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A guide for the older person and their families
by
Dr Declan Lyons
Dr Conor O’Luanaigh
Dr Ciara O’ Dowd
Dr Jean Gallagher
Contents
PART ONE
Introduction
Adjusting to becoming old and being old
What is depression?
Symptoms and signs of late life depression
Obstacles to recognising depression in older adults
Causes of depression in later life
PART TWO
Management of late life depression
Medical treatments
Psychological therapies
Social aspects of late life depression
How relatives can help
Carer stress
Networks of care
Preventing depression
Correcting the myths
Recommended reading
Other useful organisations
Introduction
Worldwide, life expectancy is increasing. Currently about 10% of the world’s population is made up of older adults (aged 65 and above). This figure is set to rise steadily, to as much as 30% in some societies. To put this in context we need to look at some figures: in 1950 the population of the world’s elderly was 200 million and this is estimated to rise to 1.2 billion by 2025, a six fold increase in only 75 years. The most significant increase in older people living longer is found, not surprisingly, in developed countries like Ireland whose birth rate along with other European countries has been falling. For mental health, these changing shifts in our population structure, will mean an increase in conditions such as Alzheimer’s disease and dementia, but also in depressive disorders. Depression affects about one in ten people aged over 65, making it the most common of the mental health disorders of later life. While this large population of older people will have greater financial resources and political influence to demand quality care when needed, the challenge will be to organise healthcare services to respond by offering early intervention for illnesses to prevent them becoming chronic or disabling.
There is evidence from ongoing research into the treatment of depression, that it is a treatable condition and that the benefits of treatment, for the individual, families and society, are immense. This guide will emphasise the need to raise awareness about depression amongst older people and their families. It will stress the need for a positive approach to detection and assessment, through to treatment and prevention. It aims to help bridge the gap between the knowledge about depression and current practice by encouraging people to seek help earlier, armed with information about the nature of depression and its treatment.
Adjusting to becoming old and being old
Most elderly people experience the same range of normal emotions, depending on circumstances and events, as they have done during other periods in their lives. Most elderly people are as satisfied with their lives as at any other age, and enjoy their retirement, their interests, their families and their friends. Despite the increased likelihood of losing a loved one or of physical illness or disability, old age is not necessarily a time of sadness and depression. The majority of older people have the resources of a lifetime of experience to face, in a positive way, the various changes that occur at this stage of their lives. However, for some older people the challenges can be great, and tremendous strain is placed on their ability to cope effectively. As a result they experience increasing distress, anxiety, demoralisation and loneliness. In some cases, increased distress is the start of mental health problems in old age.
In other cases, it represents a time of increased suffering which, nonetheless, is finally dealt with constructively. Various factors influence a person’s ability to cope with stress. These include: past experience and personality, the meaning given to current problems, their way of dealing with previous stresses, resources available to the person - both their own, and the friendship, love and support from others. There are, however, stresses that have particular association with mental health problems among the elderly especially:
Psychologists have studied the adjustments that older people must make such as facing death, finding meaning in life despite loss of role, status or health, and facing regrets and disappointments. They have highlighted how inner conflict in the face of these changes could set the scene for significant anxiety and depression.
What is depression?
Depression is a disabling illness and in some cases, if undetected and untreated, can result in suicide. It is much different from the responses of grief and sorrow to the losses and changes in life, in that even the most basic everyday task is affected by a continuous and severe sadness. Those who suffer from it report that severe depression changes life completely.
The symptoms of depression are:
Feelings - of sadness and or anxiety
Energy - lacking in energy
Sleep - over or under sleeping
Thinking - sluggishly or negatively
Interest - lost, in food, sex, or daily events
Value - not valuing oneself
Aches - headaches, chest or other pains with no physical cause
Living - seeing no point in living
Depression affects behaviour, relationships, emotions, motivation, thinking, sleep and other bodily functions. The person who could mix well socially suddenly becomes isolated and keeps to themselves. Everything is too much trouble and personal appearance is neglected. The capacity for enjoyment is reduced or disappears altogether. Appetite can be affected, resulting in the individual not enjoying food anymore and so losing weight.
