Not long after he'd undergone two major heart surgeries, I noticed that Mike*, my 75-year-old neighbor and friend, wasn't wearing the Mets cap I'd seen him with for more than two decades. As someone who specializes in behavioral health attuned to symptoms of depression in the elderly, this caught my attention, and I suspected a "heart" problem that was more than just medical.
In the space of two years, this wonderful man who'd been the vibrant, loving, patriarch of his family -- and a baseball fan extraordinaire -- had lost his wife, his daughter and following two major surgeries, his own health. Then he hit a downward spiral, losing interest in food, even his favorite stadium peanuts, feeling tired, weak and irritable all the time, not able to sleep. When I asked him a question about the Mets and their long-time rival the Phillies, a ritual we shared that never failed to get a rise out of him, he shrugged his shoulders and said, "I'm just not that in to it anymore." I knew he was in big trouble.
Family and friends had noticed, but seemed to write it off as Mike just getting older. Plus, he had been through a lot in the last couple of years. I recognized these as classic symptoms of depression and not something to be accepted, or worse, ignored. Just because a person is older and becoming more frail does not mean they have to be depressed and isolated.
Unfortunately, situations like this are very common and often end needlessly in deep despair and, worse, suicide. Many people -- including health professionals -- think that characteristics associated with depression like fatigue, insomnia and forgetfulness are an inevitable part of aging. Recent research, including a study I'm spearheading at the Visiting Nurse Service of New York (VNSNY), the nation's largest not-for-profit home health care organization, shows hands down that they don't have to be.
As many as one-fifth of elderly people seen in primary care today have depression that has a significant effect on their well being. Although the elderly only represent 13 percent of the population, they represent 16-20 percent of the nation's suicide rate, with the highest rates seen in males 80 years and older.
Analysis by the NIMH in 2009 showed that over a period of one year, study participants diagnosed with depression had total health care costs of $22,960 -- almost twice the cost of those participants without depression. Depressed seniors experience increased illness, longer hospital stays, greater functional disabilities, poorer coping abilities and sometimes death as a result of worsening depression.
Despite these consequences, detection of depression through screening efforts remains inadequate. Studies show that more than half of elderly persons treated for depression receive their principle medical care contacts through primary care, yet 30-50 percent of primary care providers fail to screen for, recognize or detect depression. Thus, many elderly people with depression -- like my neighbor Mike until his family intervened -- are left untreated.
This lack of attention by the healthcare profession is a real concern, and a 2006 analysis by the New York City Department of Health and Mental Hygiene reveals an even more chilling trend. Among individuals who committed suicide, 70 percent saw their doctors within 30 days of their death. Additionally, 43 percent of patients in primary care who were diagnosed with depression had some thoughts of committing suicide within the week of their visit to the doctor and 20 percent of patients visited their primary care physician on the same day as their suicide. These statistics are alarming to say the least and the trend can, I believe, be reversed by better assessment of depression by doctors and family caregivers.
Many seniors are reluctant to admit they are depressed due to the stigma of mental illness or for fear of being characterized as weak or a failure. This is especially true with our aging Boomer population, and it certainly describes my friend Mike. Oftentimes, seniors view an admission of depression to a loved one or their doctor as an additional burden to the person that is caring for them. Still others may view their depression as a normal part of aging, or something transient that they "can fix" on their own without outside help. It concerns me that many health care providers traditionally have a "medical mindset" and often treat the vague symptoms, but may fail to see depression as the underlying cause.
We take this problem very seriously at VNSNY, and the Behavioral Health program that I lead is having great success with homebound seniors whose depression, previously undiagnosed, untreated or under-treated is being managed and treated successfully. Patients who would not get out of bed are now fully engaged in their communities and living active lives with dramatically improved quality of life. Mike was helped with cognitive behavioral therapy that really turned his life around. There's not much he can do about the Mets missing the playoffs again this year, but he's back to his old self and watching every game -- sporting his 1986 World Series cap. There is hope.
It is extremely important for loved ones and caregivers of the elderly to be mindful of depression's warning signs and symptoms and seek professional treatment. Ignoring depression won't make it go away. Here are some things that family and neighbors can watch for, and need to mention to healthcare professionals if they are present:
- Persistent sadness or anxiety
- Sleeping too much or too little, awakening frequently
- Reduced or increased appetite and/or weight loss/gain
- Loss of interest or pleasure in activities
- Fatigue, loss of energy, irritability or restlessness
- Difficulty thinking or concentrating, remembering or making decisions
- Thoughts of death or suicide, including suicide attempts
- Feeling inappropriate guilt, hopelessness or worthlessness
Raising public and provider awareness of these warning signs of depression is essential if we are going to manage this growing health problem. We must insist that health professionals, especially primary care physicians treating the elderly, assess their patients for depression and consider new ways of treating the illness. It is a serious medical condition with very serious -- and avoidable -- consequences. We need to make family members and the general public aware as well that their loved ones may be suffering needlessly -- that their symptoms are a warning, not inevitability. Only then will our aging neighbors and loved ones be able to live out their lives feeling fulfilled and with the dignity they deserve.
Rose Madden-Baer, MSN, MSHA is Vice President, Behavioral Health and Special Projects, for the Visiting Nurse Service of New York. She is a Certified Clinical Nurse Specialist, Professional in Health Care Quality and a Home Care and Hospice Executive. She is a student in the Doctorate of Nursing Practice Program at Duke University.
*Mike's name has been changed for privacy reasons.