Dad's in assisted living now, and he's just not himself anymore. He eats very little, and he's losing weight. He said the other day that he doesn't sleep much, either. The nurses say he just stares at the TV for hours, and sometimes he seems confused.

Odds are, Dad is depressed, according to gerontologists at the University of Mississippi Medical Center and the University of Arkansas for Medical Sciences.

"Depression is one of the major disorders of aging, because aging is a period of loss. That's what it is. As we get older, we lose family members, we lose friends, and we have a propensity to become isolated. It's a loss of social contact, value in living and optimism for the future that really leads to this scenario," said Richard D. deShazo, MD, UMC's Billy S. Guyton Distinguished Professor, board certified in geriatrics and rheumatology.

DeShazo said he sees "an extraordinary number" of depressed elderly patients, and physicians and loved ones who care for seniors must be attuned to the symptoms, since depression in seniors frequently presents differently than depression in younger adults.

Jeanne Wei, MD, PhD, director of the UAMS Donald W. Reynolds Institute on Aging and chairman of the Department of Gerontology, said elderly depression is "less overt" and "may be masked by other chronic health disorders or medication." Symptoms include:

loss of appetite, sleep problems, which bring with them their own medical side effects, fatigue, anxiousness, confusion, slow movement, which may be mistakenly attributed simply to aging, lack of interest in personal care, such as hygiene, and memory loss.

"When you're sad, you don't remember so well," Wei said.

"The big thing for physicians is sorting out whether a depression actually reflects a dementia or some other co-morbid process like hypothyroidism or a malignancy," deShazo explained. "But dementia is the biggie." He added that these physical manifestations of depression may be "routed" to other organ systems or internalized.

Life-Changing Events

The aim of the Reynolds Institute on Aging, Wei said, "is to help seniors maintain their function at the highest level to allow them to stay home and remain independent for as long as possible." That's one key to avoid depression, she said. Among the general population of seniors, the depression rate is 1.8 to 2.9 percent, yet depression among nursing home patients is about 6 percent.

So, while there are steps to take to encourage a healthy attitude in seniors, such as ensuring that they stay active and social, natural life events that occur with aging may prompt a temporary depression or one more severe.

"Yes, there are more depressed older people than younger people, and they have more good reasons, because they have more situations, more cumulative life-changing events, and they have more losses," Wei said. Even if a senior's physical health is good, witnessing the deterioration and death of relatives and friends – and attending more funerals than when they were younger – takes a toll.

"This is the backdrop against which every older person has to continue to navigate," Wei said. "Then in the front are all the things going on every day, the great amount of changes that they undergo, plus many of them have to take care of their loved ones. It's very difficult to come to grips with the fact that you're going to wake up tomorrow not feeling as good as you felt today."

Stress levels also may be a major contributor to depression. Wei said she sees many husband-and-wife patients who function well "as a unit," but when one becomes ill physically or mentally, the caregiver's health and emotional stability decline, too. "The caregiver is far more likely to sustain early mortality than the patient," she said.

Suicide among depressed elderly is an overriding concern, particularly for white males 85 and older. "It's usually in the context of widowerhood or social isolation, co-morbid physical illness, chronic pain, a terminal diagnosis or the worsening of a pre-existing physical illness," deShazo said.

He noted that while only about 13 percent of America's population is elderly people, they account for 24 percent of completed suicides. "When elderly get depressed, they're more likely to commit suicide and even more importantly, as compared to younger patients, they are more likely to be successful," he explained. "They don't do gesture suicides. When an elderly person wants to kill themselves, they carefully plan it and they do it." A family history of suicide is a "big, big harbinger," he added.

Wei concurred, adding that vigilance by practitioners is required. She said most seniors who commit suicide received care by some type of healthcare provider within the prior three weeks. "In retrospect, could they see signs of the problem?" she asked.

The Stigma

Treating depressed seniors is made more difficult because, to that World War II generation, depression is something to be ashamed of. "Depression was something that reflected your lack of personal faith, and you really couldn't talk about it," deShazo said.

"If you listen to someone who's depressed, more often than not they will diagnosis it themselves. Elders don't do that," he continued. "Elders do the same thing for depression that they do for any other chronic medical condition – they just down-regulate and adapt." Wei said depression is something that seniors "can't come to grips with," and she rarely uses the word depression with her patients.

Are antidepressants the first line of defense? "That's whether you ask a psychiatrist or a geriatrician," deShazo quipped. "We tend to use antidepressants and psychotherapy together rather than using psychotherapy alone. The problem is that for many elders the psychotherapy is not covered adequately by their Medicare or they don't have transportation or they don't want to do it."

DeShazo said he prefers using selective serotonin reuptake inhibitors, rather than older drugs like Elavil and others in the tricyclic class that frequently cause side effect. He starts seniors on a low-dose SSRI and escalates the dose if there are no side effects.

While there is good news when it comes to research and new treatments for elderly depression, deShazo said, "I think the most exciting thing that's new in this area is the increasing awareness of the problem."

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