social activities
• they have some of the following symptoms:
  • weight loss (not usual but occasional weight gain)
  • hypersomnia or insomnia
  • anorexia
  • constipation
  • agitation and anxiety
  • fatigue-loss of energy
  • isolation
  • lack of sexual interest-may lead to impotence in males
  • decline in personal hygiene
  • apathy
  • psychomotor restlessness
  • hypochondriac fears
  • feelings of loss of self esteem
  • delusions of ruin and poverty
  • confusion-psuedodementia
  • memory problems

Depression is more common if there is a previous episode or episodes of depression and if there is a family history of mood instability or alcoholism. Family members and supporters need to watch for subtle changes as the person may be unaware of symptoms or be willing to report them.

A complete physical examination as soon as symptoms are noticed is absolutely essential. There are numerous medical disorders that are easily treated that can cause depression in the elderly. To assist the physician or treatment team in making an accurate diagnosis, give the physician a complete record of all symptoms, all medications and health care preparations being used for any purpose, a personal medical history and a medical history of the family. Include information on any recent changes or losses.

People with depression need to be included in the decision making process at all times. Their wishes need to be respected and if possible, honored.

Doctors and health care professionals should talk directly to them as much as possible while keeping supporters informed. They should never be talked down to or patronized. They should be treated with courtesy, dignity and respect in all circumstances. Nothing should be done for people that they can't do for themselves.

Family members, care givers and health care professionals need to be sure that the person is not been abused or neglected.

What will help

Education--Family members and supporters need to learn all they can about depression. This facilitates good decision making about treatment, care, support, lifestyle, living space, and activities. It gives the information needed to ask health care professionals the right questions.

Addressing Lifestyle Issues--Are there issues in the person's life that need to be addressed and changes that need to be made?

Diet--Poor diet can cause or worsen depression. Is the person able to purchase and prepare healthy food? Do they do this? If they can't or don't, what can be done to remedy this situation.

If they usually prepare food for themselves, others may need to prepare food for them until they are feeling better. People need to have three healthy meals a day that contain complex carbohydrates and protein. The health care team may recommend specific food supplements. Caffeine and sugar intake should be limited. Issues of excessive use of alcohol need to be addressed.

Exercise--While physical disabilities may hamper movement, older people need to get as much exercise and keep as active as possible. Movement increases feelings of well-being and is a cheap and effective anti-depressant.

Light--The strong connection between depression and light through the eyes has been discovered in recent years. Fluorescent lighting fixtures should be fitted with full spectrum light bulbs. There should be daily time outdoors. Indoor space should be light and sunny. Spending time near windows helps. If the depression has a seasonal component, a light box might alleviate the problem.

Electromagnetic Radiation--Avoid excessive exposure to electromagnetic fields. Warm comforters should be used instead of electric blankets. Electric blankets can be used to warm the bed before getting in. Hot water bottles should be used instead of heating pads.

Meaningful Activity--Is the person engaged in some meaningful and enjoyable activity as much as possible- at least some time every day? Helping a person find creative activities that make use of their abilities and talents and making it possible for them to engage in these activities can make a big difference. Perhaps volunteer work would be possible.

Support--Lack of social support has a negative effect on other stressing events and can worsen depression. Everyone needs someone else to listen to them. The greatest gift one person can give another is listening time.

Supporters should avoid criticism and judgments and only give advise and feedback when it is requested.

Does the person have daily contact with others they like and who are supportive- people who will listen to them? If they don't, how could this situation be improved? Could the person get out to church and other activities? How could a system of social support be arranged?

Living Space--Does the person have a comfortable, secure place to live that they enjoy-a place that feels like home to them? If not, how could this situation be improved?

When relocating, those who freely choose where they will live have less adjustment problems, as do those in centers that have specific preventive plans to help them accept and adjust to a new environment.

Relaxation--There are a variety of relaxation and stress reduction activities that elders may find helpful. They include:

• meditation or prayer
• listening to music
• looking at pleasant scenes or art
• body scan exercises
• guided imagery

These exercises need to be practised daily to be effective.

