Populations

Depression in the Elderly

There are many things seniors must endure. Depression shouldn't be one of them.

Mildred Reynolds, EdD, MSW has been a long-time educator and advocate. She recently completed her term as vice president of the Depression and Bipolar Support Alliance. In 1960, at the age of 30, a depression "unbelievably and indescribably painful" struck Dr Reynolds. It felt, she wrote, "like a rat was gnawing on my brain." Suicide to her "seemed not like harm to self, but relief for self." Despite completing a doctorate and working as the director of social work for the department of psychiatry in a university medical school, neither she nor the psychoanalysts who treated her had an appreciation of the illness. It wasn’t until the late 1970s that the psychiatrists where she worked began to prescribe medications for depression. Several years later, 24 years from the time she first sought help, she was finally given a diagnosis, but it took another nine years to find a combination of medications that really worked well.

"Today," Dr Reynolds writes, "I have fears, but I do not dwell on them. For example, I fear that the medication that ‘got me well’ will no longer ‘keep me well.’ If I become depressed in a nursing home, will I be able to get the psychiatric care I need? Throughout the years of living with depression, I have developed many good coping skills. But they will be of no help if I develop dementia - perhaps the greatest fear of all."

What We Know About Depression in the Elderly

Dr Reynolds' article appeared as part of a 2002 special issue of Biological Psychiatry on late life mood disorders. For those who qualify for senior citizen discounts, depression poses its own set of hazards. Biological Psychiatry cites a 1994 Indiana University study of 1,711 patients 60 years or older in an academic primary care practice, which found 292 patients were depressed and 140 remained depressed nine months later. The depressed patients were more likely to rate their health as fair or poor, were more likely to have an emergency room visit, had more outpatient visits, and more outpatient charges than nondepressed patients.

Contrary to popular belief, however, depression is not part of the normal aging process. True, older people may seem to have a lot more to be depressed about. Ten to twenty percent of widows and widowers experience depression during the first year of bereavement, but in general the percentage of depressed elderly is only marginally higher than the population as a whole, affecting some five to six million of the 33 million Americans over the age of 65. And with age comes an array of coping skills.

What may be different about some older people with depression is the condition of fine fibers (white matter) that run like wiring beneath the cortex. Lesions (hypertensities) in white matter have been identified in age-related illnesses such as dementia, and are a focus of investigation in geriatric depression. A 2003 Duke University study of MRI scans on 133 depressed patients, age 60 and over, on antidepressants has found that those who achieved and sustained remission over a two-year period had significantly less increases in white matter hypertensity volume than those who did not achieve or sustain remission.

Unfortunately, the primary care physicians who represent the front lines in health care often fail to diagnose depression in their older patients. A 1997 University of Illinois study of 141 family physicians and general internists found that nearly 100 percent agreed treating depression in elderly patients was important, but 29 percent reported that "depressed elderly patients frustrated them," and 24 percent were too pressured to routinely investigate depression. The physicians in the study said they needed more time with their patients, increased reimbursement for counseling, more training in medical conditions co-occurring with mental illness, and improved residency training in depression.

Ironically, Biological Psychiatry notes, it is easier for most physicians to order expensive and often unnecessary tests for a patient with a vague physical complaint than to spend the extra time necessary to make a more accurate diagnosis or provide education and counseling.

Symptoms of late-onset depression - which may include agitation, anxiety, and irritability - often differ from the rest of the population. They are often ignored or confused with Parkinson's or Alzheimer's or dementia - not to mention thyroid disorders or strokes or heart disease - or as a side effect of medication, which it sometimes is. Depression frequently co-occurs with these and other disorders, blending into the landscape of the victim's usual aches and pains, and tending to become difficult to spot.

The problem is compounded by the unwitting patient, conditioned to the stigmas of an earlier era. The very same person who would not hesitate to reveal to his doctor his darkest personal secrets - his incapacitating injuries, his difficulty breathing, those embarrassing memory lapses and humiliating no-shows in the bedroom - that very same person would seemingly rather be struck down by lightning or make a speech in public naked than admit in confidence to the simple fact of feeling down in mood.

