Helping an Older Adult with Depression
Rachel: Helping an Older Adult with Depression. We are very fortunate to have Dr. Samantha O’Connell as our presenter. Dr. O’Connell earned her Ph.D. in Clinical Psychology from Suffolk University and she currently performs neuropsychological assessments for the Integrated Center for Child Development, and works as an outpatient therapist for families, couples, and individuals across the developmental lifespan where she specializes in Cognitive Behavioral Treatment.
So without further delay, Dr. O’Connell, I will turn things over to you.
Dr. Samantha O’Connell: Thank you Rachel and thanks all of you for taking time out of your busy schedules to listen this webinar!
When I had the opportunity to speak about depression I was really happy, not because talking about gloom and doom makes me happy, but because depression is one of those medical conditions; yes, I said medical, that is the most widely stigmatized and there are so many myths about what is depression, what helps, and so having the opportunity to speak with you guys about this is really -- it feels really important to me.
Chances are that many of you have had some sort of experience with depression, whether it be experiencing it itself or a loved one or even caring for an older adult who has depression, and so this is a widely, widely prominent mental illness and biological illness that we all are touched with in one way or another.
And the elderly are a population that is at risk for an increased rate of depression, and so I am very happy to be speaking with you tonight about helping an older adult with depression.
Often the older adults are the ones who might feel that they have to be the most stoic about expressing any kind of emotional symptom at all, and so I do feel glad that we are talking about the specific population of older adults today.
So what are we going to cover today? Well, by the end of this webinar I hope that you will have a better understanding about what is depression, what really are the facts, how do we diagnose it, what are the symptoms.
I would like to dispel some of the myths, so talk about the hard science about depression.
Explain causes and risk factors; so what causes this? It’s so prominent, but what is it, what are the vulnerabilities that could lead to depression, and what are the risk factors that could exacerbate your risk for getting it or having a loved one develop depression?
And then to recognize signs and symptoms; so how do we really pick this out, especially in a population that might, like I said before, be more inclined to hold those feelings in. They feel perhaps that they have to be more stoic about their emotions. So how might we recognize the signs and symptoms of depression, particularly in the elderly.
And then the most important part, describing treatment options and discussing steps to take care of yourself, if you happen to be afflicted with depression or someone else.
One of the other reasons why I do really enjoy talking about depression is because it is so treatable, but unless it’s recognized it can’t be treated.
The estimates of the rates of depression in the independent elderly community can range from less than 1% upwards of 5%, but that statistic does increase about upwards of 14%, 15% when an elderly person requires home health care or hospitalization even.
But that’s the thing is that often even elderly people themselves feel like, oh, this is just a part. Life changes. We perhaps lose partners, lose loved ones; you are much more likely the older that you get. Things aren’t in the right spots anymore. Medical conditions are definitely more prominent. But most older people actually aren’t depressed, yet they are a risk group, and they are at risk because depression in elderly people often goes untreated because of this myth that it is just part of the normal aging process.
And many people think it’s just a reaction to chronic illness or to loss or to the social transition that happens when you are transitioning from middle age to elderly. But that’s not true.
Symptoms of depression may be different in elderly people though than younger people. So for example, younger people may be, as I said before, more outward with their emotions and they cry more, and elderly people, it seems, and certainly what I found in my clinical practice, is that elderly people feel like they have to be tough and put on that face that everything is fine, and many of them have been caretakers for other people, and so they just don't admit that.
When they go to the doctor they are often talking about their medical condition and so they are not really talking so much about their emotion.
So it is not typical for older people to just become depressed, but they are at risk.
So let’s talk a little bit about, okay, what is depression? What is it in general? Well, it’s very common, as far as mental disorders go. It's a common mental disorder, but it's also a biological medical disorder. And I said that to begin this webinar, because many people don't think of depression as a medical illness, but it is.
So depression is in a nutshell, we will talk more about specific symptoms, but a person will present with a depressed mood, they just -- they don't feel great, but it's more than the blues. They may have a loss of interest or pleasure in things that they usually enjoy. They feel guilty, low self-worth, and what we often see is disrupted sleep. So a person may sleep more or sleep less. They may eat more or eat less, just not feel very hungry, and overall have low energy. They are just feeling much more fatigued.
