Depression in the Elderly: Does Grandma Have a Problem, or Is She Just Getting Old?October 18th, 2018
As the expected lifespan increases with medical advancements in diagnostic tools and treatments, it is not surprising that conditions may persist or arise in the geriatric population (defined by the World Health Organization as over age 65) which have not been seen in decades past. In the behavioral health community, we, as providers are noticing depression symptoms more and more during these years, with the frequency of approximately 3% as per the National Institute of Health.
However, the changes in behavior and natural progression symptomatology of the aged need to be differentiated from a true clinical depressive episode. A disorder is considered a disorder when there is a loss of day-to-day function; but there is dysfunction with aging, so is aging a “disorder?” In other words, what is “normal aging” and what is disease state? Perhaps the best way to conceptualize it is in the context of our own grandparents, such as my grandmother, Grandma Miriam.
To give a little background, Grandma Miriam was ahead of her time, attending NYU during a period when it was rare for women to go to a university, let alone schooling beyond high school. She graduated with an English degree, married the love of her life at age 18, had four children, and owned a drapery business with my grandfather for decades in St. Petersburg, FL, before retiring to Highland Beach.
She became the president of her condo association, and quickly moved up the ranks with notoriety in the area, and she eventually was elected to be the City Commissioner, and then Vice Mayor of Highland Beach, FL. Somewhere in there, she had a significant fall, slowly started to decline, left office, and was put on Effexor XR for depression by her primary care physician, until the day she died of congestive heart failure. She had never been on an antidepressant medication until the last four years of her life.
The most important factor to note is the fact that elderlies have difficulty in expressing their depressive moods. Depressive moods, loss of interest, and the inability to experience pleasure can be seen as a feature of elderliness, and simply part of the aging process. Therefore, it is not expressed as a complaint. Stoicism, which my grandmother was an expert in, likely played a factor, but the entire family noted how she did not seem as interested in her job with the city as she had been. The smiles on her face dwindled and were replaced with a look of persistent worry. Some concerns were significant, and other worries were over trivial matters, but amplified to her.
So, what’s another worry wrinkle on an older woman? Low libido, decreased energy, sleep pattern changes, and appetite fluctuations are all part of the clinical depression criterion but are also considered age-appropriate changes in geriatric patients. Another major overlap of dysfunction in aging and depression is seen in cognitive and executive functioning impairment.
Attention, concentration, processing speed, working memory, and language can be impacted. Grandma Miriam was more forgetful, seemingly less organized in her final years; and since she had insight into this, it was even more frustrating and troubling to her, likely feeding the brewing depression. With many warning signs, eventually the picture was more obviously painted, and she was diagnosed and treated for the depression.
There are certain risk factors that come into play for late-onset depression. Typically, in our elderly years, we become mature, as our life experiences accumulate and become integrated into our person — in other words, we become older and wiser. We learn to accept the good along with the bad in life. People who have had generally healthy development periods throughout their life tend to be better prepared to handle the stress that comes with aging. However, the combination of multiple factors, including losing important social connection, growing difficulties with physical skills, and illnesses often cause geriatric patients to end up on various medications to treat their ailments and conditions.
German study conducted in 2008 among non-demented patients found that there were several factors related to depressive symptoms found in older patients, including: living alone, being female, cognitive dysfunction, low education level, alcohol and cigarette use, being divorced, and comorbid physical illness (1). Depression is often related to a feeling of loss of purpose in life, which is frequently tied in with the aforementioned factors.
However, in elderly populations, there is a strong relationship between the intensity of depressive symptoms which is not found in other age groups, as a cross-sectional study done in Japan in 2010 revealed(2). The highest risk factor for depression in the elderly was the loss of a spouse, followed by having a chronic disorder, according to an American study published in 2006(3).
Chronic illnesses, coupled with the use of drugs intended to treat them, are also associated with an increased risk of depression. Antihypertensive medicines and corticosteroids can block, increase emissions, and modify catecholamine or indoleamine systems, which can cause depression. Since we are more prone to various illnesses as we age, and use more medicines because of it, this results in an increased risk of depression in the elderly.
