My dad stays so silent of late. He has stopped going to the club, stopped gardening, which was his favourite pastime, and rarely speaks. Whenever I see, he is just in his room, behind closed doors…”
“Do not worry, that is just age. At one point in life we all will be like this. It is the same with my in-laws too…”
We all are familiar with this kind of corridor conversation that takes place between friends, relatives or colleagues.
It is true that age itself creates a vulnerability, with immense social and physical changes? We assume that the elderly should think or behave in a particular way that is culturally appropriate to their age. As a consequence, any deviation from the norm is often misinterpreted as a part of ageing, and the truth underneath stays hidden.
When the elderly tend to become more inactive, silent, withdrawn, tired or weak compared to their contemporaries, there is something more ominous which can be the reason, and that is depression. This severe form of mental illness affects all age groups alike and the old are especially vulnerable.
Physical factors like loss of vision, hearing and memory, along with falls, injuries, multiple surgeries and polypharmacy as well as social issues like loss of a loved one, grief, retirement, neglect and abuse are the risk factors for depression in the elderly.
When depression strikes above the age of 60 years, it is called late-life or late-onset depression. It is proven that physical changes in the brain and the rest of the body and the impact of environmental changes after this age lead to unique signs and symptoms for depression, which can easily be missed or misinterpreted, leading to deadly consequences of self-harm, suicide or wandering.
Keeping in mind that the elderly face unique difficulties when they are depressed and it is often the caregivers in the family who seek help, it is important that certain myths related to this illness are busted and the necessary facts brought to light.
We hope people reading this will be sensitised to early identification of depression in the elderly close to them and seek help early. Timely interventions in depression save lives and expenditure.
Myth 1: When you get old, you do not get depressed anymore.
Reality: The elderly are at risk of suffering from depression as much as young adults, if not more. The physical weaknesses and social vulnerabilities predispose them further to severe forms of the illness.
Myth 2: He is just feeling sad/low, distract him and he will be better.
Reality: Depression is a severe mental illness. It is not just feeling low or sad. While continued and consistent sadness is one of the main symptoms of depression, it is also associated with significant fatigue, lack of interest for any activities that the person liked earlier, poor ability to focus, pessimistic thoughts, feeling hopeless, and having wishes to end one’s life.
Having said that, the elderly often do not have clear-cut symptoms as above. Increased sensitivity to body pain, excessive preoccupation with minor physical complaints (like toothache, constipation, joint pain, etc), severe anxiety, forgetfulness, social withdrawal, slowness of speech and movements and lack of emotional response are the signs of late-life depression.
In severe forms, they may even complain of hearing voices blaming/abusing them when no one is around, and have false beliefs about being guilty, having sinned or that whole/parts of their body have got damaged or decayed. It is best to detect depression in the early stages for better treatment and recovery.
It is important to mention here that a lot of aged people come to us with depression as well as complaints of forgetting recent events and dates, difficulty in finding their way or dressing, and in recognising faces.
These are also common signs of dementia (like Alzheimer’s disease, in which the brain shrinks in size due to loss of nerve cells and the brain’s abilities gradually decline).
Practically, a lot of them will be having both depression and dementia. Even though we often say that the process of dementia in the brain is irreversible, all these patients will benefit and have a better life if the associated depression is treated. Here comes the importance of early identification and seeking help again.
Myth 3: My grandpa is too old for any treatment. If he stays at home, he will get better.
Reality: Depression is an illness that can be effectively treated with medication (anti-depressants), counselling (psychotherapy) and brain stimulation methods (like electro-convulsive therapy), if severe. The side effects of the different modalities of treatment are best discussed with the treating doctor before the treatment starts. The family’s involvement in the treatment process has been shown to hasten recovery and reduce stress for the family members. If untreated, depression increases in severity, can get resistant to treatment, and increases the risk of self-harm or suicide by the affected individual.
In that context, the elderly respond well to treatment and they need smaller doses of medication than others. Many medicines given for high blood pressure, diabetes or heart problems can increase depression.
As the elderly will usually be on multiple medicines, it is better to have a complete list of drugs when you visit the doctor. As such it is important to control factors like blood sugar, blood pressure, low back pain, headache, gastritis, and vision and hearing problems for optimum recovery from depression.
Studies show that old people have a good response to medication, especially electro-convulsive therapy, which is exceedingly safe and effective.
Myth 4: Old men/women do not harm themselves or attempt suicide.
Reality: The risk of suicide is higher in the elderly. Worse, those who plan suicide in depression often do not express it.
India has already seen an alarming rise in suicide rate (please refer http://www.newindianexpress.com/opinions/2019/jun/30/alarming-rise-of-suicides-and-scope-of-prevention-1997247.html) and 15 per cent of the rise is in adults aged over 55 years.
The severity of depression, having false beliefs of guilt or damage to the body, hearing voices (hallucination), prior suicide attempts or expression of a death wish, chronic pain and loneliness are all important risk factors for self-harm in late-onset depression. if we neglect the early signs and fail to supervise, the outcomes are often ominous.
The World Health Organisation estimates that 5-7 elderly in every 100 have depression. That increases to 15-30 per 100 when we screen for depression in the hospitalised population. One major reason of this rise is under-diagnosed depression associated with other medical illnesses, which resurfaces later.
Studies done at NIMHANS, Bengaluru and AIIMS, New Delhi show an increasing trend of severe depression in the Indian elderly, most of whom respond well to treatment.
Generic lifestyle changes like regular exercise/yoga, avoiding smoking/alcohol, reduced carbohydrate consumption and weight control can have preventive value.
Important social changes include increased familial support, preventing loneliness and abuse, awareness about the legal benefits for the elderly, financial autonomy and daily activity-scheduling.
Many times, a long productive life abruptly halted by retirement, complicated by loneliness following the death of the spouse is the typical example of an elderly person drifting into the clutches of depression. We are all ageing.
The best way to do it in good mental health is to be sensitive to these facts, identify the risk early and seek timely help for depression. To quote Thomas J. Watson, “Stigma is not your illness but the lack of your knowledge about it.”