‘My dad used to be an active and cheerful person, however for the past 1 year he did not want to talk much, prefers to be alone in his room. It is heartbreaking to look at him in this way.’
‘My mother is the pillar in my house and she knows how to handle everyone in the house according to their needs. Ever since, she had a fall and fractured her leg, she had trouble mobilizing. She refuses to accept help from us to take her for a bath or even to bring her for a walk. She is slowly becoming a different person.’
These two scenarios may sound familiar to some of us, or at least we may have heard it from our friends, colleagues or neighbours.. Losing a loved one, becoming ill; feeling of not being the big cheese at home anymore, decreased functions and even economical reasons can lead the elderly into depression.
Depression is a common mental health problem in the elderly. According to the current population estimates in Malaysia there are 2.3million (7.0%) population aged 65 years and above for 2020 compared to 2.2 million (6.7%) in 2019. Because of our aging population, it is expected that the number of seniors suffering from depression will increase.
Symptoms
Depression in elderly population can present in many ways. It could be a new onset, recurrent depressive disorder due to relapse of depression from earlier in life, or a mood disorder that is related to underlying medical conditions, medication or even substance used.
Symptoms can present as low mood, reduced interest, lack of concentration and energy, poor appetite, constipation, deteriorating health issues and worsening cognitive functions. Depression in elderly is associated with decline in functionality; therefore it requires increased care or substitute facility. To fulfill such a need or to assist requires a financial strength which many fail to plan when they were younger . Sadly, this will lead to financial burden, being left alone or choosing to ignore the symptoms which contributes to severe stages.
Assessment
Assessment in elderly population is similar to the assessment in general adults. Primary causes of depression need to be ruled out and appropriate laboratory investigations to be done when necessary.
Possible causes of depressive symptoms
| Possible causes | Examples |
| Drugs | Steroids, beta-blockers, methyldopa , nifedipine, digoxin |
| Metabolic/endocrine causes | Hypothyroidism, hypercalcaemia, Cushing’s disease |
| Infection | Post-viral, myalgic encephalomyelitis, brucellosis, neurosyphilis |
| Organic brain disease | Dementia, Parkinson’s disease |
Laboratory investigations for an elderly presented with depressive symptoms must be monitored. For example, urea, electrolyte imbalance, thyroid level, vitamin B12, folate , full blood count and liver function.
Treatment & Prevention
Fortunately, depression in the elderly can be treated. However, the initial crucial step is to recognize and diagnose depression. This can be challenging especially to this population due to cognitive impairment, hearing problems, staying alone which leads to incomplete patient history taking, other comorbidities and the self-limiting stigma to seek help. There is also a tendency to look at depression because of aging. THIS IS DEFINITELY NOT TRUE.
Therapy requires a combination of both pharmacotherapy and psychotherapy. It is important to understand that medication takes 2-4 weeks generally to be effective. Therefore medication compliance is vital. Certain medication can result in unwanted outcomes due to drug-drug interaction or drug-disease interactions. Therefore medication counseling is an essential part of the treatment. There are plenty of antidepressants, if one drug does not seem to be suitable, seek professional help, doctors can substitute with other antidepressants. In short, it is absolutely necessary for pre-treatment screening and monitoring of treatment. Hence, patient’s cooperation is needed to achieve the best possible result.
Prevention is definitely better than cure. Healthy lifestyle which includes a balanced diet, being active, getting enough sleep, having good social interactions and trying to keep self interest even after retirement make a huge difference in life.
However, it is also equally important to understand that life may not be a bed of roses all the time. Acceptance and seeking help will be beneficial. For the senior population, family support is the key to treatment despite pharmacological methods. Care and love are the main ingredients. Simple things, such as to speak to them, to share with them to make them feel valuable, looking at family albums,singing or listening to favorite songs or doing favorite activities together can help to enhance the memory and their confidence.
In conclusion as a daughter, son or grandchild, bring your loved ones to seek professional help when you notice something is not right. They are not depressed because they are old. They deserve to have a good quality of life. In many government hospitals, we have a multidisciplinary team for geriatric patients who consists of geriatrician, pharmacist, occupational therapist, physiotherapist and dietician. Together we can work for a better outcome for your loved ones.
Renuka Rahoo
Geriatric Pharmacist
References:
- Clinical Practice Guidelines of Management of Major Depressive Disorder 2019 2. Spoelhof GD, Davis GL, Licari A. Clinical vignettes in geriatric depression. Am Fam Physician. 2011 Nov 15;84(10):1149-54. PMID: 22085669
[This article belongs to The Malaysian Medical Gazette. Any republication (online or offline) without written permission from The Malaysian Medical Gazette is prohibited.]