Depression in the elderly
To Your Health -- CHRC Newsletter
Fall 2000
By Jonathan Segal, M.D., PAMF Psychiatry
"Years ago, my father told me that old age wasn't for sissies, now I know what he meant," sighed Marjorie, a 77-year old widow, as she sat in her doctor's office. "Since my husband died, it's been awfully quiet around the house. My kids call on the phone but they've got their own lives to lead. They have kids of their own and are working full-time. My friends try to stay in touch, but a lot of them have health problems, some have moved away and a few have died over the years. And now that my arthritis has gotten so bad, it's a lot harder to get out of the house than it used to be. Sometimes days go by that I don't go anywhere, not even to the store -- besides, I'm tired most of the time, and even fixing meals seems like too much trouble. I wonder how long I'll have to go on like this -- makes you wonder what the point is sometimes."
Does this sound like someone you know? It would sound very familiar if you were a practicing doctor in the United States. Most of us have heard such countless stories from our patients. The details may be different, but the overall thrust is the same -- older people, especially those living alone due to divorce or the death of a spouse, often face a host of challenges that test their emotional resilience. And sometimes the personal, medical, and social circumstances that older Americans face lead to significant depression. A problem that has received ever-more attention in recent years.
Why so much attention to a previously ignored problem?
One reason is that there are simply more elderly people than ever before. The average life expectancy in the United States has increased for decades, such that a woman born in the U.S. today can expect to live into her eighties, with her male counterpart trailing behind by a few years. The segment of our population living into their nineties is growing faster than any other age group. Of course most people consider greater life-span to be desirable, and most of the time it is. However, because women live longer than men, most women spend their later years living alone (the dramatic increase in divorce rates in recent decades also contributes to the increase in older people living alone). Since women have a higher incidence of depression at all ages than men, these demographic changes have created an especially large population of older women who may be vulnerable to depression as they lose the company of family and friends due to death or relocation.
Contributing Factors
Factors other than greater life-span also contribute to social isolation, which in turn increases the risk of depression. America is an increasingly mobile society -- trend that applies to all age groups. Grown children roam the country in search of better careers and different ways of life. Senior citizens too are on the move: millions have moved to Sunbelt regions from more northern areas where they grew up and lived during their working years. Of course the freedom to choose where one lives can be liberating, but it has its downsides as well. One consequence of greater geographic mobility is that older people increasingly live far from their grown children and grandchildren at precisely the time of life when other factors that also contribute to social isolation (such as retirement) are most common. Freedom has its costs, and one of them may be the loss of the family and community networks that sustained older people in more traditional eras.
Other aspects of seniors' lives can also put them at risk for depression. While living longer, many will also be living with some condition such as arthritis, heart disease, or diabetes, which limits their activities or causes chronic symptoms or pain. These limitations can deprive older people of the satisfactions of exercise, social contact, and meaningful activities such as volunteer jobs or participation in cultural events. Understandably, chronic pain often causes depression -- what could be more discouraging than being uncomfortable most of the time? In addition, some medical conditions which are common in the elderly cause depression directly through physiological mechanisms -- Parkinson's disease and stroke are the most obvious examples. Finally, excess use of prescription drugs or alcohol, surprisingly common among the elderly, may contribute to depression (or be a symptom of it).
So far we have been discussing depression in the abstract, as if we know what it is. But what, in fact, constitutes true depression, and how does it differ from a normal response to life's difficulties?
Recognizing Depression in the Elderly
In the past, what we may now recognize as depression was often dismissed by doctors and patients as "a normal reaction to getting old." And certainly aging can be difficult. Accepting limitations and losses is painful, a daunting challenge that tests the best of us. Nevertheless, there is a real difference between understandable discouragement and true depression.
While each person has his own unique array of symptoms, there are some common patterns: true depression often causes a consistently downcast or melancholy mood, a marked loss of interest in activities or hobbies, physical or emotional lethargy, an overly pessimistic outlook on life, indecisiveness, poor concentration or easily distracted, a wish to avoid social contact, and sometimes a wish for death or self-destruction.
