Depression in the Ederly
06/02/2013 08:12PM ● Published by Ashlee Cleveland
By: Dr. Robert J. Ritzema
Here’s a good thing about depression in the elderly: Most older adults never develop clinically significant depression. In fact, depression is less frequent in the elderly than in the general population.
However, here are some bad things about depression in older adults: depressive symptoms (just not full-fledged cases) are more common. Rates are elevated in some groups of elderly and depression often goes unrecognized later in life.
As many as 20 percent of elderly people experience depression at some point. Rates among those living in the community are relatively low—anywhere from 1 to 5 percent. Rates increase to 10-15 percent among community residents needing assistance in living and are as high as 30 percent among those confined to nursing homes.
Symptoms of depression can include feelings of sadness, lack of energy, decreased interest in things that would normally spark interest, weight loss or loss of appetite, sleep difficulties, withdrawal from others, feelings of worthlessness, preoccupation with death, or suicidal thoughts. More so than younger individuals who are depressed, the depressed elderly may have problems with confusion or impaired memory. Additional features common in the elderly can include increased physical complaints, deterioration in hygiene, irritability, and hopelessness. A person with several of these characteristics may well be depressed even if he or she denies feelings of sadness.
Sometimes it is difficult for physicians or mental health providers to diagnose depression because certain behaviors can be either signs of depression or signs of normal aging. For example, feelings of detachment, loss of interest in some activities, or a decrease in social involvement are characteristic of both. It is also difficult to distinguish depression from other medical conditions. Are increased somatic complaints due to depression or actual illness? Are problems with memory, concentration, and sleep due to depression or to early signs of dementia?
The causes of depression in the elderly are often similar to causes of depression at other ages. Broadly speaking, causes include biological factors, influences from past life events, and current stresses.
Genetic proclivity is an important biological risk factor for depression. Research suggests that the heritability of depression may be as high as 50%; in other words, genetic factors and non-genetic factors may contribute about equally to the likelihood that depression will occur. It appears that few cases are the result of single genes; instead, several genes incline a person to depression, and people differ in how many of these genes they inherit. Even if someone has a strong predisposition towards depression, other factors affect whether that tendency is manifest in actual depressive symptoms. That’s where the other causal factors—past influences and current stressors—become important.
Influences from the Past
One significant contributor to depression at any age is a history of childhood abuse. Sexual, physical, and emotional abuse have long term effects, often affecting the entire span of life. For example, a woman in her 60s whose father would fly into drunken rages still has vivid recollections of these episodes, feeling once again like a helpless child. These memories are associated with increased feelings of depression. Troubling events that occurred after childhood, especially those that produced permanent effects, can also result in late-life depression.
Our pasts affect more than just our memories. They shape our views of ourselves and of the world. They can lead to what one psychologist calls “early maladaptive schemas”, biased ways of thinking about oneself and others that lead to skewed perceptions or unwise decisions throughout life. They are like a tax that the past continues to levy throughout life. Thus, one person may have an incompetence schema, believing that they are unable to handle the ordinary tasks of life unless others help them. Another might have an abandonment schema, expecting that others won’t continue to provide care and support but will deliberately or unintentionally become unavailable. Such ways of thinking are resistant to change, and may become more rigid and extreme late in life. For example, one man with an incompetence schema managed to function reasonably well until he retired at age 69. Within a few years, he became extremely reliant on his wife and asked her for help and direction for even the simplest tasks. She found his constant requests unbearable and took a part-time job so that she would have time away from him. Shortly thereafter his mood became depressed.
Another avenue through which the past can instigate depression in the elderly is via a life review. Older adults are likely to reflect on the lives they have lived and to experience either satisfaction or dissatisfaction as a result. If one feels content with decisions made and proud of accomplishments, there is a sense of integrity and wholeness. On the other hand, if one regrets what he or she has done or failed to do, there is emptiness and despair. That emptiness and despair often takes the form of depression.
In addition to genetic predispositions and past experiences, current stressors can also contribute to depression in late adulthood. Some forms of stress associated with an increased risk of depression that are particularly likely to be present in late adulthood include:
· Medical problems. The risk of depression is elevated in those with chronic health problems, especially those that result in disability. In particular, there is an increased risk of depression associated with cardiovascular disease, stroke, diabetes, and chronic pain. Also, some medications can cause depression.
· Losses. The most damaging loss is that of a spouse, but losses of close friends and family members can also be quite troubling. Most grieving older adults are sad but not depressed; nonetheless, some do develop a full-fledged depressive disorder. Other losses that can have a significant impact on an older adult’s mood can include loss of one’s career, of status in the community, or of ability to perform valued activities.
· Powerlessness. A major reason that depression rates are elevated in nursing homes is that many decisions are made for residents and they have little control over their lives. Powerlessness is particularly stressful for those who had the greatest degree of power earlier in adulthood. White males are particularly likely to be affected; their loss of power contributes to a higher suicide risk for this group.
· Loneliness/Isolation. Here are the words of Steve, age 91 and living in a nursing home, as reported in the Marin Independent Journal: "Once we were very handsome and were chasing the girls away. Now no one seems interested in us except our caregivers, and that gets old, too. . . . My mind is spry and alert, but my body is decrepit. I get lonely often. Sometimes I even call my health-care provider and make up an excuse about my health so that I have the nurse to talk to.” As friends die off and mobility decreases, many of the oldest old spend their days sitting and waiting in vain for someone to visit. It’s not surprising that month after month of such isolation can lead to depression.
Since depression in the elderly may be difficult to distinguish from a variety of other conditions, it is important to obtain an evaluation from a professional who is experienced in assessing mental health problems in the elderly. Many physicians who work with older adults have the expertise to make such an assessment, as do many psychiatrists, psychologists, or clinical social workers. The provider’s specialty is usually not as important as their experience with emotional problems in the elderly. Once a diagnosis of depression has been made, treatment typically involves medication, psychotherapy, or both.
There are a variety of antidepressant medications that can be used in the elderly; for the most part, the same antidepressants that are effective in younger adults are effective in older adults. Older adults are often more sensitive to medications, though, so often the dosage must be lower to start. There also is an increased risk of side effects. Thus, drug treatment may be more complex and take longer than is typical with younger adults.
Psychotherapy consists of a series of conversations with a trained mental health professional, usually a psychologist, clinical social worker, or licensed professional counselor. These conversations differ in format and focus depending on the theoretical orientation of the professional, but, in general, they entail an exploration of current and past problems; an explanation for why depressive symptoms have developed; new learning about one’s emotions, thoughts, or psychic makeup; and development of skills to handle one’s difficulties. It’s important for the client and therapist to relate well to one another and to agree on the approach being used, so a change of therapists may be advisable if these factors seem absent in the first handful of sessions. There are a multitude of therapeutic orientations, and most of these have research data to support their effectiveness.
A few approaches that seem particularly well-suited for treatment of depressed older adults are:
· Reminiscence-based approaches, in which the therapist leads the client in a guided life review
· Cognitive Therapy (or Cognitive-Behavioral Therapy), which focuses on the person’s habitual self-talk and associated underlying beliefs
· Interpersonal Psychotherapy, a time-limited approach that identifies and works on an interpersonal issue that is problematic for the person
Despite the fact that treatment is usually effective, many depressed older adults never seek professional assistance. It doesn’t need to be that way! There are competent and caring professionals available to provide medication management or therapy. Help is just a phone call away.
Dr. Robert Ritzema is a Licensed Practicing Psychologist at the Fayetteville Family Life Center