I was speaking with one of my patients yesterday who I have known for years–we’ll call him Norm. (that is not his name of course).  He was at skilled rehab after having been in the hospital with an episode of congestive heart failure and an acute kidney injury that placed him on dialysis for a few days.  Thankfully, his kidneys recovered (sort of) and he was at our rehab for strengthening.  He had the usual concerns–not getting enough therapy, the food is always cold and terrible, and I want to get out of here. Very standard statements in a skilled rehab facility.  Then he fires off “my feet are numb and painful, and the pain medications do not help.” Now I can’t do much about the first three concerns, but now…the feet–maybe I can help there.  So I asked him, “how can I help you with your feet?”  My patient has peripheral neuropathy and he described exactly how his diagnosis affects him physically–numbness, tingling, and fiery sensations in his feet.  Ok.  Got it. But there is so much more here.  Norm turns around and takes a stack of individually wrapped notecards out of his side table and hands them to me, trying to change the subject.  The focal piece of each card is a photograph–each one is different and depicts a quintessential Maine nature scene.  I turn the first card over and Norm’s name and the date are inscribed on the back along with a price tag.  These are his cards.  We talk about the cards, the process, the photography, the craft fairs where he used to sell them.  He lights up and then gets quiet.  And here it is–the problem with his feet is not the pain or the fiery sensations. The problem is that he can’t trust them anymore, and because he can no longer trust them, he no longer feels comfortable getting out on the trail to take those photos. He gave up.  He now sits in his recliner most of the day and stares out the window.  He stopped going to craft fairs. He sleeps until later in the morning because there “is nothing to look forward to.” He is a little irritable (slight understatement)….Norm is depressed.  That’s the important nugget here. And nobody has caught this. 

So how do we know when our loved ones in the community are depressed?  Our neighbor?  Our elderly friend?  Ourselves? Depression in the senior population can be insidious and present slightly differently than when we are younger. Add to that the fact that our social circles, by default, shrink, and it becomes very difficult to identify until it’s deeply seated. So here are some tidbits and pearls of information concerning geriatric depression so that you may understand it, recognize it early in you or a loved one, and implement lifestyle changes or, if need be, medication so that we all maintain a sense of well-being.  

So what contributes to the development of geriatric depression?

 Biological Changes: As individuals age, changes in brain chemistry, hormonal fluctuations, and alterations in neurotransmitter levels can predispose older adults to depression. 

Chronic Health Conditions: The presence of chronic illnesses such as heart disease, diabetes, arthritis, or neurological disorders can increase the risk of depression in older adults by creating feelings of helplessness and hopelessness, and ultimately a sense of loss of control over the surrounding environment. In addition, chronic health conditions can lead to delays in the diagnosis of geriatric depression and may complicate the treatment. 

Medications: Certain medications commonly prescribed to manage age-related health conditions may have side effects that contribute to depressive symptoms.  For example, many blood pressure medications lead to dizziness and fatigue which can contribute to decreases in activity levels–previously active seniors may not have the endurance they  worked so hard to build.

Loss and Grief: The loss of loved ones, retirement, or declining physical abilities can trigger feelings of grief, loneliness, and sadness, leading to depression. Retirement alone can inspire feelings of loss of purpose, which is why adopting and maintaining a set of hobbies is so important!

Social Isolation: Social isolation and loneliness, often exacerbated by factors such as bereavement, limited mobility, or diminished social networks, are significant risk factors for geriatric depression.  Families are busy, and children of seniors often have busy lives with their own families, so social interactions decrease over time.

What do we look for in a depressed individual later in life? 

The symptoms of depression in older adults may manifest differently compared to younger individuals. Some common signs and symptoms include:

Persistent Sadness: Feelings of persistent sadness, emptiness, or hopelessness that persist for most of the day, nearly every day.

Loss of Interest: Loss of interest or pleasure in activities (anhedonia) that were once enjoyable, including hobbies, social interactions, or personal relationships.

