Heart Health

Depression Among the Elderly

August 8, 2011

Depression Among the Elderly

In my first year of medical school an instructor posed a question to our class: “If you could develop a cure for one disease what would you choose?”  The year was 1989 and the disease that was on everyone’s mind was acquired immunodeficiency syndrome (AIDS), an illness that at the time seemed to be blossoming faster than the black plague epidemic of the dark ages and for which no treatment was available.  Most of my classmates voted to cure AIDS while others opted for various different types of cancer.  A few suggested diseases affecting third world countries, such as malaria and tuberculosis.  No one volunteered a cure for heart disease (I guess that means job security for me).

The lecturer then spent the next hour making a case for finding a cure for a particular disease that affects over a third of the population and is associated with considerable impact to personal productivity and quality of life: depression.  His perspective was that people afflicted with depression suffered as much or more than patients with any other ailment, only in a less visible way.  He also suggested that the high suicide rate among those with severe depression implies that, at least for these individuals, living with their illness is even worse than death.

I have since thought a lot about the point that our instructor was trying to make and have come to agree with him.  My opinion on the matter has strengthened since I began caring for many older patients who have a combination of heart disease and depression.

While I don’t consider myself (even remotely) an expert in the treatment of depression I often discuss this issue with my patients, usually at their request.  In some ways I think my patients put me in the same category as their bartender—for some reason they have an easier time discussing some problems with me (who, they suspect, will provide an impartial opinion but who won’t commit them to some type of treatment) than their own physician.  “My family doctor thinks I have helminthic halitosis and wants to start me on sublingual metronidazole.  What do you think about that?”  I suspect a lot of times they are more forthright with me than they would otherwise be simply because a question to a heart doctor about a non-heart item makes it an unofficial question.

This is how I often end up on the topic of depression.  If you were to open a textbook on the subject you’d find a dozen different types of screening tests and questionnaires that help you identify patients with depression.  I have come to rely on a simple approach that involves a single question: do you think you’re depressed?  True professionals will take me to task on this over-simplification but I find that it works well for most patients willing to open up about this.

Depression among older patients is an interesting phenomenon.  If a young person loses interest in life, lacks enjoyment and happiness, and drifts into hopeless despair, most likely he’ll be correctly diagnosed by family and doctors.  When older people exhibit the same characteristics, however, those around them simply write it off to the effects of aging.  The average 85-year-old person is widowed, has lost half her friends to death or incapacitation, is unable to engage in the type of physical activities she’s enjoyed in the past, has difficulty remembering recent events, is plagued by chronic pain and discomfort, has to rely heavily on others (for transportation, meals, housekeeping), loses a taste for food, has difficult reading because of poor vision—and none of these things is getting any better.  Of course she’s depressed, they say.

It’s for this reason that depressed seniors rarely reach out for help.  The problem is made worse by the stoicism of the Greatest Generation, the D-Day heroes and Rosie the Riveters who grew up during the austere 30’s and knew darn well that June Cleaver never moaned about her domestic dissatisfaction.  Despite this, depression is present in more than a third of elderly individuals with heart problems and is seen in about 40% of those who are hospitalized, have cancer, or have suffered a stroke.  Worse, the 12% of the U.S. population that makes up the 65-and-older crowd accounts for a disproportionate number of suicides (16% of all suicide deaths in 2004).

Depression is a big problem for our youth, but it’s at least on the radar of doctors and counsellors.  Does a sad and hopeless heart attack survivor raise the same red flags?  He should.  Depression among this class of patient portends a four-fold increase in death.  Among stroke survivors, the diagnosis of depression predicts a ten-year survival rate 70% lower than their happier counterparts.  And these death rates aren’t due to suicide—depression itself is a disease that somehow degrades the elderly body as much as any other chronic illness.

It is human nature to hope for a better tomorrow when we suffer from sickness today.  The belief that “things will improve” allows us to muster the strength to recover from even the most miserable illness.  When a life-threatening ailment such as a heart attack is compounded by the inability to foresee a brighter future, the result can be an outcome that is significantly worse than predicted in our cardiology textbooks.

So, keep an eye out for this problem—in yourselves, in your parents and grandparents, and in your patients.  While we don’t have a silver bullet cure (my medical school instructor will have to wait a few more years before we can eradicate this scourge) we have therapies for depression that can help substantially.  Our family members will be better off, our cardiac patients will recover more fully, and I’ll gladly give up my job as bartender.

  1. Andrew

    Surely this confusion over the word "depression" fails to take into account that many elderly are lonely, isolated and never have contact with the outside world. The answer my learned friend is to include the elderly like spending time with them, listen to their stories and build up there self worth. Answers aren't found in books rather in the human spirit.

  2. Eric Van De Graaff, MD

    Dr. Newson, Thanks for adding your expertise as well as the helpful links. Dr. VDG

  3. Melody Newson, MD Psychiatrist

    I would like to offer available resources in the Omaha area which provide evaluation, treatment, group psychotherapy, and support for families who have loved ones suffering from depression. The Heritage Immanuel Center is an inpatient behavioral facility which provides psychiatric treatment for our aging population whether symptoms are due to depression, dementia, or other mental illness. We have a well trained staff which includes board certified geriatric psychiatrist, internist, therapist, nurses, and behavioral technicians. Below are resources which are provided to patients and families for additional support: http://helpguide.org/mental/depression_elderly.htm http://www.nami.org/Template.cfm?Section=By_Illness&template=/ContentManagement/ContentDisplay.cfm&ContentID=7515 http://www.healthyplace.com/depression/elderly/depression-in-elderly/menu-id-68/page-3/ http://www.webmd.com/depression/news/20110102/bright-light-eases-depression-in-elderly-people http://www.psychologyinfo.com/depression/seniors.htm As physicians we enjoy supporting families through education, which may help to reduce the stigma so often associated with mental illness. In reading the above blogs the insight and awareness is greatly appreciated, which demonstrates we are making progress in our efforts to treat mental illness.

