Depression in the Elderly

by Lory Bright-Long, MD

Depression is a very prevalent problem in the elderly. Surveys have estimated that nearly one in four of the over 65 population and nearly one-half of nursing home residents may suffer from some form of depression. Psychiatrists have questioned whether the depression that is diagnosed in late life is different from the depression experienced in younger patients.

We know that those who experience depression in their younger lives have the vulnerability to have recurrent depression throughout the life span. People with recurrent Major Depressive Disorder or the depression of Bipolar Disorder may exhibit depression throughout their lives. What about those individuals who have never had a depression before? Are there different types of depression that may affect the over 65 age group differently?

With age does come the possibility of having a chronic medical illness, a significant change in work or life style, and the possibility of losses of friends and loved ones. The depressive disorders related to medical illness, losses/prolonged grief, and adjustments to new and difficult situations may be quite different from a major depressive disorder occurring in late life.

Depressive symptoms include: sleep disturbance, loss of interest in usual activities and decreased motivation to pursue interests, increased feelings of guilt and self doubt which interfere with daily life, decreased energy, a change in ability to concentrate on tasks, a change in appetite, or feelings of helplessness and hopelessness may be present in any type of depression. The differences in the symptoms of the disorders may only be in the intensity, length of time they are evident, and how much the symptoms affect daily functioning.

Depression is often associated with stroke, heart disease, diabetes, severe arthritis, Parkinson's Disease and the dementia disorders. Individuals with a chronic disease may experience a grief-like response to being ill. There are many physical and emotional adjustments that come with having a chronic illness. Due to an acute or chronic disease, an individual may experience a loss of a work role, a need to change living environments, and/or a loss of freedom and well-being. The medical illness itself may have significant effects on one's sleep, appetite, or energy level. Medications used to treat disorders may have an effect on the way one feels or may actually cause depressive symptoms. One must not accept depression as an inevitable consequence of being "old and sick". Working with a physician who understands the interactions of illness and emotions can lead to an understanding of how to separate the physical from the emotional. Once that separation is recognized, an individual can learn new treatment strategies for both. Understanding the specific disease process and how medication can be used along with other forms of therapy may reduce the negative emotional effects. Learning new skills such as relaxation, imagery, pain-reducing exercises, meditation, and other ways of self-expression may give one a sense of mastery over a chronic illness. A review of medications used to treat the illness may be necessary and medications adjusted. There also may be a role for antidepressant medications in conjunction with the treatment of another medical illness.

Depression associated with prolonged grief may respond well to bereavement counseling either in an individual or group setting. Adjustment disorders with depressed mood may also respond well to counseling and/or changes in one's activities but also may require antidepressant medication for complete resolution.

So when are medications necessary? When the depressive symptoms continuously interfere with ones day-to-day life style for greater than a week or two, it is time to discuss medications with your physician and request a referral to a psychiatrist familiar with aging.

Medications used for depression in late life are the same medications used in younger patients. It must be remembered that they can be highly effective when used in the proper diagnosis, used in appropriate doses for an adequate time, and monitored closely. Antidepressants have two drawbacks. First, it does take some time to have an effect on mood and resolution of the depression. Some medications will have a more rapid effect on sleep or feelings of anxiety, but it may take 10 days to 6 weeks before the medication has a full effect on the depressive disorder. Because older patients may have concomitant medical problems, take other medications, or may have some changes in the way their bodies handle medications, physicians caring for older individuals will "start low and go slow". It is important to introduce medications at lower doses than with younger patients and to gradually increase, but also we know that most elderly individuals do tolerate and require doses of antidepressants very close to their younger counterparts. Twenty-five years ago, psychiatrists had limited choices when prescribing antidepressants to the older patient. Even though the tricyclic antidepressants or TCAs were effective in treating depression, they had significant side effects on blood pressure and pulse rate, caused constipation and urinary retention, interfered with other medications, and had the potential to cause memory loss. The most studied medication in older adults is nortriptyline (trade name may be Pamelor) and is still used judiciously in older patients. The newer antidepressants, such as the selective serotonergic reuptake inhibitors or SSRIs (Prozac, Zoloft, Paxil, and Celexa), are the most frequently prescribed in general medicine. The most frequent side effects are nausea, vomiting, diarrhea, insomnia, and sexual dysfunction. Physicians still must be careful about combining these medications with other drugs used for medical illnesses since there may be interactions. There are other medications to choose from and patient and physician should give another family of antidepressants a trial if there is no effect in 8-10 weeks, or side effects are problematic.

Treatment of depression may seem to be a challenge due to the multiple causes of depression in late life and the multiple choices of treatment. The one important aspect of treatment is to develop a strong working relationship with a professional who can act as a guide through the process and help the individual discover strengths and reserves that are available. Depression is a treatable disorder at any age.

For more information on late life depression, the American Psychiatric Association has information available through the Council on Aging, or contact the American Association for Geriatric Psychiatry Website: www.aagpgpa.org or E-Mail: main@aagpapa.org.

ABOUT THE AUTHOR:
Lory Bright-Long, MD, is a geriatric psychiatrist practicing exclusively in nursing homes on Long Island. She is a graduate of Medical College of Ohio and completed her Psychiatry Residency at Stony Brook University Hospital. After completing a Geriatric Psychiatry Fellowship in conjunction with Stony Brook and the Office of Mental Health, she joined the Stony Brook faculty. Since 1996, she has directed the Kipp Pavilion for Special Dementia Care at St. Johnland Nursing Center in Kings Park, New York. She participated in the American Psychiatric Association's development of Practice Guidelines for Alzheimer's Disease and Related Dementias and was a co-author of a manual for psychiatric care in nursing homes published in 1999.