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Baycrest Breakthroughs 2008

Depression and the Elderly: Life Sentence or Treatable Disease?

Eyes_DepressionBreakthrough brain research shows depression in older adults is more complex than in younger individuals.

For the last several months, Gerry has been very worried about her mother, Raye. A formerly vital and energetic woman in her late fifties, Raye seems to have become a totally different person lately. Her friends report that she no longer comes to their weekly coffee klatches and invitations to other gatherings are turned down more often than accepted.

When Gerry comes to visit her mother, she often finds her napping. And when she tentatively mentions the word “depression,” her mother reacts with uncharacteristic sharpness: “What do you want?” Raye asks bitterly, “I’ve just lost my best friend and my job – all within the space of a year.”

Gerry’s conversation with her mother raises a very important question: How do you distinguish between a natural grieving process and the onset of depression?

Dr. David Conn is Baycrest’s psychiatrist-in-chief and the medical director of its mood and related disorders clinic in the Brain Health Centre. He is also co-chair of the Canadian Coalition for Seniors’ Mental Health. Dr. Conn defines depression as “a noticeable and persistent change in mood, which may be caused by stress, psychosocial problems and/or chemical changes in the brain. Anxiety levels and sleep patterns may change and some people may lose their appetite, while others may eat more and gain weight.”

Dr.David ConnA loss in concentration sometimes accompanies depression in older adults. Some people may have increased anxiety or agitation, while others may become lethargic. Financial difficulties, retirement from work, a move into a retirement or nursing home are all lifestyle issues that can spark the onset of depression. Genetic or biological factors may also be underlying causes or the depression may be the result of another illness, such as stroke. Statistics have shown that women are nearly twice as susceptible to depression as men.

As for the best way to treat depression – with talk therapy or with medication – Dr. Conn reports, “At Baycrest, we find a combination of the two is the most effective. People need to keep in mind that anti-depressant medications don’t start to work for two to three weeks; sometimes the full effects may take two to three months. Therapy can be highly effective for some individuals and also helps people to cope along the way during this process.”

Dr. Guy Proulx, head of Baycrest’s psychology department, explains that diagnosing depression in elderly adults is much more complex than among younger people. “One big issue is that many times there are multiple compounding chronic diseases,” he says. “We spend a lot of time disentangling the different areas of cognitive functioning from physical illnesses. It’s very challenging to tease out all these conditions, but we are making progress.”

Dr. Proulx gives as an example, patients who have suffered a stroke. “There’s a slope of recovery that takes place when you have a stroke, and when you get aggressive about treating an underlying depression, which happens all too often, you can make the difference between institutionalization and independent living.”

Dr. Guy Proulx“Depression can be reversible,” Dr. Proulx maintains, adding, “I predict that we’re going to be hearing a lot more about mental illness and the elderly in the near future. It’s an area that’s begging for more research in clinical trials. Both government and private sources of funding are needed to help propel us forward in this important endeavour.”

Dr. Linda Mah is a clinician-scientist with Baycrest’s Kunin-Lunenfeld Applied Research Unit (KLARU), a staff psychiatrist in the Baycrest Mood and Related Disorders Clinic and an assistant professor in the division of geriatric psychiatry, faculty of medicine at the University of Toronto. She maintains the observation that many elderly people view symptoms of depression, such as lack of motivation, excessive worrying, and withdrawal from people or activities, as a weakness in personality. “

They see [depression] as a flaw in their character, something that they ought to be able to deal with,” she says. “But we know depression isn’t simply a character flaw because there are [observable] brain changes in depressed people. I tell people that depression is a bona fide medical illness. Just as they can’t will away angina, they can’t will away depression.

“That said, it can be difficult to differentiate between depression and dementia,” she says. “The diagnosis is frequently more certain as the course of illness evolves over time.

“[Seniors] see [depression] as a flaw in their character, something that they ought to be able to deal with.”

“A delay in making an accurate diagnosis means a delay in starting the appropriate treatment –whether this be treatment for depression or initiating medications to slow the progression of Alzheimer’s disease,” says Dr. Mah. In addition, she reports that, to date, much of the neuroimaging research has focussed on younger depressed adults.

She says that depression studies involving older adults have focussed primarily on cognitive functioning, with little research on emotion in older depressed adults. “The kind of work I’m doing can teach us about the changes in the brain that accompany emotional processing in late-life depression,” she says. “Understanding emotion-specific brain changes may be a first step in differentiating depression from dementia.”

“In the studies I’m conducting, we show subjects faces with emotional expressions, while lying in the MR scanner, to see if depressed older people have different levels of activity in the emotional areas of the brain, as compared to individuals who are not depressed,” she says. “In younger depressed individuals, we see that the emotional areas of the brain [the limbic system] are over-active – they’re always on, as opposed to people who don’t have depression. And we see parts of the brain [in the frontal lobe, an area that controls other functions] that are under-active in depressed people as compared to healthy adults.”

Dr.Mah will also be researching elderly depressed subjects’ physical responses in the brain as they relate to clinical responses to anti-depressant medication. Treatment of depression in seniors is challenging since late-life depression is more resistant and tends to take longer to respond. It is also not currently possible to predict which anti-depressant medication will be effective in treating an individual patient’s depression.

“Clinically, we try [treating the depressed patient] with one medication and wait six to eight weeks to see if the patient responds. If he or she doesn’t, we try another medication, wait another few weeks, observe for a response, and so on. There is a lot of trial and error and time lost when we could be aggressively treating the patient with the medication that will be effective in treating that individual’s depression.

“A lot of older people sometimes accept that depressed feelings are just a normal part of life.”

“A long-term goal that is very exciting is the possibility that we may in the future be able to predict, using brain imaging, who will respond to a certain antidepressant medication,” Dr. Mah says, adding, “Further research is really important to help us accurately diagnose and effectively treat late-life depression so that we can maintain and restore seniors’ abilities to function independently and enjoy their golden years.”

So what should you do now if you or a loved one seems to be suffering from depression?

“With older adults, psychosocial support is essential,” says Ruth Goodman, a Baycrest senior social worker for the past 27 year. “Every older person wants to be heard and acknowledged. Listening to what’s on their mind, showing genuine concern – and of course hugs or a calming hand – is very important.”

Ms. Goodman adds that older people feel a real sense of loss for many of their former roles – as employees, as life partners and as friends and mentors. “Despite these losses, they still need to feel respected and honoured,” she says.

“A lot of older people sometimes accept that depressed feelings are just a normal part of life,” Ms. Goodman reports. “But depression isn’t a normal part of aging.” Most people have a lot of resilience and with the right treatment and support they can be helped to tap into this vital resource. Eye

“At Baycrest people don’t need a referral if they have a concern and are unsure how to access a service for depression,” she says. “They can just call the main phone number at 416-785-2500, or walk in. A social worker at Baycrest’s Seniors Counselling and Referral Service is always available to help direct the person or concerned family member to the right resource.”

Individuals aged 60 or over who are suffering from depression but are not currently on antidepressant medication are invited to participate in Dr. Mah’s current or future research studies. Interested parties can contact her at 416-785-2500, ext. 3365.

 

 

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