And then one thing that we often see across the developmental span is poor concentration, which is difficult to diagnose in the elderly, because sometimes there is an age-related memory decline or just concentration may change as one ages. But often it’s chalked up to that, when it's really not; it may actually be a symptom of mood.
So depression can become chronic or recurrent, which can lead to substantial impairments in an individual's ability to function. Taking care of everyday responsibilities can become affected. That's one of the big things that goes along with diagnosing depression is how much of the person’s life is affected here and how much distress has it caused.
So one way to recognize depression in the elderly, because a lot of these symptoms, besides the mood, just appetite changing, low energy, poor concentration can be part of the typical aging process, but the mood really isn't, but like I said before, elderly people may be less likely to express their emotions, and so one way is we can look for mood changes, sometimes related to changes like retirement or loss of independence.
As I stated before, the rate of depression really goes up once the person's independence gets taken away. And if we stop for a minute and think, okay, what does that mean, independence being taken away? For many, and many that I speak with, it’s things such as not being able to drive a car anymore. Well, that may seem to be not that big of a deal. Being able to drive your own car or drive yourself to your own appointment, go to the grocery store whenever you feel like it is a big deal. So often we see that elderly become much more depressed as a result of having some of that independence taken away.
Of course the death of spouse is one that's much more likely to happen the older you are, just based on statistics alone, and of course normal sadness is always going to be a part of that. But if that grief is accompanied with some of these other changes that we see here, like sleep, appetite, energy, and it's really prolonged, that could be turning into a more significant depression.
Just some other things that we can look out for in a depressed adult is things like just becoming much more irritable or anxious or even talking about death.
So let me stop right here to really talk about some of the myths. Depression is one of the most stigmatized mental and medical illnesses we have out there, and some of the myths perpetuate that so I would like really like to take a point to talk about each of these because they are really important.
Depression is not contagious. So being around a person certainly won't make you more depressed, although if you take in that negativity and stress, that’s certainly possible.
I work with a lot of caregivers for elderly and often -- well, they are even more at risk for depression because of all of the stress that care giving takes as the person, but also if an elderly person that they are taking care of is depressed, they could be absorbing some of that negativity if their mindset is also translating that to negative thoughts, which leads to feelings and then behaviors also.
This is an important one, this second bullet here, I wish I could have you all say it with me, depression is not the same as feeling sad or blue. Many of us have no idea what it’s like to feel truly depressed, but all of us at one time or another know what it’s like to feel sad or blue, and a lot of us have felt clinically depressed.
The prevalence rates are higher than one would think, hovering around about 10% in the United States. But it’s very different than feeling sad or blue. And if we think that depression is the same as feeling sad or blue then we are much more likely to think that, oh, you can snap right out of that.
Depression is not a character flaw or a personal weakness. I worked with a family member of somebody who was depressed recently and they were talking about feeling that their child was tricked into marrying somebody who really wasn’t that great of a person. Well, that person is indeed a very, very wonderful person, smart, intelligent, capable, caring, but within the context of depression, they just are not themselves and cannot do the types of things that make them feel wonderful and be wonderful to others.
And so that myth that depression is a character flaw or a personal weakness is just not true. It’s a mental illness and it’s a biological illness.
Depression is definitely not responsive to suggestions like snap out of it! And if any of you have had experience of someone who is depressed, of course we feel that way, we want to say, snap out of it, be yourself, just look on the bright side, but if someone that’s truly and clinically depressed, those suggestions are absolutely not helpful. The person is likely dealing with a lot of self-loathing anyway and boy, do they wish that they could snap right out of it. And so when we say that to somebody, snap out of it, it just reiterates what they are feeling in their own mind and heart and that’s something that they can't do.
And so I wish it was so easy. I would tell all of my patients, snap out of it, if I thought that would be helpful, but in fact, it would severely break my alliance with my patients and it’s just not helpful.
Depression is not something that is just in your head. It’s actually in your body. Research really supports that. Sure there’s the negative thoughts that go along with the emotions, the negative emotions that lead to negative behaviors or maladaptive behaviors, but it’s actually in your body. There are real hormones and neurotransmitters that are affected that leads you to feeling fatigued. Some people are actually slowed down in a particular type of depression.
