by Peter Oppermann, Ph.D.

These are the expressions of Mrs. A., a depressed 72 year old woman who until two years ago was driving her own car, going to meetings at her church, shopping, cooking, and managing her own finances. She was also socially involved with friends and enjoyed playing bridge. However, in the past two years, two of her bridge partners were hospitalized, one died and she suffered a stroke which left a residual paralysis of her right arm, but no cognitive deficits. Clearly a great deal has changed for this person in the past two years, and she has much to mourn, but the hopelessness, helplessness, worthlessness, and exaggerated sense of dysfunction she expresses are evidence of more than grief. She can barely identify with the person she was just two years ago, who was so highly functional and independent. Her family physician told her that "she was just getting older" and she "had to accept it." In reality,  Mrs. A. is not just getting older; she suffers from depression.

Depression is not a normal part of aging. It is the most common and most treatable  medical/psychiatric disorder in late life, which effects about 15 percent of older adults, about 20 percent of hospitalized older patients, and over 40 percent of nursing home residents. However, elderly adults may present with a variety of complaints which are not always readily identifiable as psychological in nature. Symptoms may range from a simple attitude of negativity to the more severe inclination towards suicide: Therefore, Depression should be regarded as a clinical problem to be treated just as we regard hypertension and diabetes--as significant chronic illnesses that require evaluation and treatment.

We all have "blue" days or weeks and periods of extended grief after a significant loss, but Depression is a sadness that doesn't seem to get better and may be accompanied by feelings of hopelessness, worthlessness, helplessness, decreased interest and pleasure in activities, lethargy, anorexia, insomnia, decreased concentration, memory impairment, delusions and suicidal thoughts.  Depression results from the complex interaction of biologic predisposition and life events.

Recognizing depression in the older person is not always easy since it is often masked by other problems such as physical ailments, memory loss, confusion, lack of appetite and disturbed sleep patterns. Often depression in the elderly goes undiagnosed and untreated, particularly when they live in institutional settings.

Similar to their susceptibility to other physiological and psychological disorders, older adults may have increased vulnerabilities to depression. Why is that so?

• Changes in the quality and quantity of neurotransmitters in the brain of the older adult probably affect his/her susceptibility to depression.
• Second, while  loss of physiological function with normal aging, namely in the liver, kidneys, brain, heart, and muscle-skeletal system in itself does not lead to illness, it may make an elder less flexible in coping with physical or psychological stresses.

Several different factors seem to contribute to depression:

• Genetics--some depressions tend to be hereditary
• Physical Illness or changes in physical functioning can also cause depression
• Chemical imbalances in the brain caused by strokes or the aging process
• Certain medications, or mixes of medication, can contribute to depression
• Losses--probably the biggest contributor to depression. Older adults continually experience multiple losses: spouses, friends, relatives, pets, homes, status, jobs, financial security, independence and autonomy
• Loss of youth and vitality--in this country, a high value is placed on youth and vitality and productivity. Older adults may feel "used up" and non-productive
• Negativity--people who have generally been negative and pessimistic most of their lives are prone to depression.

Yes, there are several different kinds of depression ranging from transient and mild to the most severe:

1. Adjustment reaction with depressed mood: This type of depression is a reaction to a major change in the person's life. It is of short duration--six months or less. Examples are: having a beloved pet die; children moving out of the state; change of a roommate; acceptance of living in a more restricted environment.
2. Dysthymia: This is a chronic depression where the person has been depressed for at least two years. It is usually mild to moderate. Although the person functions daily, s/he almost always seems down. An example might be someone who has a history of long-standing unhappiness, or is described as having always been negative, pessimistic, or complaining.
3. Major Depression: This is a severe depression which comes on suddenly and often leaves the person unable to function in a normal manner. This is usually precipitated by a traumatic event or loss. An example of this might be loss of a spouse or significant relative, or receiving news of a catastrophic illness.
4. Bipolar Disorder: Also known as manic depressive illness. The person experiences extreme mood swings--ranging from not sleeping for 48 hours and talking incessantly, to being very sad, crying uncontrollably, and threatening suicide.

The following checklist of symptoms may help you. While a  depressed elder will generally not have all of these symptoms,  just a few of these symptoms
can indicate depression:

• prolonged sadness
• sleep problems--sleeping too much or too little
• poor appetite/significant weight loss, or constantly wanting to eat/weight gain
• irritability and demanding attitude and behavior
• lack of energy, always being tired
• feeling hopeless and helpless, low self -esteem
• vague physical complaints
• feeling worse in the morning than later in the day
• self devaluation:" I am no good, no one cares, I should just die"
• social isolation--refuses to leave the room; prefers to be alone
• no longer engaging in activities they once enjoyed, or participating in the activity but no longer enjoying it
• negativity and pessimism
• intermittent crying
• uncooperativeness
• difficulties with concentration and decision making
• short-term memory loss
• attention problems and confusion

• D Dysphoria
• E Emotional lability (for example, easily cries or easily becomes irritable)
• P Physical complaints
• R Rumination
• E Energy Loss
• S Suicidal thoughts and plans
• S Sudden mood changes
• I Insomnia
• O  Omission of pleasure
• N Negativity with regard to self, world, and future

 Most of all, it is important for you to be a "detective." What changes in your patient/ family member  do you observe:

• Is s/he less cheerful or less happy than usual?
• Does s/he seem worried?
• Does he or she appear quiet and withdrawn?
• Is he or she negative?

