Depression in the Elderly

1
Depression in the Elderly

• Christopher C. Bruzzini, M.A.
• ACS, AIRC, ARA, ChFC, CLU, FALU, FLMI, PFSL
• Munich American Reassurance Company (MARC)

2
Introduction

• Depression in older people is often __(missed)__
  or _(untreated)_

3
Introduction

• Depression is not a _(normal)__ part of aging
• Symptoms seen as _(inevitable)_
• It is a _(serious)_medical condition

4
Introduction

• It can be hard to recognize depression
• But theres good news

5
Introduction

• People who are depressed often feel better with
  the right treatment

6
Introduction

• If someone doesnt get help, that person might
  not feel better for a long time
• Watch for clues

7
Facts About Depression in the Elderly

• __(2)__ million Americans turn 65 each year
• Of the 35 million Americans who are 65 or older,
  depression affects more than
• __(6.5)_ million of them (or _(18)_)
• Depression is a leading cause of disability in
  the U.S. and worldwide

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Facts About Depression

• It can result in a 55 percent greater decline in
  physical performance
• Growing old is the hardest passage in our lives
• Similar to inhabiting a foreign country
• Older Americans comprise 13 of the population
  but account for 25 of all suicides

9
Facts About Depression

• Severe Depression in the Elderly is as dangerous
  to their lives as
• Cancer
• Heart disease
• Emphysema
• High blood pressure

10
Facts About Depression

• More common among baby boomers
• What percent of depressed elderly persons receive
  treatment?
• A. 10 B. 33 C. 50 D. 75
• There is an average of one suicide among the
  elderly every how many minutes?
• A. 60 B. 90 C. 180 D. 240

11
The Diagnosis of Depression

• Signs and symptoms are extensive
• May have a few symptoms or a vast array
• Diagnosis can be made when at least five of the
  typical symptoms persist for at least two weeks

12
The Diagnosis of Depression DSM-IV Criteria

• 5 or more of the following symptoms for 2 weeks
  or more
• At least one symptom is depressed mood or loss of
  interest or pleasure in nearly all activities
• Plus
• Changes in appetite or weight
• Insomnia or hypersomnia
• Psychomotor agitation or retardation
• Fatigue or loss of energy
• Feelings of worthlessness or guilt
• Difficulty thinking, concentrating, or making
  decisions
• Recurrent thoughts of death or suicidal ideation,
  plans or attempts

13
The Diagnosis of Depression

• Recommended standard procedure the persons
  history, physical examination, evaluation of
  mental status, lab tests
• Can reveal metabolic disruptions
• Mood changes and signs of depression can be
  caused by medicines
• Add the stigma
• In the future Biologic markers

14
The Diagnosis of Depression Commonly Used Scales

• SDS - Zung Self-Rating Depression Scale
• 20 items False Positive rate (40) Confusing
• BDI Becks Depression Inventory
• 21 items 5 minutes to complete Reliable
• GDS - Geriatric Depression Scale
• 30 items Specifically for the elderly No
  somatic items Yes/No format

15
Signs and Symptoms

• Physical
• Emotional
• Cognitive (Thinking)
• Suicidal Thoughts and Deeds

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Physical Signs and Symptoms

• Older people known for aches and pains
• Abdominal distress
• Headaches
• Chest pains
• Arthritic joints
• Eyesight, hearing
• Dont go away when treated
• Physical Appearance
• Woman with the purple dress

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Physical Signs and Symptoms

• Vegetative symptoms (severe depression?)
• Change in appetite or weight
• Sleep (too much or too little)
• Constipation
• Chronic fatigue, tiredness, lack of energy

18
Physical Signs and Symptoms

• More about Activity
• Decreased or Increased activity
• Sexual activity Impotence
• Especially clingy dependent
• Less desire for sex
• Substance use/abuse
• Alcohol is a powerful depressant
• Used to anesthetize, but can increase symptoms

19
Emotional Symptoms

• Often nonspecific (guilty, hopeless)
• Irritability
• Persistent sad or anxious mood
• Worries about money, family, health, demanding
  behavior

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Emotional Symptoms

• Facial Expression
• Crying, restlessness, irritability
• Emptiness and demoralization
• Passive vs. Irritable
• Often co-exists with other anxiety disorders
• OCD, PTSS, Panic disorder, Social phobia

21
Cognitive Symptoms

• Difficulty remembering
• Memory failure, focusing, making decisions
• Delusions
• Hallucinations
• Dementia
• Dramatic

22
Cognitive Symptoms

• Repetitive storytelling
• Self-blaming
• Overly critical, pessimistic
• Seem to have forgotten the time when they
  functioned well
• Apathy Whats the use of trying?

