Depression of later life (old age)

Dr K Shantibala Devi Yumnam *

Depression is a very common mental illness and about 1 in 7 people experience a depressive episode during their lifetime. Depression usually have a recurrence or even a chronic course thereby leading to significance impairment in psychosocial functioning which account for the fourth leading course of disability. The economic cost can be staggering, spent on medical treatment and also loss of productivity and premature deaths worldwide. Depression affects suffered by women then in men and reasons implicated are hormones, more psychosocial stressors suffered by women and childbirth. Depression occurs before age 20yrs in 40%, 50% in age group 20yrs to 50yrs and 10% after 50yrs of age.

Depression illness disorder in later life is linked to poor health which adds to the many medical illness common in the age.

How do we know one has depression?

From time to time one experience low mood, sadness depending on the situations and events. But in depression there is a qualitative change in mood which is intense and uncomfortable, associated with other physical symptoms of appetite and sleep, problem and in many areas of functioning.

There is sense of emptiness and sadness and others will see them as off mood or tearful. Interest and pleasure in all activities will be diminished with lack of attention and concentration, feeling dull and lethargic. There may be poor appetite or increase in appetite leading to weight loss or weight leading to weight loss or weight gain and also difficulty sleeping either of increased sleeping and sleepiness. Restlessness or retardation both mentally and physically. Weakness, fatigue and loss of energy is another complaint. Inability to take decision and sense of worthlessness, hopelessness, inappropriate guilt feeling and recurrent thought of death, desire to suicide or making attempt to end life. The above mentioned symptoms if present most of the day, almost every day for a period of two weeks affecting previous level of functioning can be diagnosed as having depressive illness.

Types of depression in later life may be mild depressive disorder, moderate depression and severe depression. In mild depression the symptoms are felt as distressing but can symptoms felt as distressing but can continue to function in life relatively normal. In moderate type symptoms are subjectively more distressed than in mild form and though they can maintain their daily life function, they struggle with considerable difficulty. However in severe depression there is marked distress and are often agitated or retarded and their ability to function in their usual role is severely limited and impaired.

Presenting symptoms

1. Age-related factors: Late life depressive disorders in older people usually complain less of sadness than younger adults and more concerned on physical health. Hypochondrial complaints are the mainstay with several unexplained pain syndromes such as aches and pain of joints, back pain, chest pain, abdominal pain or musculoskeletal pain of any part of the body. Other symptoms present are insomnia, sense of loneliness, forgetfulness anxiousness, tenseness, changes in personality traits behavioural disorder, inappropriate concern of bowel movement, disturbance in appetite, late-onset abuse of alcohol etc. since the complaints are mostly physical rather than emotion, with minimal expression of sadness, and diagnosis of depression may be missed.

2. Psychosis: Psychotic symptoms are likely to occur more higher in late-life depression. They usually present with delusion (false, fixed belief) of having severe medical illness, delusion of guilt, poverty and worthlessness. When severely depressed, patients may have delusion that his organs are damaged and that they are no more alive. Auditory hallucinations or hearing of voice that is not present of saying bad and negative things about them. There is frequent self murmuring and self-talking, withdrawal, anger and being hostile as they feel others are out to harm him or poison him.

3. Apathy and amotivation: Apathy and lack of motivation is another symptom seen in late life depression where there is lack of emotional response and goal-directed activity. They feel fatigue, lethargic and absence of drive, indifference poverty of thought and action. These are seen more so after a stroke, head injury, neuronal degeneration (dementia)

4. Suicide: Older people with depression are at risk of committing suicide. Elderly rarer/ take overdoses of medicines as a means to commit suicide and the means differ from culture to culture. In the western and pain killers are common and U.S shooting by firearms among older depressed men are quite frequent. Suicide attempts among older population are not to draw attention or suicide threat or by accident. Their intent ar; serious.

What are the suicide risks in later life depression?

The general factors include those who had past suicide attempt or episode of self-harm, male gender living alone who have no social or family support who had experienced negative life events. Presence of longstanding stressors which may be environmental or financial and presence of chronic medical conditions including cancer. Elderly who misuse and abuse alcohol are also at higher risk of committing suicide. Illness factors such as mental illnesses (mood disorder, psychosis, substance use) and who have sleep problems, agitation restlessness, guilt feelings, hopelessness and low self-esteem and hypochondriacal pre-occupations are a major risk factor that can propel to ending their life. There are also specific behaviours such as suicide intent or plans expressed, altering wills and severe self-neglect.