This last point is something that I am super passionate about. Depression is not something to be ashamed of. And so the slogan there “Stamp Out Stigma!” is borrowed from the National Alliance for the Mentally Ill (NAMI), which is a lovely organization that really can give some good information about what mental illnesses really are.
But the truth is, is even though there’s so much information out there is that people who struggle with mental illness, including depression, especially older people, they feel ashamed. Why can't I just snap out of it? My life is great. I have wonderful things in my life and yet I still feel this way. So often when the person does have on the outside or on paper what would be a wonderful life that would lead to happiness and yet they don't, there is a lot of shame, there is a lot of shame.
And families also in talking about that and in recognizing if a family member or a loved one or an elderly person that they care about is depressed that there is some part of shame, and that shame certainly is perpetuated through myths and through the fact that we just really don't talk about this so much.
So let’s talk a little bit more specifically about depression in older adults. So I had said earlier that, yeah, adults have an increased risk for depression. So in the general community they may not make up a very large group, but they are at risk.
So one of the risk factors is that older adults have a lot more, statistically speaking, medical problems, such as diabetes, cancer, but there are lots of different medical issues, and we do know that medical issues correlate very strongly with depression.
With older adults, with everybody, depression often goes misdiagnosed and undertreated, but especially so for older adults. And this isn’t a bullet to blame any doctors or anything like that, because doctors working with older adults are often trying to disentangle a whole slew of things, but older people are often talking about their medical conditions and they see the doctors for medical conditions, and so it is often misdiagnosed and undertreated, because they are just not talking about it.
Depression can also be -- it can be a side effect of some of the medications that are commonly prescribed for older people, like medications for hypertension and conditions like heart attack and hip fracture, things like that, those have been associated with the development of depression as well. So sometimes it may just be chalked up to a side effect when really there is something more going on.
Another thing about depression in older adults is we know that neurotransmitters that are linked to happiness, the happy chemicals in your brain, like dopamine and serotonin and norepinephrine, those actually become less abundant as people age. And that paired with the fact that many medications that elderly people take, they can cause some depressive symptoms, and then we sort of have the hat trick of negative things going on there; there’s life changes, loss of independence, social isolation, bereavement, all of those things all put together really make depression in older people much more prominent.
And when we really look at the statistics when it comes to suicide, we find that adults, especially adult males, especially adult White males, they represent a very high suicide risk. They account for 16% of all suicides the elderly people do. That’s a high number. That’s a very high number. So it’s something that we absolutely should be taking seriously and talking about, and I will continue about that later on in this presentation.
Depression does affect both men and women, and it’s an equal opportunity offender, so every social, racial, ethnic, everybody can be affected by depression.
For that point, every group can be affected at the same rate it seems, although research shows that African-Americans and Latinos are more likely to be misdiagnosed.
So it’s very important is along with having a treatment provider who understands the unique culture of the elderly, it should also be a treatment provider who you or your elderly person finds to be culturally competent, because it’s very important and those facts are real that some cultures are misdiagnosed.
The last point right there in bold is the positive one, it’s highly treatable. It really is. And what we find in older adults is that older adults actually seem to respond even a bit better to some of the treatments out there for depression. So it’s a very positive finding.
All right, what are some causes and risk factors for depression? All right, so genetic, biological, environmental and psychological, factors. What does that mean? I highly ascribe to the bio, psycho, social approach to viewing depression.
What does that mean? Okay, the bio part. What you are born with, your genetic predisposition. You will see in a later bullet that if there is a family history of depression, you are much more likely to get it. That’s part of your biology, part of what you are born with, it’s just another risk factor.
It also can be environmental. So whether that be environment that you are reacting to or could be the environment in the womb being exposed to all sorts of things, or even as a person throughout your lifespan being exposed to certain chemicals or teratogens, that could make you more likely to be at risk for depression.
And then of course some psychological factors; what we make of experiences that happen to us, our personalities, how we view the things, our resilience. There are different characteristics that make you more at risk for depression.
The second bullet there, experiencing stressful events like death of a loved one that elderly people face at a higher rate than the majority of the population.
The loss of a loved one right there; one of the statistics that I recently read is that 10-20% of those people who have lost a spouse will develop significant depression within the first year. That’s really high. And one can understand of course the grief and the bereavement that goes along with that, but if it’s left untreated the person can become disabled by their depression, and that is not the typical bereavement process or the meaning-making process; those are things that happen to us.