Often, sleep is disrupted and waking early in the morning may be made worse by the mood being at its lowest in the mornings. Severe depression reduces motivation and slows mind and body. Often it distorts thinking and even memories, leaving the person preoccupied with negative themes such as poor physical health, guilt, self-reproach and unworthiness. Agitation and anxiety sometimes complicate depression and may paralyse the person’s capacity to make decisions or manifest itself in constant seeking for comfort and reassurance. There may also be more tearfulness than usual. Mania is far less common than depression in older people and often occurs in persons with a long standing bipolar disorder. If a person has experienced one or more manic episodes then they would be classified as having bipolar disorder rather than a pure depressive (unipolar) disorder.
New episodes of mania in an older person may occur following a stroke.
The elation in older people may be characterised less by feelings of well being and more by irritability and agitation. If an individual has 4 or more of the symptoms of depression, for 2 weeks or more, they may be suffering from a depressive episode and should consult their doctor.
Symptoms and signs of late life depression
It is known that ageing may heighten some features of depression and suppress others. But overall it is important to stress the similarity of depression between various age groups. Older people are often reluctant and embarrassed to describe psychological or emotional issues. Often a common feature of depression is complaints about memory difficulties that are distressing, and anxiety symptoms may dominate the clinical picture but are actually secondary to the depression. Relatives will often point to a lack of interest and motivation. Behavioural problems such as uncharacteristic hostility, frequent unexplained falls, irritability or increased alcohol use may also point to a depressive picture. Suicidal ideas should be probed, as older males have a particularly high rate of completed suicide often through indirect means, such as self-induced starvation or dehydration, or failure to take important medical drugs.
Obstacles to recognising depression in older adults
It is vital to stress that depression is not a normal part of the ageing process.
However, people in general still associate many symptoms of depression with ageing because less is expected of older adults after retirement. Society has long held the view that growing old is equated with misery and this has been reflected in literature, mythology and attitudes. Depression is seen as an understandable reaction to growing old. This bias towards accepting and tolerating a lower level of functioning among older people is also held by many health professionals. It ignores the potentially serious consequences of untreated depression.
The symptoms are both physical and psychological and can interfere with the person’s ability to carry out the most basic of daily activities. The diagnosis of depression may prove more difficult as carers and professionals may be unsure about vague indistinct symptoms expressed by older individuals. The older person may focus on physical ailments rather than feelings, leading the doctor to focus on possible chronic physical illness and thus overlook depressive symptoms.
Many symptoms of depression overlap with all sorts of physical illness in older persons making life difficult for the diagnosing doctor. If an elderly person has dementia, the dementia can hide the diagnosis of depression and a potentially treatable aspect of this illness can go untreated.
Causes of depression in later life
There are factors in a person’s background that constitute a risk for depression and life events which often bring it about. Against these are factors which are protective, sometimes called buffers. These include psychosocial factors, such as social support and the security of a person’s surroundings. It is usually the interplay of these that determines whether a person develops depressive disorder, rather than one particular factor. This is why some people develop depression in the absence of an adverse life event, and why in others a major life event does not lead to a depression.
It’s important to emphasise two points:
Factors associated with depression in older people include:
Precipitating factors include:
Protective or buffering factors include:
In fully assessing depression and what causes it, it is important to recognise the role of the person’s own vulnerability and difficult life events that they may face. Disability due to physical ill health is strongly associated with depressive disorder and should thus be minimised as much as possible. The irritation and frustration of chronic pain or disability can predispose to depression - it can be seen as ‘the last straw’ if other stressors are present. A truly holistic approach in the assessment of depression is necessary, focussing on both psychological and any physical symptoms. Over-thecounter pain-killing drugs and alcohol may mask symptoms of depression in an individual, and ultimately worsen mood. Important chronic conditions are severe arthritis, cardiac disease, stroke, dementia and Parkinson’s disease. Having hearing difficulties has also been found to be associated with depression.
PART TWO
Management of late life depression
Doctors generally try to carry out as full an assessment as possible in an older person, taking a history from the client and family and performing an assessment of the mental state and the risk of self-harm. A physical examination may also be required as may a range of blood tests or other investigations. The doctor may decide to refer the patient to specialist services if the patient is at risk of suicide or self-neglect. If the symptoms are severe (such as psychotic features) or if the patient has complex problems or lacks social supports, they may be referred to hospital. Despite various efforts, depression is still frequently under-diagnosed in older people.
Just as becoming depressed is usually the result of a combination of physical, psychological and social factors, so the pathway out of depression is also complex. Most elderly people with a depressive disorder will therefore require some combination of physical, psychological and social interventions to achieve the best recovery and, just as important, to maintain that recovery and prevent relapse.