  4. Eric Van De Graaff, MD

    Mary, You have correctly noted that I omitted any mention of therapy from my blog post. This is partially out of consideration for the limited space I have on the subject, but mostly because I don’t have enough expertise in the field to be able to provide much useful information. Families frequently struggle with depression among elderly parents, grandparents and spouses. The challenge is that depression is often co-mingled with other illness, such as dementia, that makes treatment even more difficult. With that in mind, I believe your first step is to arrange a thorough medical evaluation of your loved one in order to determine if there are other factors that can contribute to depression. Some examples, in addition to dementia, include hypothyroidism, sleep apnea, anemia, and chronic pain. Furthermore, several of the medications we use for other problems can cause mood and mental status changes in elderly patients. A good resource could be a visit to a geriatric specialist. In my experience, these doctors–who are internal medicine physicians with additional training in geriatrics–are very good at teasing out other possible underlying causes of depression. The use of medications to treat depression in this population is beyond my expertise, but suffice it to say that a good primary care doctor should be well versed on this subject. Finally, common sense remedies may end up being the best (and these are things I’m sure you’re already doing). Offer your services around the home, pay frequent visits, help your loved one get out of the house as much as possible, and let them know that despite their age they are still valued and treasured. Mary, I wish I could do better. Good luck with everything. Dr. VDG

  5. Mary E Ramm

    How can family members help a depressed senior? Do you have any resources available?

  6. Ruby

    Dear Dr. Eric Van De Graaf, It’s a great pleasure to read your blog. I find your post very informative. This post simply gave a better view on the world of the elderly enabling us to realize how to be there, and how to care for them. As a reader, I consider your writing to be a great example of a quality and globally competitive output. It would be a great thrill and honor if you could share your genuine ideas and knowledge to our community, Physician Nexus. With this you can gain 1000 physician readers from over 62 countries on Nexus. We would love for you to visit our community. It's free, takes seconds, and is designed for physicians only - completely free of industry bias and commercial interests. Best, Ruby Jean Abarcas On behalf of the Physician Nexus Team www.PhysicianNexus.com

  7. Daisy Duke

    Being a geriatric nurse manager for several years I have seen depression in the elderly. Depression is something I see a lot in the elderly and especially in people who suffer from Alzheimers disease. We pull out the great old geriatric depression scale to assess all our new elderly admits. The scale is full of questions like, "Do you feel worthless?" and "Do you feel like your life is meaningless?" I want to scream every time I even look at that form. I don't think those questions help people, and the treatments and interventions we have for scoring high on the scale are pathetic at best, and damaging at worst. Sometimes I will get really excited when I see an antidepressant drug work in a patient I care about. I do have to admit I have seen remarkable changes in some elderly people with drugs, but the effects tend to wear off over time and the sadness returns. I think one of the real changes that could be made in our society to help depression in the elderly is to value our elderly the way we value our young people. I think we could all do a better job to assume the life of an elderly person is of great experience, wisdom, and value and not tragedy ridden and worthless. Sometimes I see doctors who are sloppy with a "Oh he's 85 years old anyway.." justification behind their lack of thought or work. I think diseases in the elderly merit as much attention as diseases like AIDS in the young. Life is sometimes treated less valuable as it comes near it's end, but my heart will never forget my 95 year old patient and friend who died asking, "How can I save my life?" In my heart he was still the guy who was there the day Pearl Harbor was bombed. He was young and brave. He was the guy who lost his best friend that day...and the guy who cried as he described why he never married the girl he loved. He was so valuable at 95, and he was my friend. A young person goes through a tragedy and they are better and stronger for it. An old person goes through difficulties and suddenly they are being asked if they are depressed and worthless. I love my patients and if I do just one thing in this world someday I hope I help to find a cure for an "old persons disease" like Alzheimers disease. Today one of my favorite elderly patients was calling out "HELLO HELLO" I just walked over and put my arm around her and hugged her. She said, "Oh thank you! What are we doing now?" I said, "We're going to dinner soon." She said, "Okay! That sounds good. Where are we?" I said, "We're home, and I LIKE you!" Though I can see the color changing in her face she feels the value I place upon her and her life. I know she will be taken by Alzheimers disease soon but I love my old people and I have hope for the elderly and improving their quality of life someday by helping to find a cure to their #1 beast disease (Alzheimers). More than a focus on depression they need the same love and attentive focus that we give to a young patient. Could we understand more about beta amyloid plaques? Could we understand more about what causes these plaques and understand more about brain metabolism? How does the brain work? What damages SH enzymes? Is Alzheimers disease caused by oxidative stress, increased Hg, and decreased glutithione? Since glutithione can't be orally absorbed would increasing it with another drug help? What role does Tau play in the disease? How are the neurons of someone with Alzheimers different? Why is the mitochondria isolated to the top of the neuron and unable to work in the axonal sheath in people with AD? Why did the immunization approach to a cure cause encephalitis? What new and exciting things did all the people come up with who met for ICAD (International Conference on Alzheimers Disease) in Paris last month? I wish I could I have been there! I have so many questions in behalf of my elderly patients.....and Do you feel your life is worthless is NOT one of them!

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