Newer mental health practitioners and the public often have inaccurate information about depression, leading to the condition frequently going unrecognized. It is therefore not surprising that many are left silently suffering, particularly the elderly, whose symptoms may be hard for even seasoned healthcare providers to recognize. It’s ironic that hypertension is called the “silent killer” but there’s no lack of conversation about it. On the other hand, depression, a leading cause of disability and suicide worldwide, is only heard about with any regularity on pharmaceutical commercials. Perhaps depression is still too taboo for popular culture; what is seen of it dictates a resemblance to Eeyore or a brooding, gothic teen cutting themselves. While such presentations are unmistakable, other times depression is hidden in plain sight. This is no more prevalent than in our senior citizens.
As therapists, we need to not only recognize depression might look different in elderly patients, but we may also be helping a client who is a caretaker for someone elderly, and have to coach them on identifying depression in the person and how to talk to them about it. Caring for depressed people can take quite a toll on caretakers; enhancing the person’s mood can bring a significant relief to the care for and the caretaker.
First, let’s understand that depression goes beyond sad moods and losing interest. There are also changes in appetite, sleep and energy. There is dwelling on the past and hopelessness. Cognitive problems like poor concentration often occur, and depressed people can look physically agitated or move with extremely slowed movements. Readers are invited to read The New Therapist series beginning on 07/12/2020 about Major Depressive Disorder, perhaps the most common manifestation of depression.
Traps in recognizing senior depression:
- It might be assumed that increased sleep, memory fogginess and crankiness are simply natural to the aging process. We may chalk up their crankiness, for example, to irritation about numerous medical appointments, then figure that going said appointments is fatiguing, so there’s naturally more napping. Perhaps it is figured that low motivation and appetite loss is another medication side effect. Perhaps we should be more careful and recognize that dealing with increasing ailments and loss of independence is depressing.
- We can be quick to attribute cognitive trouble to dementia. However, the American Psychiatric Association (APA) and mood expert Francis Mondimore, MD, explain that a key feature of senior depression is reduced intellectual functioning that mimics dementia. One way to tell the difference is that depressed seniors find the cognitive deficits extremely frustrating and dwell on it, adding to hopeless feelings. Individuals with dementia may not realize the cognitive troubles.
- The third problem is that mental health can be difficult to discuss, so we don’t ask, or assume if something is troubling they’ll tell us. This is dangerous because generational and cultural habits often dictate “keep your problems to yourself,” especially for men. The end result: we don’t inquire about their mood or thoughts, the two keys in learning if it is depression.
Steps in identifying depression in seniors:
Now that we’re more aware of the details of senior depression, if we see clues like the above we would do well to ask some questions. If you have a potentially depressed senior in your life, let them know you’re concerned, and consider asking the following:
- Are they feeling sad or depressed? Ask for details. They may use terms like “blah,” “gray cloud,” or “I don’t care” to describe their mood, all evidence of depression.
- Are they dwelling on the past or worrying about the future?
- Do they believe they’re a burden to others?
- Do they ever wish they would rather not wake up or think about suicide?
Of course, medical complications could be mimicking depression. Considering elderly people tend to encounter more medical problems and be on a variety of medications. Therefore, a physical examination, as discussed in the 3 posts on Medical Mimicry, is of utmost importance in the evaluation process.
While elderly people could be prone to endogenous depression, as in Melancholic or Atypical Features, meaning no particular life event set it off, there is a good chance a psychosocial stressor is at hand. It is my experience that elderly people’s depression frequently stems from loneliness as their social circle collapses, or they are reflecting on things they regretted they did not do in life.
Increasingly limited physical abilities may make them less capable of meaningful activities like volunteer work, travel, or career. In such cases, our work involves helping them adapt to new ways of approaching those things, perhaps in conjunction with an occupational therapist, or to discover new meaningful activities. While it could be seen as simply “emotional hand holding,” elderly clients often glean a lot from beginning therapy with a more cathartic experience focusing on life reflection, during which other grist for the mill, like the aforementioned existential items, comes to light.
Clearly, diagnosing depression takes a trained eye. It is even trickier with seniors where we can make assumptions that symptoms are normal parts of aging. Of course, if you observe any of the red flags herein, consult with medical professionals as soon as possible. In the end, asking some simple questions can help us help seniors put a shine back on their golden years.
Tomorrow, The New Therapist probes the complexities of identifying depression in youth.
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association, 2013.
Mondimore, Francis (2006). Depression: the mood disease (3rd ed). The Johns Hopkins University Press.