It is important to know that a depressed person is not always overtly sad. Instead, he or she may simply seem apathetic, unreactive, preoccupied, or indifferent to activities and interests that once brought pleasure. Personal hygiene may suffer, especially among those living alone. Exaggerated anxiety or irritability are often part of the picture, as are insomnia and loss of appetite (particularly serious in the elderly, whose physical health is easily jeopardized by weight loss or dehydration). Depressed people may overuse alcohol. Thus, a seriously depressed person is not his or her real self, but a distorted version of that self, often noticeably different to others.
Depression can be particularly hard to recognize in the elderly, since some of its more insidious symptoms (such as fatigue, loss of appetite, and disrupted sleep patterns) can also be caused by, and are often blamed on, physical illness. Another barrier to recognizing depression is that, like the Greek god Proteus, it can take many forms. Elderly depressed people tend not to complain of the most classic depressive symptoms (like sadness), but instead may develop a near-fixation with minor physical ailments like constipation, or an exaggerated fear of financial ruin when no such danger exists. In fact, doctors rarely hear depressed older people describe themselves as depressed. They are much more likely to bring out a long list of physical symptoms for which no specific medical cause can be found, and only careful and insightful questioning will reveal the alteration of mood and functioning that constitutes the underlying depression.
Why should we care about depression among the elderly? After all, don't older people have more serious problems to worry about, like cancer or heart disease? There are at least two reasons to pay attention to depression. First and foremost, it causes suffering as debilitating as that caused by physical pain. Many patients describe the hopelessness that accompanies serious depression as more excruciating than any physical ailment they have ever had. And secondly, at its extreme, depression can be a killer. Surprising as it may seem, many studies confirm that the elderly, and especially elderly-men, have the highest suicide rate of any age group. In addition, depression can kill in at least one other way -- we now know that serious depression occurring after a heart attack affects a patient's long-term survival just as powerfully as do more traditional measures of risk such as high blood pressure or abnormal heart rhythms.
Having said all this, at least a few words of encouragement are in order. We should not be overly alarmist. Statistics show that most senior citizens are healthier, more prosperous, and more active than their counterparts in previous generations. But neither should we be blithe -- given the sheer number of the elderly, even a small incidence of depression still leads to tens of thousands of new cases per year.
Finding Help and Support
Fortunately, today depression is less stigmatizing and more treatable than ever, and intensive professional treatment is not always necessary. Mildly depressed elderly people often get better by attending support groups, activity programs, and community events. For example, for the patient that I have named, Marjorie, at the beginning of this article, simply attending a senior citizens center a few times a week and getting better relief of arthritis symptoms may be enough to raise her spirits considerably. Those living alone may need to consider moving into retirement communities, as it is especially critical to reduce social isolation. An elderly person's physical health needs careful attention. Review by a doctor may reveal ways to reduce chronic pain if present, including methods such as physical therapy or massage. And those suffering depression due to caring for a spouse with dementia often get relief by joining groups such as the Alzheimer's Association, which provide education and support.
If depressive symptoms are more serious, professional attention may be necessary. Counseling may help a person cope with loss, family conflict, or health problems. Antidepressant medications are also a mainstay of treatment for significant depression. Modern antidepressants are much safer and have fewer troublesome side effects than older ones. These medications, once shunned except in extreme cases, often produce dramatic improvement and welcome relief from suffering. Perhaps most importantly, today's primary care doctors are much more alert to depression than in past years, and many of them know how to use antidepressants wisely. In more serious cases, they may refer elderly patients to a psychiatrist for evaluation and treatment.
Either way, the important thing is for depressed older patients to get the attention that they need. Fortunately, today's elderly are more willing to acknowledge depression as a problem than in previous generations -- and are less hesitant to get help for it. Detecting depression in the first place is the most critical step. As long as someone recognizes the problem, modern treatment is more effective and more available than ever.