Late Life Depression Life-Threatening

If only doctors would talk to their patients. Researchers from the University of Pittsburgh and other centers recruited 5,201 individuals aged 65 and over from four communities in the US, tested them for depression, and tracked them for six years. Nearly 19 percent of the subjects died over the course of the study. Further investigation showed that those with high baseline depressive symptoms had a nearly 24 percent mortality rate compared with 18 percent for those with low baseline scores, leading the authors of the study to conclude that depression was "an independent predictor of mortality" in older adults.

The study was published in the June 26, 2000 Archives of Internal Medicine. An editorial in the same issue observed that the study "places depression squarely in the company of some familiar risk factors for mortality," including hypertension, smoking, stroke, and heart disease. Accordingly, the editorial recommended: "Depression now demands the aggressive level of research in the next quarter of a century that smoking, cancer, and heart disease have received in the past quarter of a century."

If depression can lead to life-threatening medical illnesses, the converse also applies. Biological Psychiatry cites a 1998 UK study that found that medical illness triples the risk of depression in older adults over one year, including heart disease, cancer, stroke, and neurologic illnesses such as Parkinson's and Alzheimer's. Approximately one-fifth of patients have depression following heart attack, congestive heart failure, and heart transplant.

Then there are co-occurring psychiatric disorders. Biological Psychiatry cites a number of studies that show alcohol dependence is three to four times greater among elderly individuals who are depressed.

We can only guess at how many extra beds in the hospital - not to mention days inside - that are the result of hidden depression. How many operations and their complications, how many prescriptions written, how many hours spent in the care of a health professional - all those Medicare and Medicaid dollars, all those HMO premiums, all that money that ultimately comes out of our own pockets - how many billions or tens of billions of that is wasted due to unseen depression?

Deteriorating health, a sense of isolation and hopelessness, and difficulty adjusting to new life circumstances often combine to create a hell on top of a hell that demands ultimate release. It's one of those bitter facts of death that tend to get swept under the carpet - suicide in the elderly far exceeds the population as a whole. Amongst elderly white males, the suicide rate is six times the national average. Amazingly, 75 percent of these had seen a doctor within the last months. And as the baby boomer generation starts trading in their Walkmans for walkers, the overall statistics will go through the roof, initiating a public health problem of major proportions.

Guidelines for Elderly Patients with Depression

The sad part is none of this ever has to happen, for elderly people have the same response to antidepressants and other therapies as the rest of the population. Accordingly, if you are an older person, or are caring for one, it pays to be mindful of the following:

Depression is not a natural condition of old age and should not be tolerated as part of the process of aging. Older people are as responsive to treatment as the young.
Have your doctor administer a routine depression screening test. There are three main ones: The Hamilton Depression Scale, the Beck Depression Inventory, and the Geriatric Depression Scale. The last one consists of fifteen simple yes/no questions. If your doctor is not competent enough to administer a depression test, then seek out one who is.
Insist on a similar test if taken to the hospital. A recent Case Western Reserve University survey found that 30 percent of elderly patients who presented themselves to the hospital emergency room met the researchers' criteria for depression, but only 27 percent of these were recognized by the emergency room physicians and only 13 percent were referred for further evaluation.
Take any talk or idea of suicide very seriously. Elderly people are far more likely than the rest of the population to follow through.
Support matters. Depression is twice as rampant in nursing homes as elsewhere.
There may be physical or other causes of actual depressive symptoms, including low blood pressure, hypothyroidism, Parkinson's disease or the side-effects from its medications, as well as grieving the loss of loved ones.
Antidepressants should be prescribed according to one's individual needs, if possible. According to an article in Medscape: Prozac is longer acting, so missing a dose or two will not have a major effect. Zoloft has perhaps fewer drug interactions. Paxil tends to be more sedating, which can help those who have trouble sleeping. Wellbutrin and Serzone don't cause the sexual side effects or disruption of REM sleep associated with other medicines.
Finally, there is no shame in admitting to depression.

Updated Dec 15, 2003, reviewed Feb 15, 2008

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