Changes in Appetite or Weight: Significant changes in appetite, leading to unintentional weight loss or gain.

Sleep Disturbances: Insomnia or excessive sleepiness, including difficulty falling asleep, staying asleep, or waking up too early.

Fatigue and Low Energy: Persistent feelings of fatigue, low energy levels, or a general sense of lethargy.

Physical Aches and Pains: Unexplained physical symptoms such as headaches, digestive issues, or body aches without apparent cause.

Cognitive Impairment: Difficulty concentrating and making decisions, increased irritability, or experiencing memory problems beyond what is typical for age.  This is often dismissed as a “normal age related occurrence.”  If you or a loved one is experiencing this along with various other listed symptoms, do not just simply attribute these difficulties to aging or the onset of cognitive decline. Take a closer look at the situation.

Suicidal Thoughts: Thoughts of death or suicide, suicidal ideation, or suicide attempts.  It is normal to contemplate death as we age.  It is, after all, inevitable.  But there is a difference between thinking about the concept of death and truly seeking it out. While suicide rates are generally lower in older adults than in younger age groups, older adults with depression have a higher risk of completed suicide due to factors such as physical frailty and social isolation.

 Treatment Approaches:

 Evaluation for geriatric depression often begins with a series of screening tools, a physical exam, and laboratory evaluation.  Thyroid dysfunction and deficiencies in vitamin D and B12 can often present with similar symptoms.  Remember, our guts change over time and absorption of those ever important micronutrients decreases. Decreased absorption of vitamin D and B12 can lead to cognitive deficits, fatigue, chronic pain and a lack of energy.  While we never delay the treatment of possible depression, it is important to rule out these other conditions as they can have significant consequences if left untreated.  

Effective treatment of geriatric depression often involves a multidisciplinary approach and almost always includes the following elements. 

Psychotherapy: Cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), and problem-solving therapy (PST) are evidence-based psychotherapeutic approaches that can help older adults address negative thought patterns, improve coping skills, and enhance social support networks.

Medication: Antidepressant medications, such as selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs), are commonly prescribed to manage depressive symptoms. However, careful consideration of potential side effects and drug interactions is crucial, especially in older adults with multiple comorbidities. (Perhaps this is a future topic for discussion!)

Physical Activity: Regular physical exercise has been shown to improve mood, alleviate depressive symptoms, and enhance overall well-being in older adults. Activities such as walking, swimming, or tai chi can be particularly beneficial.

Social Support: Building and maintaining social connections through participation in community activities, support groups, or volunteer work can help combat loneliness and isolation, providing a sense of belonging and purpose.

Caregiver Support: In cases where older adults with depression rely on caregivers, providing education, respite care, and support services for caregivers is essential to ensure optimal management of depression and overall well-being.

So now we have all this clinical information on how to identify and deal with depression in our older selves, our family members and our community. This is all important stuff.  But let’s not forget what has the potential to really derail us later in life, what really leads to some of these darker places. Loss of PURPOSE. And with loss of purpose comes a loss of connection and a sense of hopelessness.  We become isolated from the “working world” around us. We don’t know where we fit in anymore.  So start early and craft a life that you can stand to be in when you no longer live your previous younger life–find hobbies, part time jobs, exercise programs, social connections.  Create a NEW purpose and live it everyday. 

Norm is getting ready to discharge home from skilled rehab next week and we have made a plan.  He will discuss altering his pain medications with his primary care provider.  He agrees to see a social worker for therapy.  He declines antidepressant medication at this point–does not want to add another pill, and I think that is fair. He agrees to get back out there and pick up his camera again…with a few adjustments. And he promises to let me know when the next craft fair takes place so I can visit his booth. At the end of the conversation, he says “wait a minute” and slowly stands up from his wheelchair. I give him a big hug and I don’t want to let go. He asks me if I make house calls. I laugh because, well, I don’t. But he knows where he can find me if he needs me. 

Stay well. Take care of yourself and each other.