23
Suicidal Thoughts and Deeds Special Symptoms

• Higher male to female ratio than other groups
• Men account for up to 84 of suicides among
  persons aged 65 years and older
• Fewer attempts per completed suicide
• Risk factors differ from those among the young.
  In addition to a higher prevalence of depression,
  older persons are more socially isolated and more
  frequently use highly lethal methods

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Suicidal Thoughts and Deeds Special Symptoms

• Three most common methods of suicide used by
  persons aged 65 and older
• Firearms (_71_)
• Overdose (_11_)
• Suffocation (_11_)
• Other forms (__7_)

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Suicidal Thoughts and Deeds Special Symptoms

• Older persons with depression rarely seek
  treatment for the illness
• Many who go on to commit suicide have reached out
  for help
• __25___ see a doctor the day they die
• __40___ the week they die
• __75___ the month they die

26
Suicidal Thoughts and Deeds Special Symptoms

• Suicide attempts in the elderly should not be
  dismissed
• Suicidal feelings occur, at least fleetingly in
  most depressed people
• Suicide as a solution to ones problems is
  different

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Suicidal Thoughts and Deeds Special Symptoms

• The role of physicians as well as others
• Ask the elder whether he or she has thought about
  self-harm or suicide
• Enlist the help of others (mental health
  professionals or the police)

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What Can Cause Depression In Older People?

• Many potential causes
• Tends to run in families
• Prolonged stress, loss or a major life change can
  trigger the depression
• A disabling illness or recent surgery

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What Can Cause Depression In Older People?

• Loss
• Retirement
• Living on less money
• Moving out of the family home
• Other changes

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Which Older Persons are at Highest Risk for
Depression?

• Unmarried and widowed individuals
• Those with chronic conditions
• Nearly Three Quarters of people over 65 fall into
  this category
• If recovery is delayed, treatments are refused,
  or problems with discharge are encountered,
  suspect depression

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What Can Be Done?

• The first step is to accept that help is needed
• We begin aging when we stop learning
• An active brain produces new dendrites
• They may resist help
• Encourage visit to MD

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Treating Depression

• Once diagnosed, 80 of clinically depressed
  individuals (including older persons) can be
  effectively treated

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Treating Depression

• Anti-depressant drugs
• Psychotherapy
• Psychosocial treatment
• Electroconvulsive therapy
• Alternative treatments

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Treating Depression

• Anti-depressant drugs
• Can take 4-12 weeks to see results.
• Noncompliance a concern
• (__75__) fail to take meds
• Start low and go slow
• TCAs, MAOIs, SSRIs
• General practitioners

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Treating Depression

• Talk therapies (psychotherapy)
• Used in mild-moderate depression
• Interpersonal therapy
• Cognitive-behavioral therapy
• More than a band-aid

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Treating Depression

• Psychosocial treatment for those who have
• Life crises
• Little social support
• Few skills
• No physician

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Treating Depression

• Electroconvulsive therapy (ECT)
• Underused/unavailable
• Myth/misinformation
• Life-saving potential
• Usually reserved for severe depression
• Maintenance antidepressants after
• Unilateral usually attempted first

38
Treating Depression

• Alternative treatments
• Supplements
• Massage
• Aroma
• Herbals
• Meditation
• Homeopathic
• Fish oils
• Vitamins

39
Treating Depression

• Depression is a chronic disease
• Most experts recommend treatment for 6 months to
  1 year after acute treatment achieves remission
• For those whove had 2 or 3 episodes during their
  lifetime, treatment may need to go longer

40
Some Other Suggestions

• Take classes
• Read (Join a book club or other discussion group)
• Keep a journal
• Stay up-to-date on technology
• Teach others skills

• Care for a pet/plant
• Explore cultural life (senior centers)
• Continue artistic/musical talents or develop new
  ones
• Travel (if possible)
• Drink more water

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Preventing Depression

• Prepare for major changes in life
• Maintain personal connections and find someone to
  talk to
• Hobbies help keep mind and body active (MAKE
  time for them)

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Preventing Depression

• Physical fitness
• Exercise (3 times/week)
• Balanced Diet
• Medication compliance
• Rest

43
Despite Common Myths

• They can share the benefits of wisdom and
  experience
• They can seek out new opportunities
• There is hope
• The elderly CAN learn new things

44
Focusing Exercises

• Can give us a glimpse of the difficulties the
  elderly face

45
Focusing Exercise 1

• Using the following grid, find 01 and cross it
  out, then find 02 and cross it outcontinue up to
  49.

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Focusing Exercise 1

• 06 13 33 46 18 38 19
• 04 44 02 29 10 27 35
• 22 26 31 49 08 40 01
• 41 14 12 03 36 15 20
• 32 23 17 37 39 07 25
• 47 30 09 42 05 34 11
• 24 16 45 21 43 28 48

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Focusing Exercise 2

• Repeat the exercise, with this new grid
• Find 01 and cross it out, then find 02 and cross
  it outand continue up to 49.
• Simulated vision impairment

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Focusing Exercise 2

• 41 14 12 03 36 15 20
• 32 23 17 37 39 07 25
• 47 30 09 42 05 34 11
• 24 16 45 21 43 28 48
• 06 13 33 46 18 38 19
• 04 44 02 29 10 27 35
• 22 26 31 49 08 40 01

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Focusing Exercise 3

• Cross out all the letter us you can find in the
  following slide, counting them as you go along

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Focusing Exercise 3

• There is something about preparing for old age
  that ranks it alongside personal finance
  reorganization and testicular examination. We
  prefer to place it on the back burner or, even
  better, forget all about it. In some ways, old
  age is harder now than it was 50 years ago.
  Although severe poverty among the elderly has
  effectively been abolished by social security,
  aging still holds terrors, arising mainly from
  what may happen to our physical and mental health
  in our later years.