Older adults with Dementia may also experience depression--either secondary to their awareness of cognitive losses such as extreme forgetfulness, disorientation, naming difficulties, or as an adjustment reaction to entering residential settings or nursing homes. Usually their depression manifests differently than with cognitively intact adults. It is usually displaced as a general behavioral disturbance such as yelling, physically abusive behavior such as striking out, paranoia, complaining, uncooperative and resistive behavior.

Most forms of depression are easily treated with proper evaluation and follow up. People showing signs of depression should have a medical evaluation to rule out any physical problems that may be causing or contributing to the depression. If a person seems depressed, consider a referral to a psychologist. In most cases, proper treatment will include a thorough evaluation and assessment of the person and his/her situation by a psychologist. If the depression is severe, a  referral to a psychiatrist for antidepressant medication may also be necessary. Thus, early intervention and appropriate treatment can often improve the elder's level of functioning and quality of life. In addition to ongoing monitoring of medication by a physician, psychotherapy or counseling may also be needed, which can be provided by the psychologist, or by other trained and experienced mental health professionals. Both, individual and/or group therapy can be helpful.

One-on-one counseling focuses on supporting the individual and validating his or her feelings. The therapist helps the person verbalize feelings such as anger and frustration, and assist him/her in building self esteem and having a more balanced outlook--reducing negative thoughts and beliefs. Individual therapy helps the older adult deal with the "whys" and "hows" of their thoughts, feelings and relationships. It can also help identify and support the strengths and useful coping mechanisms the older adult has utilized in the past. Thus, one-on-one therapy can reduce a sense of hopelessness and improve the outlook on life.

Group therapy can also be helpful with depressed older individuals. It provides a place for them to socialize, develop positive relationships with others and improve social skills. Group members can then turn to each other for support and encouragement, and group therapy promotes active involvement in daily affairs and provides a sense of purpose and something to look forward to. With demented depressed adults, supportive group therapy can help build trust and prepare them for behavioral interventions . The patients are unable to increase their pleasurable activities until they trust and feel understood by others. By first allowing them to work through their feelings, they are later able to delight in the opportunities presented in long term care.

So what can I as family member and/or care-giver do to help a depressed elder before they are seen by a mental health professional? Older adults, who are depressed will often tell their care-givers things they would never tell, or have never told, anyone else. Thus, they need, and will greatly benefit from, emotional support by their care-givers:

1.  Be supportive and empathic.
2.  Allow him/her to express their concerns and fears to you.
3.  If s/he is angry and irritable towards you, be very careful not to personalize this behavior and blame yourself. This is often a normal part of depression.
4.  Try to listen without being judgmental or offering advice or solutions.
5.  Be complementary and give him/her choices whenever possible.
6.  Attempt to keep the individual busy with interesting activities.
7.  Be patient. The elder may not think and respond as quickly as they did when they were younger.

Taking care of a depressed person/resident can be challenging; but by showing empathy and understanding, you can help a person cope with, and in milder cases even overcome, their depression. Here are some helpful hints:

• Be empathetic and show attention and interest. Attempt to understand what he or she is gong through and convey this to them.
• Try not to be frustrated by the person's negativity and pessimism. Keep a positive attitude, even if the elder person can't.
• Help the individual in decision-making; help narrow his or her choices, if necessary. Encourage him or her to make decisions independently.
• Do not take "no" for an answer. When a person "refuses", be gentle but firm in your suggestions.
• Make statements instead of asking questions. Instead of asking "are you okay?" you may want to say , "You look sad today."  Give the person ample time and opportunity to talk about how they are feeling, and possible reasons why.
• When the person begins to show signs of improvement, offer praise and encouragement.

Key Points to Remember when dealing with depression in the older adult:

• Depression is not a normal part of aging
• Depression is a clinical problem which is treatable
• Signs of depression are not always easy to detect
• You may be the only one who recognizes a resident's depression
• You can be instrumental in helping the resident through depression
• Refer the resident for a psychological evaluation and treatment
• Be aware of possible side effects of medication given for depression
• Give choices whenever possible
• If a resident "refuses", offer gentle encouragement
• Do not give false reassurances

In Summary:
Most forms of depression are easily diagnosed and treatable by mental health professionals. Early intervention is the key and appropriate treatment can improve the quality of life for many depressed older individuals. Through a combination of appropriate mental health treatment and supportive interventions by family and care-givers you will find that the depressed older person will be less anxious, less demanding, more cooperative, have fewer complaints, become more active, and eventually even need less medication.

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