Dr. Andrew Mohanraj

DEPRESSION should not be perceived to be a normal part of aging.

In fact, many older adults feel satisfied with their lives, despite having more illnesses or physical problems than younger people.

However, when depression is present in senior citizens, it can be difficult to detect.

This is because depression in older adults may have a different presentation, compared to younger people.
For example, for some senior citizens, sadness may not be their main symptom and their overall symptoms may also be more subtle.
Some may display decreased energy or fatigue by moving or talking more slowly and have difficulty concentrating, remembering or making decisions.

These can mask underlying depression.

They may also have unexplained physical symptoms such as headaches, digestive problems, and other bodily discomforts.

One of the earliest signs of depression though would be loss of interest in pleasurable activities.

It could be something ordinary like reading the newspapers first thing in the morning or watching the evening news on television.

The feeling of numbness leading to sudden disinterest in such routine activities is cause for concern.

Social triggers

Often, social factors underlie depression in older people, especially the loss of a spouse, social isolation, boredom, and financial problems.

They may also frequently experience depression after other major life events, like a diagnosis of a heart condition, stroke or cancer.

Sometimes, depression in older adults may be related to chronic use of alcohol or pain medication.

If a person has experienced depression at a younger age, they are more likely to have depression as an older adult.

Yet others may become depressed for no clear reason.

This used to be referred to as endogenous depression and has the possibility of emerging in old age for the first time, indicating a genetic predisposition to depression.

Everyone needs social connections to survive and thrive.

But as people age, they often find themselves spending more time alone.

This may not necessarily be bad.

At times, some people do crave solitude.

Being alone can be relaxing, meditative, and rejuvenating.

However, social isolation typically refers to solitude that is unhealthy.

Older adults may avoid social interactions, including those that were once enjoyable, or cancel plans frequently and feel relief when plans are canceled.

They may also experience anxiety or panic when thinking about social interactions.

Social isolation can involve emotional isolation, which is an unwillingness or inability to share one’s feelings with others.

When socially isolated individuals lack emotional interaction and support, they can become emotionally numb.

Loneliness and social isolation are associated with higher rates of depression and death wishes.

Can be treated

Depression is a medical condition that requires treatment from a mental health professional.

While family and friends can help by offering support in finding treatment, they cannot treat a person’s depression.

Often, the older family member might already have regular follow-ups with a doctor for a medical condition, perhaps a heart condition or hypertension (high blood pressure).

If that relative is suspected to have symptoms of depression, it is best to get their regular doctor to make a referral to a psychiatrist.

This may involve a detailed discussion on the observations made about the patient, as what non-mental health medical practitioners detect may not always

be symptoms of depression. Elderly people also often mask

their symptoms or are in denial of their distress.

Even severe depression can be treated, so it is important to seek treatment as soon as symptoms are noticed.

Medications for depression include those intended to balance hormones that affect mood, such as serotonin.

Selective serotonin reuptake inhibitors (SSRIs) are antidepressants commonly prescribed to older adults.

A psychiatrist can prescribe and help monitor the medications and potential side effects.

There is also a need to examine the risk of drugs interacting with each other, as the older adult is likely to be on other medications as well.

The psychiatrist will also rule out other medical conditions like hyperthyroidism and anemia, which can mimic symptoms of depression.

Psychotherapy, which can help a person identify and change troubling emotions, thoughts and behavior, is usually done by a clinical psychologist.

An example of such a therapy specific to the treatment of depression is cognitive behavioral therapy (CBT).

The two ‘D’s

Dementia is a syndrome involving deterioration in memory, thinking, behavior and the ability to perform everyday activities.

This is not a normal phase of aging, although as we progress into old age, it is not uncommon to experience more frequent episodes of forgetfulness.

Dementia is usually caused by underlying neurological conditions such as Alzheimer’s disease, vascular dementia, Lewy body dementia and others.

Symptoms will gradually worsen over time as the underlying brain damage or degeneration progresses.

Memory impairment is a hallmark of dementia, especially in the early stages.

Individuals may have trouble remembering recent events, conversations, and appointments. Dementia affects various cognitive functions beyond memory, including language, problem-solving, reasoning and decision-making.

Changes in personality, mood and behavior are common in dementia.

People might become more irritable, agitated, or exhibit inappropriate behaviour.

Some forms of dementia may involve motor symptoms like tremors, difficulty walking or changes in coordination.

Brain imaging scans, such as MRI (magnetic resonance imaging) or PET (positron emission tomography) scans, often show structural changes in the brain that are consistent with the specific type of dementia.

Dementia can cause some of the same symptoms as depression, while depression can also be an early warning sign of possible dementia.

However, depression must not be confused with dementia, as depression is highly treatable while dementia is a progressively worsening condition.

Medications for dementia may be useful to retard further deterioration of memory and thinking skills, but they are not a cure.

Depression and dementia can also coexist, leading to a condition known as depressive pseudo-dementia or just pseudo-dementia.

This term refers to cognitive symptoms that mimic dementia, but are actually caused by severe depression.

However, pseudo-dementia is potentially reversible with appropriate treatment of the underlying depression.

When depression is effectively treated, cognitive function can improve.

Accurate diagnosis crucial

Distinguishing between true dementia and pseudo-dementia can be challenging, as both conditions can present with similar symptoms.

Understanding the differences between the two can help in making a more accurate diagnosis.

Brain imaging scans can provide valuable insights into brain structure and help differentiate between the different conditions.

If there are indications of depression, monitoring the patient’s response to treatment for depression can help distinguish between true dementia and depression.

A misdiagnosis does a great disservice to those exhibiting symptoms of depression, as a quick and accurate diagnosis followed by appropriate intervention can result in the patient bouncing back to normalcy in no time.

It is important to note that in older adults, depression and dementia can be complex and overlapping, and may require input from various medical professionals, including neurologists, psychiatrists, and neuropsychologists.

If you suspect that you or someone you know is experiencing cognitive impairment, it is best to seek a comprehensive evaluation from a qualified healthcare provider.

It is unfair and inaccurate to assume that someone has dementia solely based on their age.

Ultimately, a holistic and patient-centered approach that considers both medical and psychological factors is essential for accurate diagnosis and effective management of cognitive changes in older adults.

Datuk Dr Andrew Mohanraj is a consultant psychiatrist, the Malaysian Mental Health Association president, and an adjunct professor of psychiatry
at Taylor’s University. For more information, email starhealth@ thestar.com.my. The information provided is for educational and communication purposes only, and it should not be construed as personal medical advice. The Star does not give any warranty on accuracy, completeness, functionality, usefulness, or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property, or personal injury suffered directly or indirectly- ly from reliance on such information.