The type of thought impairment and its significance in late-life depression

What lead to late-life depression? In late life depression genetic cause is less but it can be precipitated by negative life events such as loss(near relatives, financial etc) depression is more common in women at all age particularly who are widows and divorces mostly due to long standing stress and difficulties faced by women. Elderly who have had past history of persistent depressions alcohol dependence and schizophrenia are move at risk. Physical, medical ill-health and handicap with poor social support, poverty, loneliness and who have personality problem can also lead to depression in late-life. Medical conditions and drugs that may cause organic depressive disorder.

Medicals conditions illnesses include diabetes, thyroid disorder, hypercalcaemia, anaemia and sub nutrition. Others include heart disease, stroke, brain tumors, dementia, Alzheimer’s disease, Parkinson’s disease SLE, cancer of lung and pancreases, syphilis, AIDS and other chronic infections. Drug that arc implicated in causing depression are:
1. Antihypertensive (beta-blockers, reserpine, digoxia, mifedipine, calcium channel agents etc)
2. Steroids
3. Analgesics (opioids)
4. Antiparkinson
5. Neuroleptics, benzodiazepines
6. Alcohol, interferon

Common life events and chronic stress that causes depression

Life events:
1. Death of spouse, offspring
2. Separation
3. Acute physical illness, life threatening medical, surgical illnesses
4. Sudden displacement or homelessness
5. Major financial crisis 6. Conflict, quarrel with family or friend and even
7. Loss or death of a pet.

Chronic stress:
1. Declining health and inability to move around leading to dependence
2. Impaired memory, hearing and vision
3. Any major family problem and marital difficulties
4. problems at work place, socio-economic decline and retirement
5. Being a career of chronically ill and dependent family members.

Other associated illness with depression in late life

Other illness associated with late life depression cognitive impairment - depression is highly prevalent in dementia and chronic depression is a risk factor for dementia.

Stroke and mood disorder
After a stroke in about 20% of patients develop depression within the first year (3-6 months) Post stroke emotionalism
Emotional changes following a stroke are common and effect 20%- 25%. In emotionalism there may be sudden crying or laughing without any reason or warning. Depressed mood and emotionalism can occur together.

Coronary heart disease
In 15% to 20% of patients who had coronary event (myocardial infarct or heart failure etc) depressive symptoms occur further, presence of depression is a risk for cardiac diseases and early death

With age diabetes type 2 h Diabetes
With age the development of type 2 diabetes increase and diabetes is associated with development of depression. Research shows that presence of depression in diabetes patients increase the risk of complications and poorer blood sugar control.

Depression is associated with several medical conditions which further complicates leading to poor outcome. Other conditions where depression is present are cancer and pain disorder, chronic lung diseases which are common old age problem.

Treatment of late life depression
Various treatment approach is required for diagnosis of the type of depression and associated medical disorders as the goal of treatment is to attain remission, to reduce suicide risk, to help patient achieve optimal functioning by treating the whole person and to help prevent relapse and recurrence of the illness.

First- general assessment
Detailed history talking, mental status examination, screening cognitive impairments.

Investigations/tests
1. General blood picture test
2. Kidney function
3. Thyroid function
4. Calcium, B12, folate level
5. Lives function
6. Syphilitic serology
7. CT scan of brain
8. ECG
9. EEG

Pharmacotherapy/drug treatment includes antidepressants, anxiolytic and antipsychotic. The type of drugs used depends on the patients symptoms. Dose of medicines also is considered on the age and the presence of other medical conditions.

Psychological treatment

Psychotherapy is a must in the treatment of late-life depression. In mild to moderate depression its effectiveness is quite significant. Some of the psychotherapies used are cognitive behavioural therapy (CBT) and behaviour therapy, interpersonal therapy (IPT) and dynamic psychotherapy. CBT helps the patient to understand the links between low mood and both negative thoughts and subsequent behaviour. It will help to control negative thought process. IPT helps patients change and accept their current change and accept their current situation.

Problem solving therapy (PST) motivates patient gain a sense of memory over difficulties and to give sense of control over their life. In mild to moderate depression research have proved the efficacy of psychotherapy. However pharmacotherapy and psychotherapy when used in combination is more effective and gives desired result. Family therapy to those living together and giving care are important in late-life depression who also has dementia.

Conclusion

Late-life is a time when difficulties and problems comes in a package of family burden and conflict, several medical illness physical weakness, reduced mental capacity, retirement, separation, loss etc to a large population if not all. 50% of depression occurs between age 20yrs to 50yrs and 10