Ideally the management of depressive disorders involves specialists such as nurses, social workers, occupational therapists and psychologists. A treatment plan should be agreed with the patient and their families to outline the goals; when they are to be reviewed; what treatment is to be given and by whom.
The modern management of depressive disorder is divided into three phases, namely:
A patient may show a response but still have symptoms. Remission is the point at which all or almost all symptoms have disappeared. In younger patients, this may take 6 to 9 months, wheras in older patients it may take longer.
Treatments of depressive disorder include
Medical treatments
The doctor will explain the nature of his/her condition to the patient, as well as the treatment suggested. He or she will also help to reassure the patient by:
Up to 70% of older people suffering from moderate to severe depression improve significantly with antidepressant drugs. There are no set differences in how quickly a person begins to improve, although in general, older people may take longer to recover than younger adults.
Drug treatments are divided into older and newer antidepressants, newer medications being easier to take with fewer side effects. This is important for older patients who may be prone to drug interactions if they are already on medications for physical illness. If the depression is severe and psychotic symptoms are present, antipsychotic treatment will be required in addition to an antidepressant. Antidepressants, especially the more modern treatments, are safe and often effective when a person with dementia has a depressive component to their illness. If a person has not responded to initial treatment with an antidepressant, the doctor may prescribe lithium which can often be beneficial, especially in terms of preventing relapse.
ECT or electroconvulsive therapy can be effective in moderate or severe depression when antidepressants have failed. Some studies have suggested it is even more effective in older adults and avoids many of the side effects associated with medication. The treatment is administered under complete anaesthesia and is brief and painless in itself.
Psychological therapies
There is emerging evidence of the usefulness of psychological therapies in treating depression in older adults. Age is not a barrier to psychological intervention. Cognitive behaviour therapy and interpersonal therapy have been found to be beneficial and when combined with medication is more effective than either type of treatment alone. Cognitive behaviour therapy seeks to help a person recognize and change negative thinking patterns that contribute to depression.
Interpersonal therapy concentrates on effective interactions with other people in order to improve relationships, which in turn can reduce depressive symptoms. Problem solving or solution focussed therapy may be useful in less severe depression as can life review which helps older people to integrate and derive meaning from all their past experiences.
Social aspects of late life depression
Where poor housing, social isolation or bereavement have contributed to the development of depression, a complete and lasting recovery is unlikely until these factors have been addressed in their own right. Bereavement counselling and family therapy are interventions which can yield positive results when appropriately targeted. In the problem solving approach to depression other interventions may include referral for home help and meals on wheels, referral to a day centre, luncheon club or support group and helping people to check on their welfare entitlements. These simple initiatives, although seemingly minor, can make a big impact on depressive disorder.
How can relatives help a depressed older person?
The greatest skill, in helping any other human being in psychological distress, is the ability to listen and convey concern in an understanding and non-judgemental way. Depressed people may have little confidence in their ability to entertain or talk to people, so not forcing them to talk and simply being there to offer emotional support at a time of need is essential.
Practical help with everyday chores such as meal preparation or laundry may help maintain morale by keeping essential routines going. Openly discussing the problems they’re experiencing without over analysing them, and offering reassurance that things will improve is usually all that’s required. Helping out with remembering to take medication will acknowledge the significance of the illness and helping out with transport to hospital or GP visits is an enormously practical gesture of support.
Carer stress
Illness is a time of great stress for families particularly children of depressed older people who may be busy with commitments of their own. Offering support to caregivers of older people is essential, as often full time carers especially, have significant rates of depression themselves. When carers are isolated or uninformed about certain aspects of mental illness, misinterpretation of symptoms can occur, leading to elder abuse and poorer outcome of psychological conditions like depression. Carers should be encouraged to seek as much professional support as possible, and as many entitlements to which they are entitled. Much mutual support from other carers is also available from various voluntary organisations, such as Aware.
Networks of care
Managing a depressive disorder in an older person is not simply a matter of selecting the right intervention from a range of medications and psychological treatments. Holistic care is important. Attempting to bring about a positive style of coping and adapting and good social support can aid recovery from depression. Integrating medical and social services into caring networks allows the whole range of needs of older people to be addressed. The support derived from such a network of relationships both formal and informal is invaluable in buffering the stresses of ageing.