My grandparents were victims of the economic crash in 2007, losing hundreds of thousands of dollars in stocks, their nest egg. They had to leave their penthouse in Highland Beach, and instead of moving into the posh retirement home for which they had initially been saving, they moved into a humble independent living community. My grandmother developed hypertension and atrial fibrillation.
After the fall, she was placed on various pain-killers and non-narcotic pain medications, as well as corticosteroids. The health of my grandfather was declining as well. Physical disease may directly cause symptoms of depression, since it is often associated with a limitation on physical activity, reduction in quality of life, and requiring the support of another person. After the fall, Grandma Miriam simply could not do what she used to do.
The clinical history of late-onset depression often differs from s-onset depression. For example, a familial history or genetic predisposition for depression seems to be more connected to early-onset depression. Late-onset depression appears to be more linked to vascular dysfunction. Clinical depression did not run in Miriam’s family, but her atrial fibrillation put her at high risk for stroke. While depression can cause dysfunction in memory and attention at any age, these cognitive dysfunctions, specifically in executive functioning, are more distinct in late-onset depression.
Currently, the DSM-V does not specifically define depression in the elderly; the same criteria applies to anyone over the age of 18. Recent studies, however, are demonstrating that the presentation of late-onset depression in an elderly is different from the presentation in other ages. In neuropsychological test performances on patients age 60 and over, it was determined that people with unipolar depressive disorder scored lower than healthy people in the same age group. Also, apathy and psychomotor retardation are more commonly observed in elderly depression as compared to younger age groups. Miriam had a flat affect most of the time in her last few years; the smiles were rare.
There are many factors that need to be taken into account when using medicines with elderly patients. This is because many older people have multiple physical diseases and consequently use multiple medicines for treatment. It’s important to consider not only the pharmacokinetic effects (what the body does to the medicine), but also the pharmacodynamic effects (what the medicine does to the body). After age 65, the changes in the physiologic system and the properties of the medicines may increase both the frequency and intensity of side effects.
In other words, the geriatric population is more sensitive to medication due to metabolism changes with aging, as well as the fact that negative drug-drug interactions are more likely as they have co-occurring medical conditions requiring medications. Many elderly patients have bags and bags, lists and lists, cabinets full of prescription bottles. Also, many of these medications need to be taken in the morning, or at night, with a meal, or away from a meal.
This is not the population to have a complicated schedule, as memory and concentration issues are a struggle. So, Effexor XR was chosen for Miriam, in a low dose due to its potential side effect of elevating blood pressure, which was already an issue for her. To the day she passed away, she was on a low dose with minimal benefit. As I was early in my psychiatry residency training at the time she was initiated on the antidepressant, I had little-to-no input on her care. I also had little-to-no knowledge of alternative treatments for depression, such as Transcranial Magnetic Stimulation (TMS) therapy. For many of these aging patients, non-medication interventions could be a much better option.
Though I cannot travel back in time with the knowledge and experience I have accumulated today and use it to give my grandmother a better quality of life in her final years, I can learn from this personal experience to take better care of my own patients, because they can and should experience life free of depression, at any age.
Want to learn more about why TMS may be the best treatment for depression for elderly patients in Broward County and Martin County, FL? Contact Success TMS today by calling 561-240-0194 or filling out a contact form.
1. Van’t Veer-Tazelaar PJ, van Marwijk HW, Jansen AP, Rijmen F, Kostense PJ, van Oppen P, van Hout HP, Stalman WA, Beekman AT. Depression in old age (75+), The PIKO Study. J Affect Disord. 2008;106:295–9. [PubMed]
2. Kaji T, Mishima K, Kitamura S, Enomoto M, Nagase Y, Li L, Kaneita Y, Ohida T, Nishikawa T, Uchiyama M. Relationship between late-life depression and life stressors: large-scale cross-sectional study of a representative sample of the Japanese general population. Psychiatry Clin Neurosci. 2010;64:426–34. [PubMed]
3. Schoevers RA, Smit F, Deeg DJ, Cuijpers P, Dekker J, van Tilburg W, Beekman AT. Prevention of late-life depression in primary care: do we know where to begin? Am J Psychiatry. 2006;163:1611–21. [PubMed]