Another more on the biological side, lack of sleep. That’s something that certainly can make for a risk factor for depression, just not getting the proper self-care that one needs. Again, sleep changes as we grow older. At different ages there is -- we know that sleep becomes much more disruptive the older that you get, and so if a lack of sleep really compounds, then that could be a risk factor for depression.
This next bullet, drug abuse, alcohol abuse, a family history of addiction, that’s a tricky one. I would like to take a few more moments to expand on that one, because, all right, what came first, the chicken or the egg? Someone is feeling depressed and so they turn to substances or substances cause depression? Well, both.
So sure, substances can make you more likely to develop a depression. We know things like prolonged marijuana use for some people can lead to a poor mood. We know that prolonged use of a whole lot of things can certainly lead to that, but what I really like to also make a point to say is that alcohol and drug use is another one of the most stigmatized condition, because often people who do develop an alcohol or drug problem, there is an underlying depression or anxiety that’s there that leads them to be much more likely to become at risk for alcohol or drug use. So it goes both ways, but that’s one that’s very stigmatized as well, and there is a lot of people who don’t consider that there could be mental health before the drug use.
So family history of depression; that’s the biological piece, it’s just part of your genetic risk factor, just like having a parent with diabetes or heart disease, or bad teeth, any of those things, they are in your genetics. So if there is a family history of depression that is a risk factor.
It absolutely does not mean that you will get depression if you have had a family member who has had depression, but it means that you could be at risk for that.
We know that there is a big genetic component, but twins study have told us a lot. So twins share, identical twins share 100% of genetic material, but we know that if one twin gets depression, if it was all biological, then the other would get it, but that’s not the case. The statistics are higher because they share the birthing environment and they often share the similar life, but it’s certainly not a 1:1 ratio, there are other things.
There are two parts of that; bio, psycho, social, the psychological parts and the social learning factors are also big risk factors.
Certain medical conditions certainly can lead to depression, and some medical conditions mimic depression. So some medical conditions like concussion or hypothyroidism can actually look like depression, and so that’s why it’s important to really get an accurate diagnosis.
So let’s talk a little bit about, okay, how do we go about diagnosing depression? I would like to stop just for a minute because we will go into all of these symptoms, and it’s certainly isn’t for all of us to sit there and look at the symptoms and to diagnose ourselves, because there are lots of reasons for why we could, take that first bullet point; having a hard time falling asleep or staying asleep or just not liking things we used to like. So it’s important to get an accurate diagnosis, particularly because, like I said, symptoms that look like depression can actually be something else, including a medical condition or even a different mental illness, such as bipolar depression or other things like that, posttraumatic stress disorder or a myriad of things.
But when we do diagnose someone we have this whole slew of different symptoms that have to clump together, you have to have five or more of them, and you have to have them for at least two weeks in order for major depression to be diagnosed, and they definitely look different depending on your age and your gender. There are all kinds of things, but here are some of them, difficulty falling asleep or staying asleep, but also sleeping too much.
So sometimes depression looks one way, sometimes it looks the other.
Just not enjoying things that you used to enjoy. So just not getting a kick out of the things you used to, withdrawing a bit from your social activities, withdrawing a lot, feeling guilt, feeing worthless, feeling helpless, those are big symptoms of depression.
Slowed movement and speech; the medical term neurovegetative slowing. That’s a big one for just being slowed down. It’s the distinct bodily characteristic that some people experience when they have depression, but not all. There is certainly a lot of fast moving depressives out there as well.
Fatigue, decreased energy, being more irritable, neglecting personal care; for an elderly person, maybe forgetting their medication, neglecting their hygiene.
What’s interesting about that hygiene also though is that often there are different reasons why an elderly person may not want to shower.
So for example, I have talked to many elderly people whose family members are harping on them about taking a shower, but they just don’t want to feel cold. It’s a different sort of dynamic that may be happening in that the hygiene may be going for a different reason. So again, it’s really important to disentangle a whole lot of different reasons why people could be having these symptoms. But if they are all clustering together, it might be indicative of depression.
