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ANN ARBOR,
MI - Retired nurse Dorothy Kirkpatrick hasn't let her age slow
her down much. In fact, her latest project was helping open a University
of Michigan Health System geriatrics clinic at her local church,
so that seniors like her can get convenient and specialized medical
care.
But a while
back, at a regular checkup, her physician noticed subtle symptoms
that Dorothy herself hadn't yet seen - signals that she might be
both depressed and in the early stages of Alzheimer's
disease. He wanted her to see a neurologist for testing. At first,
she resisted the idea, thinking, "This doesn't happen to me."
But now, after being diagnosed, receiving treatment and joining
a UMHS group for people like her, she has both conditions under
control.
Millions of
older people around the United States face the same mental health
problems that Dorothy did, but the vast majority aren't getting
the kind of help she got, says Helen Kales, M.D., a psychiatrist
who treats elderly patients at the U-M
Geriatrics Center and the Ann Arbor Veteran's Administration
Healthcare System (VA). And without professional treatment for their
depression, their mental and physical health can decline faster
and further than ever.
Depression,
and depression combined with dementia, often escapes the notice
of older people, their relatives and their doctors too, Kales says.
They may not know or recognize the symptoms. Or, they may think
that slowing down or feeling sad is a normal part of getting older
-- or that the health problems and personal losses that can come
with old age would depress anyone. Meanwhile, the depression worsens,
decreasing their ability to enjoy life or tend to their health.
This widespread
missing of depression in the elderly may be due to an old stereotype
that's just now fading. "Depression was dismissed as a natural
outgrowth of aging, which we now know it's simply not," says
Kales.
Even some physicians
thought that depressed feelings were unavoidable for people with
medical problems, which many older people have. "But research
has really shown us that this is not the case. Many patients with
various illnesses lead very healthy, productive and enjoyable lives,
and so depression is an illness that complicates those diseases
- it shouldn't be viewed as a natural outgrowth of them."
Strangely,
the old stereotype about older people feeling depressed because
of illness or the death of a loved one went hand-in-hand with a
belief that "real" depression - the kind that can be diagnosed
and treated by doctors -- was actually less common in people over
age 60.
But that belief
is changing. "The rates of depression in older people were
previously thought to be lower than those in younger adults, but
recently it's been found that the rates may actually be quite similar,
at about 5 percent of older women and 2 to 3 percent of older men,"
Kales says.
Those rates
of diagnosed depression, she adds, have recently been found to be
much higher in older people who have a number of medical conditions
or a single severe illness - as many as one in four of older people
staying in hospitals or nursing homes.
This combination
of mental and physical ills can pose special problems. "In
illnesses like diabetes, depression worsens the patient's ability
to tend to complicated drug regimens like insulin," says Kales,
who is an assistant professor of psychiatry at the U-M
Medical School.
"Depression
also prolongs the rehabilitation from illnesses like heart attack,
hip fracture or stroke, making patients' function much worse,"
she adds. "And it's been found that in patients who have had
heart attacks and major depression, their death rates from medical
causes are significantly higher six months after the heart attack
than in patients who had no depression." And, she says, depression
can lead to suicide - which is more common in older people.
There's also
a growing sense that many older people with depression have symptoms
that look like memory loss and dementia - or that, like Dorothy
Kirkpatrick, they have both depression and dementia disorders like
Alzheimer's at the same time. "The relationship of depression
and dementia is quite complex and may occur in several ways,"
explains Kales. "Depression slows thinking, so it's harder
for patients to concentrate, and sometimes this can become so severe
that patients actually appear to have dementia. This condition has
been named 'pseudo-dementia'."
Depression
may even increase the risk of memory loss and dementia, by causing
chemical changes that can damage the hippocampus, a part of the
brain involved in memory. And, vice versa, patients whose memory
and thinking ability are declining because of dementia diseases
like Alzheimer's are more likely to suffer from depression.
In the late
1990s, Kales and her VA colleagues retrospectively studied the health
care experiences of 7,115 older patients who had depression, dementia,
or both, finding high rates of nursing home, inpatient medical and
psychiatric care among patients with both depression and dementia.
This study was followed by a detailed prospective one-year follow-up
study of older VA patients with depression, dementia or both, in
order to better understand why patients with both depression and
dementia had such high rates of nursing home and inpatient care.
"What
we found was that patients with both depression and dementia simply
did worse," she says. "Their depression was detected less
often by their physicians and was treated less often. Of most concern,
after one year, up to 40 percent of these patients had been placed
in nursing homes. This rate was significantly higher than those
with depression or dementia alone. It looks like depression in these
patients with dementia might be accelerating them on the road to
nursing home placement." Patients with depression and dementia
also went to the hospital more.
The good news
for all older adults, Kales says, is that new treatments and understanding
offer hope to older people with depression.
"Treatment
can include medications known as antidepressants, and can often
include psychotherapy, "talk" therapy, which can be quite
beneficial for other patients," she notes. "Newer antidepressants
are quite effective in the elderly," with fewer side effects
and a lower likelihood of interfering with other drugs.
Group therapy
can also be great for seniors, Kales says. "They can discuss
their problems and symptoms with others who are going through the
same thing, and realize that it's not their fault, that it's an
illness that needs to be treated and discussed and brought out into
the open."
Many seniors
with memory loss or depression are turning to alternative medicine,
including herbs like gingko biloba and ginseng that have been touted
as being able to boost their memory or their spirits. Some of these
unproven remedies can interact with prescription drugs.
This winter,
Kales reported the results of a study of the use of these substances
among 82 elderly people with depression, dementia, or both, and
56 of their caregivers. She found that overall, 20 percent of the
patients used some form of herbal supplement, while the rate was
16 percent for caregivers. And the majority of both groups didn't
tell their doctor that they were taking the substances - a troubling
trend because of the risk of drug-herb interactions.
Rather than
medicating themselves with unproven therapies, Kales urges seniors
who think they might be depressed or having early memory loss to
talk with their doctors about getting tested and treated. Like Dorothy
Kirkpatrick, they may find that it can make all the difference.
Symptoms
of depression:
- A long-term
sense of hopelessness, worthlessness, anxiety or sadness
- Appetite
changes, such as eating too much or too little
- Sleep changes,
such as sleeping too much or too little
- Suicidal
thoughts or actions
- Feelings
of fatigue or being "slowed down"
- Not enjoying
life or activities that used to bring pleasure
- Crying
too often or too much
- "Overlap
symptoms" from physical illness, such as trouble thinking
or sluggishness
Facts about
depression and dementia in the elderly:
- Depression
is not the same as the sad but temporary mood caused by the death
of a loved one or changes due to retirement, moving or illness.
Depression is an illness that lasts.
- Many older
adults with depression may feel anxious or irritable, rather than
"sad".
- At any time,
depression affects about 5 percent of elderly women and 3 percent
of elderly men. About 15 percent of seniors will develop depression
sometime in their older years.
- Having an
illness can bring on depression.
- Symptoms
of depression may be "masked" by symptoms of physical
illnesses. And, depression's symptoms can appear to be symptoms
of memory loss or dementia.
- Depression
in the elderly is quite treatable, with medication, talk therapy
and group therapy.
- People taking
herbal supplements for memory or depression should tell their
doctors.
Resources
on the World Wide Web:
U-M Depression Center
National
Institute on Aging: Depression
Written by
Kara Gavin
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