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Focusing Exercise 4

• Now cross out all the ts you can find in the
  following slide, counting them as you go along

52
Focusing Exercise 4

• Research has shown that certain types of
  short-term psychotherapy, particularly
  cognitive-behavioral therapy and interpersonal
  therapy, are effective treatments for late-life
  depression. Combining psychotherapy with
  antidepressant medication, however, appears to
  provide maximum benefit. In one study,
  approximately 80 percent of older adults with
  depression recovered with combination treatment.

53

• Sometimes I feel sad or depressed and think Im
  doing something wrong. With all the work Im
  doing to change my life, shouldnt I feel happy
  all the time?
• No. Sadness is just as much a part of
• life as happiness. Just as all the seasons are
  a part of nature, all my feelings are part of me.
  
• Would I awaken on a rainy day and refuse to let
  it rain? Would I claim that Im going to do
  everything I can to stop the rain?
• No. When it rains, it rains.
• I accept the fact that there are times when I
  feel sad. I will let it be a part of being
  human.
• - Anonymous

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• Thank you.

55

• Questions?
• cbruzzini_at_marclife.com

56
Where to Get More Information

• Alzheimers Disease Education and Referral
  (ADEAR) Center1-800-438-4380www.alzheimers.org
• American Association for Geriatric Psychiatry
  (AAGP) 301-654-7850www.aagpgpa.org
• American Geriatrics Society212-308-1414www.ameri
  cangeriatrics.org
• American Psychological Association
  (APA)1-800-374-2721www.apa.org

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Where to Get More Information

• Depressive and Bipolar Support Alliance (DBSA)
  1-800-826-3632www.dbsalliance.org
• National Alliance for the Mentally
  Ill1-800-9051-NAMIwww.nami.org
• National Depressive and Manic-Depressive
  Association1-800-82-NDMDAwww.ndmda.org

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Where to Get More Information

• National Institute on Aging (NIA) Information
  Center1-800-222-2225www.nia.nih.gov
• National Institute of Mental Health
  301-443-4513www.nimh.nih.gov
• National Mental Health Association (NMHA)
  1-800-969-NMHA (6642)www.nmha.org

59
References
Billig, N, To Be Old and Sad Understanding
Depression in the Elderly (Lexington, MA
Lexington Books, 1987) Cooper, PG Depression
brief version (Senior Health Advisor 2002.1),
McKesson Health Solutions, LLC (Clinical
Reference Systems), 2002, Retrieved 6/15/2004.
galenet.galegroup.com JAMA, Depression
symptoms of depression in the elderly contribute
to physical decline. JAMA and Archives
Journals, 6/3/1998. Retreived 6/15/2004.
www.medem.com JAMA. Suicide in older persons.
JAMA and Archives Journals, 3/3/2004. Retrieved
6/15/2004. Mayo Clinic Staff, Expand your mind
a healthy habit for healthy aging Mayo
Foundation for Medical Education and Research
(MFMER) 31 Dec 2003, Retrieved 6/15/04,
www.mayoclinic.com National Alliance for the
Mentally Ill (NAMI), Depression in older
persons, May 2003, Retrieved 06/29/2005,
www.nami.org National Institues of Health, Care
managers help depressed elderly reduce suicidal
thoughts. 3/2/2004. Retrieved 6/15/2004.
www.nih.gov/news/pr/mar2004/nimh-02.htm
60
References
National Institute of Mental Health, Older
adults depression and suicide facts, 2003,
Retrieved 6/15/2004. www.nimh.nih.gov/publicat/el
derlydepsuicide.cfm National Institute of Mental
Health, The invisible disease depression. NIH
publication No. 01-4591, Retrieved 6/15/04.
www.nimh.nih.gov/publicat/invisible.cfm National
Institute on Aging, Depression dont let the
blues hang around AgePage, Retrieved 6/15/04,
www.niapublications.org/engagepages/depression.asp
. National Strategy for Suicide Prevention. At a
glance suicide among the elderly. Retrieved
6/15/2004. www.mentalhealth.org/suicideprevention
/elderly.asp Pipher, M, Another Country, (New
York, NY Riverhead Books, 1999) Rackl, L,
Depressing news for the elderly Daily Herald
(Arlington Heights, IL). 16 Sep 2002, Retrieved
6/15/04. http//galenet.galegroup.com/servlet/HWR
C/Hits?docNumCJ91717061 Whitsett, DA, Dolgener,
FA, Kole, TM (1998) The Non-Runners Marathon
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