My beautiful, fiercely independent grandmother Audrey has always been one of the most positive forces in my life, even as she has endured the death of my grandfather and most of her friends. At the same time, she has faced such mounting challenges as the gradual loss of her hearing and, more lately, the affront of having to walk with a cane. But now, on the eve of her 94th birthday, her vision has deteriorated to the point that she’s having trouble reading her beloved newspaper every morning. For the first time, she seems sort of depressed.
Watching Grams struggle to keep up with the family-dinner chitchat on a recent trip home, I couldn’t help but wonder whether the particular trials of growing older — from the death of loved ones to gradual declines in health, self-sufficiency and control — inevitably lead to this unhappy outcome.
The short answer is that aging does seem to make us more vulnerable to depression, but it’s not a foregone conclusion.
“Even though so many things happen as we get older — lots of losses and physical changes — most people weather those by adapting, and adapting without becoming depressed,” says Susan Lehmann, director of the Geriatric Psychiatry Day Hospital at the Johns Hopkins Hospital. There’s a difference, she adds, between feeling profoundly lonely or blue and true clinical depression, which is a mood state involving physical and behavioral manifestations that does not shift easily.
Lehmann notes that research has shown that major depression occurs in about 2 percent of people 65 and older, while minor depression strikes about a quarter of them, with the number even higher in nursing homes. All forms of the disease can be debilitating: “It might be called minor depression, but it can have a major impact on functioning and quality of life, so we really need to take any signs of a problem seriously,” she stresses.
Depression is much more common in women than men from puberty all the way through the mid 80s, Lehmann says, when occurrence evens out. It’s also worth noting that while heredity can play a role in depression at any age, it seems to be much less of a factor than cardiovascular and other changes in the brain as we get older. “We believe that other biological factors rather than genetics or family history seem to be important in late-life depression,” she says, noting, for example, that imaging studies have found small changes in the white matter of some elderly brains, possible evidence of mini strokes that may be related to depression.
Other medical conditions can also play a role: “Diabetes doubles the risk for depression, and depression may even be a risk factor for developing diabetes — they are feeding each other,” says Lehmann, adding that there’s a similar relationship between depression and coronary heart disease.
So how do you know if your parents or grandparents have a real problem, as opposed to fleeting sadness or loneliness? They probably aren’t going to scream “I need help” from the rafters.
“Depending on the generation, culture or context, elderly patients are much less likely to talk about or report a depressed mood,” says Lorenzo Norris, medical director of psychiatric services at the George Washington University Hospital. “This generation, particularly patients now in their 80s and older, grew up at time when the prevailing attitude was ‘You pick yourself up by your bootstraps, keep your chin up and keep your problems quiet,’ so there can be an element of shame, of being afraid that people will think you are ‘crazy’ and also thinking that depression is in one’s head or a sign of personal weakness. They don’t think of it as a neurobiological illness, like most younger people do; they think of it as something you just knuckle up and get over.”
As a result, experts say that it’s important for family members and caregivers to be on the lookout for signs of minor depression, which often presents quite differently in older people.
For example, seniors will typically complain about physical symptoms or problems rather than emotional concerns.
“It’s very common for patients to talk about a lot of GI problems, stomach problems, headache, pain, but not necessarily sadness and not crying spells . . . which can lead the focus to only be on their arthritis or GI problems, and to miss the fact that these are symptoms of depression,” says Lehmann. She adds that major changes in appetite, weight loss, sleep, energy and concentration can also indicate depression, along with losing interest in and enjoyment from things that are normally pleasurable, such as gardening, music, church or spending time with their grandchildren or friends.
If you see any of these warning signals in someone you love, encourage that person to schedule a full medical workup, counsels Karen Johnson, associate chair of psychiatry at MedStar Washington Hospital Center.
“With an elderly patient who is depressed, especially with a first onset, the key thing is to rule out something organic versus something functional — to rule out that these symptoms aren’t the result of a medical issue like a left frontal lobe stroke or hypothyroidism or any of the medications for hypertension or other conditions that can cause depressive symptoms,” she says.
Dementia can also present as depression, and — perhaps more significantly — depression can cause cognitive impairment that mimics dementia. “One of the distinguishing features [of] depression in late life . . . is that it slows down thinking so much that patients can’t remember things, problem-solve, make decisions or manage their households, and it looks like they have dementia,” says Johnson, who notes that these symptoms typically abate when the depression is treated.
The good news is that there is a range of highly effective pharmaceutical and psychotherapy options for dealing with depression at any age.
“Older people respond to treatment just as well as younger people; there’s no barrier to getting well,” Lehmann says.
Still, it’s important to be aware that antidepressants might need to be prescribed differently for seniors. “The general rule with an elderly patient is ‘start low and go slow,’ ” explains Norris. “Medications can have a tendency to be more potent [for older patients] even though they actually need the same dosing, so you have to start at a lower starting dose and titrate it up slower.”
Talk therapy is another beneficial option. “It’s crucial for educating people about illness so they don’t feel guilty about it, as well as for giving a sense of hopefulness and encouragement helping to fight negative thoughts and making goals and plans to move forward,” says Lehmann.
Is there anything you can do to guard against developing depression later in your own life?
Yes, within limits.
“People who are more resilient and adaptable to change and who have been through other changes like moving, retirement or children generally do better,” says Lehmann, who again stresses that depression shouldn’t be expected — or accepted — as a normal part of the aging process. “By the time someone has lived to 65, 75 or 94, every life has loss, every life has been challenged, and people get through it.” Even so, she notes that research has proved that a strong social network — including meaningful connections to others, whether it’s children and grandchildren or a community or church group — is strongly protective against depression.
I’m planning on several more visits home in the near future, to spend time with my grandmother but also to listen and keep a watchful eye out for any indications of a more serious problem. Whatever the outcome, I hope to be as positive and optimistic a force in her later life as she has been in mine.