There are numerous local and national organisations ranging from active retirement groups, to national campaigning and lobbying bodies such as Friends of the Elderly or Age Action, to information resource centresadvertising services as diverse as befriending schemes, respite breaks or welfare entitlements. The voluntary sector also fills the gap left by many statutory services, but making older people aware of, and encouraging them and their families to avail of these services is crucial.
Preventing depression
As depression in older people is often associated with social and economic difficulties and poor health, any measures that can improve their general welfare and living standards may help to prevent the occurrence of depression. Preparation for retirement through pre-retirement courses and improving the financial status of retirees through adequate pension provision will boost their sense of independence and help them to feel less of a burden on the rest of society. Older people should be encouraged to consult their GP at an early stage about physical health problems.
Reducing the stigma of mental health problems through greater public and professional awareness will result in earlier treatment and intervention avoiding crisis presentation and severe distress. Support for the bereaved through bereavement counselling is essential in those who are isolated and thus vulnerable to developing a clinical depression.
Correcting the myths
The greatest falsehood about ageing shared by many older people, professionals and policymakers, is that ageing and mortality are synonymous. Consequently depression in later life is seen as being justified and understandable as all seniors descend into dependency and disability.
This ignores the individual experience of ageing and leads to stereotyped generalisations about older people. Old age can be a time of freedom and opportunity, new roles such as grandparenthood, perhaps part-time or voluntary working. Expectations about health are changing and increasingly the boundaries of optimal physical and psychological functioning are being pushed back through new technology, illness prevention and holistic treatment approaches. One of the most compelling reasons for seeking treatment of an illness like late life depression is that up to 80% of clinically depressed people can be successfully treated and even substantial relief given to those with depressive symptoms being part of an illness like dementia. For that reason old age may predict to some extent, but no longer defines decline and disability.
Follow this link for more information on Aware's depression support groups.
Recommended Reading
Baldwin R C, Chiu E, Katona C, Graham N. Guidelines on Depression in Older People, London, Martin Dunitz, 2002.
Birren J E, Warner-Schaie K. Handbook of the Psychology of Ageing 3rd Ed, San Diego, Academic Press, 1990.
Breitung J C. The Eldercare Sourcebook, Chicago, Contemporary Books, 2002.
Curran S, Wattis J P, Lynch S. Practical Management of Depression in Older People, London, Arnold, 2001.
Kennedy G J. Geriatric Mental Health Care, New York, Guilford, 2000.
Norman I J, Redfern S J. Mental Health Care for Elderly People, New York, Churchill -Livingstone 1997.
Smyer M A, Qualls S H. Ageing and Mental Health, Oxford, Blackwell, 1999.
Other Supporting Organisations
Age Action Ireland Ltd
30/31 Lower Camden Street
Dublin 2
Tel: (01) 4756 989
Email: info@ageaction.ie or Library@ageaction.ie
Website: www.ageaction.ie
Age Action Ireland aims to improve the quality of life of older people, especially those who are most vulnerable. Acts as a network of organisations providing services for older people and carers in Ireland. Provides a library and information services.
Alone
1Willie Bermingham Place
Kilmainham Lane
Dublin 8
Tel: (01) 679 1032
Fax: (01) 679 1032
Website: www.alone.ie
Alone aims to promote awareness of older people’s problems.
Friends of the Elderly
25 Bolton Street
Dublin 1
Tel: 873 1855
Fax: 873 1617
Email: info@friendsoftheelderly.ie
Website: www.friendsoftheelderly.ie
Friends of the Elderly aims to combat the loneliness of elderly people by providing friendship, social contact and opportunities for involvement in community activities, and helping them become more fully integrated in their own communities. Services include social contact, home and hospital visiting, transport, holidays, outings and parties.
Federation of Active Retirement Associations
Shamrock Chambers
1-2 Eustace Street
Dublin 2
Tel/Fax: 679 2142
Email: fara@eircom.net
Website: www.fara.ie
Self help organisation which helps to make retirement meaningful and enjoyable through participation in social, cultural and recreational activities.
Senior Help Line
Third Age Centre
Summerhill
Co Meath
Tel/Fax: (046 95) 57766
Helpline: 1850 440 444 (7 days, 10am-1pm & 7pm-10pm)
Email: thirdage@indigo.ie or info@thirdage-ireland.com
Website: www.thirdage-ireland.com
Voluntary helpline for older people, run by older volunteers. Offering support to isolated and lonely older people.