Medications--Medications are a choice in treating depression. However, in later life there is an increased sensitivity to medication and an increased incidence of untoward effects due to aging differences in absorption, distribution, metabolism and elimination of drugs. Therefore doctors start with lower doses and increase them more gradually. This makes it essential that family members and other supporters monitor the person closely, and be especially aware of early signs of Tardive's Dyskinesia. Patients and supporters need to learn about the medications and possible side effects before they are administered. The medications must be carefully managed.

There are many "alternative" therapies such as food supplements and herbs that people have found to be effective with fewer side effects. A visit to a naturopathic physician can be less intimidating and very worthwhile.

To avoid medication problems:

• take medications only on the recommendation of a trusted health care professional and using them only as prescribed
• be aware of possible side effects including Tardives Dyskinesia and reporting them to the physician
• consistently using the same pharmacist for all prescriptions to avoid problems with drug interactions
• developing and using systems to be sure the medication is taken regularly
• report any lapses in medication treatment to the physician
• insist on regular blood testing
• pay close attention to lifestyle issues such as diet, exercise, light and rest
• avoid the use of alcohol while taking psychiatric medications

Counseling--Counseling with an an empathetic therapist can help if a person is willing to do this. It probably will not help if a person is forced or coerced into going. The counseling relationship must be based on mutual rapport. It should provide validation, empathy, support and advice. Shame, blame or guilt should not be part of the counseling process.

Therapy works well when the person has good powers of insight. Self observation may help the person to cope better with various traumas and loss that are part of old age. Difficulties, limitation and problems connected with age must be taken into account and not minimized. Home visits may enhance the therapists understanding of presenting problems.

Hospitalization--Hospitalization is usually not the treatment of choice. It is only used:

• to prevent suicide
• for safety and protection
• if supporters cannot provide care
• when medications need to be closely monitored-especially when they are first administered
• if the person is agitated or out of touch with reality

Guidelines for Dealing with Depression in the Elderly

Suicide in the Elderly

Suicide attempts in the elderly are very serious in both medical and psychological terms. They tend to be very determined to die and use methods which tend to insure their success. Failure is most often due to the unforeseen intervention of others.

• Highest rates of suicide are among those over 60, especially men. They use "harder" methods.
• Elders may allow themselves to die through neglect, refusing food, not taking medications, etc.
• They are not as apt as younger people to tell others of their intention.

Suicide Risk Factors

Family members, health care providers and other supporters should be aware of the following suicide risk factors:

• 27 of 30 suicides were by people who had been diagnosed with depression
• divorce, widowhood or single status--marriage has a minimizing effect
• males are at high risk within six months after the loss of a partner
• lower socioeconomic status
• retirement of those who have few other interests
• living in a urban area
• persistent insomnia
• marked feelings of guilt and inadequacy
• estrangement from family and friends
• extreme isolation
• hypochondriac delirium
• agitation
• alcoholism
• organic mental dysfunction
• depression induced by a physical disorder
• painful, debilitating and/or terminal illness
• the threat of extreme dependency or institutionialization

Suicide Prevention

To prevent suicide and improve the quality of life, pay close attention to all lifestyle and health issues. In addition, give them lots of opportunities to express themselves. Let them talk as much as they want or need to. Work with them to develop a system of close supporters. Help them find meaningful things to do with their time. Work with health care providers to address sleep and anxiety issues. Medication and/or short term hospitalization may be necessary. Family members and health care professionals need to take preventive action, even if the person don't want them to-it may be necessary to save their life.

Information File and Treatment Plan

Keep all information on health care and depression, including information on medications and test results, in a special file for easy access.

Include in this file a plan of how the person would like to be treated and who is responsible for making treatment decisions in the event that they are unable to make decisions for themselves.

This plan includes:

• a list of symptoms which would indicate the person cannot make decisions for themselves
• family members, supporters and health care professionals they want to make decisions for them
• preferred, acceptable and unacceptable medications, treatments and treatment facilities.

Everyone who might be called on to make decisions needs to have a copy of this plan. Remember-even though the person may be deeply depressed, they need to feel that they are in control of their lives as much as possible.

Other articles by Mary Ellen Copeland