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April 2, 2001
Depression in Old Age
Even a little may have costly effects
By Linda Lowenthal, R.N., M.S.N.

Illustration: Geriatric Depression

For several years, 84-year-old Grace Turner* had gradually withdrawn from once-cherished activities. She dropped out of her bridge club, turned down most luncheon and movie invitations, and cut back on family visits. When pressed for an explanation by her concerned daughter, Grace would cite fatigue and "colon problems" as her excuses. This social withdrawal seemed to precipitate a vicious cycle of increasing lethargy and then even less activity.

Her regular physician had diagnosed her with irritable bowel syndrome (IBS), a collection of symptoms including abdominal pain, bloating, and unpredictable bowel-movement patterns ranging from diarrhea to constipation. There is no cure for IBS; management is symptomatic and usually consists of combinations of dietary changes, medication, and avoidance of stress.

In treatment, Grace tried a number of medications. She increased the fiber in her diet and experimented with avoiding certain foods. During the next year and a half, Grace underwent three endoscopic tests. Still, her symptoms persisted. Grace lost a dangerous amount of weight and began to spend more and more time alone in her home. Finally, she sought the opinion of a gastroenterologist, a physician who specializes in intestinal disorders. After a careful review of her case and some additional testing, this physician recommended no changes in diet or medications, but strongly urged a psychiatric evaluation, with particular attention to possible depression.

At first Grace was highly indignant. She accused the gastroenterologist of thinking she was "crazy," denied that she could be depressed ("What do I have to be depressed about?"), and refused to see a psychiatrist, claiming that she wanted to have nothing to do with "mind-altering drugs" and that she was not going to discuss her personal life with a stranger ("What's the point of going over all that?"). In short, Grace was willing to undergo all kinds of uncomfortable medical tests to solve her problems, but generational prejudices against psychiatry and the perceived stigma of mental illness threatened to stop her from getting the help she needed.

Eventually, however, Grace gave in to the urgings of her family and saw a psychiatrist. In spite of Grace's unwillingness to fully cooperate, the psychiatrist believed that some degree of depression was present and prescribed an antidepressant medication, which Grace agreed to take as directed. In about a month, some of Grace's symptoms began to subside. Her appetite increased, she gained back some of the weight she had lost, and her bowel patterns became more stable than they had been in many years. She began to accept more invitations to go out and seemed to particularly enjoy new movies.

Grace's story may not be unusual. Many seniors live alone. Many face the inevitable losses -- declining abilities, the passing of loved ones, and new health problems. Activities once marked by passion or pleasure lose their attraction. Depression, especially in the elderly, can seem normal. According to experts, a great deal of research is needed on the causes, effects, treatments, and even the need to treat depression in the elderly.

In trying to describe and define depression, doctors have developed strict criteria for what are termed major and minor depressions. These include characteristics, both mental and physical, that are enumerated in the set of psychiatric guidelines known as the Diagnostic and Statistical Manual , 4th Edition (DSM-IV). Many people may have some of these symptoms, but not to the degree necessary for the formal diagnosis of depression. The question arises -- what about these people, especially the older ones, like Grace, who may deny all symptoms or have only some of the symptoms, some of the time -- what are they at risk for? Do they face the same problems as people who have full-blown major or minor depression?

Recent research

These questions were recently addressed by a group of researchers at the University of Rochester School of Medicine and Dentistry. They examined several hundred community-dwelling seniors for the presence of depressive symptoms. The subjects with symptoms were then assigned to different groups based on the degree of depression identified. The researchers then tested the functional abilities of the participants. Somewhat to their surprise, they found that older people who might be described as slightly depressed had disabilities comparable to those of patients who qualified for a formal diagnosis of major depression. The disabilities measured included problems with performing routine activities of daily living, self-care in health matters, and cognitive abilities.

How do health care providers identify depression in seniors?

  • Diagnostic interviews -- face-to-face discussion
  • Input from family members
  • Standardized questionnaires
  • Physical exams and lab tests to rule out other conditions

Questions to ask yourself:

  • Are you basically satisfied with your life?
  • Have you dropped any of your activities and interests?
  • Do you feel that your life is empty?
  • Do you often feel helpless?
  • Do you feel that your situation is hopeless?

Major health risks to the elderly that have been found to be associated with depression:

  • Heart disease
  • Falls
  • Cognitive decline
  • Cancer
  • Higher overall mortality

The cost to society

If depression in any degree is a risk factor for other serious medical conditions, or if it exacerbates existing problems, treating depression could have a great impact on the overall health picture of millions of older persons. Treatment for depression is available and will continue to improve, especially if it is viewed by seniors like Grace as a reasonable option free of stigma, shame, or stereotypical misconceptions. Mental health care then becomes merely another aspect of the overall health care picture, one of a better opportunity for fulfillment and optimal function for those who are facing their final years.

* The patient's name has been changed.

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