Depression in the Elderly
by Scott Falley, M.D.

Elderly Depression: Case Example

Case example.  Your father, Joe, 83, lives alone, having lost your Mother two years ago.  He has a bad heart and although his knee arthritis is killing him, he cannot have surgery because of the heart condition.  He can no longer garden, which is his favorite hobby.  You find that the house is messier than usual and that the cupboards are no longer stocked with the usual variety of foods. His friend, Jim, has called you that Joe is no longer coming to the VFW meetings, which is a concern as he has always been a faithful with attendance.

On your visit with your dad last week he seemed to stare off into the distance, to talk less, and to complain more about not only the knee but about feeling “just tired”, not sleeping very well now, and thinking about giving up on the VFW because he wouldn’t have much to contribute anyway.

You ask your father if he is depressed.  His answer is “I’m not a head case.”

What do you do at this point?  Is your father depressed or is something else going on?

DEPRESSION:  BASIC FACTS

Depression – not rare through a lifetime.

Depression – NOT a normal consequence of aging.

Depression – not more common in the elderly if health and independence remain intact.

Depression – risk goes up significantly if a senior loses their health and independence

The following risk factors help predict a risk of depression in the elderly and contribute to losses of health and independence:

• Female sex
• Social isolation
• Widowed, divorced, or separated marital status
• Lower finances
• Generally poor health/physical illness.  ESPECIALLY heart attack,         
• Stroke, and cancer
• Uncontrolled pain

DEPRESSION:  DEFINITION, CAUSES, PERCEPTIONS, BARRIERS TO CARE,  DANGERS

Depression – a prolonged situation of marked sadness or loss of enjoyment of life which interferes with daily functioning and relationships.

Depression – we suspect that an imbalance in brain chemistry is part of the picture. The imbalance may either be the cause or the result of depression.

Depression – an acute or ongoing negative or stressful life event or loss leads to prolonged sadness, guilt, or frustration.  A genetic predisposition is sometimes seen.  If the negative influences last long enough, the brain chemistry becomes unbalanced and a depressive illness develops.

Objective, physical correlates of changes in brain anatomy and chemical activity can be seen.  Depression has both emotional/spiritual and physical components.

Concept of mood disorder, not mental illness.  A proper understanding of the nature of depression will help us recognize and treat this condition. 

Traditional perceptions about depression are a barrier to adequate diagnosis and treatment of this illness.

Depression in the elderly is under diagnosed and under treated.  This can reflect both the patient’s perspective and the physician’s first impression.

It is important to diagnose and treat this condition due to the burden of suffering and medical consequences.

DEPRESSION: TOOLS TO RECOGNIZE, AND WHAT TO DO NEXT

To go back to our case example, one could ask Joe questions from screening questionnaire tools. Consider the following if you or a loved one might be struggling with depression.

Tool #1.  Two question test. A yes to either or both is suggestive.

     During the past month, have your been down, depressed or felt hopeless?

     During the past month, have you been bothered by little interest or   

     pleasure in doing things? 

Tool #2.  Five question test.

     Are you basically satisfied with your life?

     Do you often get bored?

     Do you often feel helpless?

     Do you prefer to say at home rather than going out and doing new things?

     Do you feel pretty worthless the way you are right now?

Two or more suggestive answers means we should look further.

A medical evaluation should follow.  This can be done by the general family or primary doctor. If possible, alert the doctor that a mood problem is suspected.

DEPRESSION:  TREATMENT OPTIONS

Involved family or friends may be able to solve a mild depression; historically this was all there was.  Don’t let things linger too long, however.

Psychotherapy (counseling or talk therapy):  This gold standard is underutilized for various reasons.  If a life event is identified as being involved, this approach holds particular promise.  It takes time.

Medical (drug therapy).  We might need this for severe depression, with suicide risk.  There are safety concerns that are controllable. It might work faster.

Don’t be shocked!  Electroconvulsive therapy is still around.

SUMMARY

• Those elderly who suffer loss of independence or health are at risk for depression; otherwise, there is no increased risk at all.

• We need to do better at identifying this very treatable problem.

• Elderly depression is harder to diagnose because of stigmas surrounding the condition itself and other variable that may be present in the elderly.

• Consider the concept of mood disorder, not mental illness.  Depression  may indeed be “in our head” but not in our imagination.

• Short questionnaires, carefully used, can help clarify if depression is present.

• A medical evaluation is mandatory, because something else may be going on.

• Treatment is likely to be helpful and should be attempted.  A return of more counseling/psychotherapy would be nice.  Medication is generally safe and essential as part of the treatment plan for severe depression

• A cure is reasonably possible; lifelong medication or counseling is not generally necessary.