And then finally there is weight loss or weight gain; that indicates a change in appetite. It gives more evidence that depression is truly a biological condition, as well as a mental health, emotional, and cognitive condition.
Difficulty concentrating and poor memory. These may be some things that people just chalk up to, oh, that’s normal age, memory decline or concentrating. But if it’s clustering along with some of these other symptoms, it may not be.
Ongoing sad, anxious or empty feelings and thoughts, that’s a big one. That one has to be there in order for the diagnosis, a dysphoric mood in general.
Physical aches and pains without a clear cause. That one is hard in the elderly population because there is a lot of physical aches and pains that go along with a normal aging process. But in elderly people and others if there is no clear cause that could be a physical manifestation of depression.
And then finally, thoughts of dying or suicide. That’s a big one. As I said before, elderly account for 16% of the suicide rate and that number skyrockets, particularly for White males over 65. And that’s something where it’s serious, and just asking someone about, are you having thoughts of hurting yourself, isn’t going to make it more likely to happen.
So when we talk about what to do, one of the things to do is maybe just ask if you are seeing all of these symptoms happen at the same time. And if we are finding that someone is at risk, definitely get help, get help right away. They can call crisis 911, the number is there. That’s something that you certainly could help a loved one do if they are feeling suicidal.
There are many treatment options. This is the positive part. Depression is a horrific, but there are lots of things that can help. They can range from healthy lifestyle changes to therapy.
My bias is cognitive behavioral therapy, which is, cognitive is a soft part. I think my life won’t get better, which leads to the feeling of hopelessness, which leads to the behavior of why try, I am not going to do anything versus my life is really bad. I feel really sad, but I am hopeful that treatment can help and therefore I get treatment and I do better. So that’s a very short version of what cognitive behavioral therapy is, but it’s working on the thoughts behind the emotions that lead someone to withdraw.
Talk therapy or even group therapy can help someone feel more connected and really move from a depressed state to a more well state.
Medication is one of the most widely researched interventions for depression and it’s certainly one that’s one of the most effective.
And there are a myriad of other nontraditional therapies, such as light therapy, acupuncture, all sorts of different kind of therapies that may be helpful for certain people, but what’s the most important thing to know is that treatment does work.
So how to help yourself, I would like to take a moment here to really recognize that this webinar is intended to help us think about depression in the elderly, but the truth is, is that many of us may experience something that’s more than the blues. So I hope that learning about depression such as with this webinar can help you to know what to do or to have just more information if you are starting to feel like, you know what, those symptoms really fit me or someone I care about.
Building emotional skills, setting small goals. The big things are not going to happen if you truly are depressed, but the small ones can.
Fighting the urge to isolate that really comes with depression will be important.
Cultivating supportive relationships with people who understand or who will listen when you do explain it and then understand.
Really important, taking care of yourself; eating, exercising, reducing stress. Even if that depression starts to become pretty bad pushing yourself to do little thing can really help change the course.
Evaluating and setting priorities in your life can be helpful.
I would really recommend postponing major decisions until you feel better. One of the symptoms is concentration just isn’t that good and so postponing major decisions, I really highly recommend that.
Definitely follow the doctor’s treatment recommendations. So make sure that you are connecting with the doctor that you trust, that you don’t feel stigmatized by it, that you feel connected with.
And then trusting and following that doctor’s recommendation.
Speaking to a health care professional if symptoms worsen.
These are some tips to help a friend or a loved one or an elderly person. Talk to the person; in behavioral terms what do you notice?
Be supportive and nonjudgmental; listen carefully. Reflect back what they are feeling rather than say, oh, it’s not bad or things will get better; maybe say something like, I am hearing that it’s really hard to just get out of bed right now, just that connection can help them feel more understood.
Encourage a friend or a loved one to get appropriate assessment and treatment.
Encouraging social activity and exercise, but not pushing.
And of course never ignoring talk of suicide. People are afraid of asking the question, but like I said before, asking the question doesn’t make the person more likely to hurt themselves; in fact, it could lessen the chance, because now it’s out there and they can talk about it.
So in conclusion, it is not a part of normal aging. Depression isn’t. It’s highly treatable. It’s important to work with a health care professional to get a good diagnosis and appropriate plan and to really take depression seriously, in particular suicide seriously.