Boomer generation triggers 'silver tsunami' of depression

For more than 40 years, Judy Young and her 75-year-old spouse, Meg Chalmers, shared so much: camping, antiquing, traveling. The retired nurses from Northwood, N.H., planned many more active years together. "We thought we would have a wonderful retirement, doing many things, enjoying a fantastic quality of life, having our health," said 68-year-old Young.

But two years ago Chalmers was diagnosed with early Alzheimer's, and Young assumed a new role, that of caregiver. After six months of wrestling with what she called daily grief, Young realized she was suffering from depression.

Many such baby boomers will cope with depression later in life, when the illness can present symptoms and challenges specific to that age group. Seniors who are depressed are more likely than those who are not to die or have serious complications after a major medical event. While seniors are less likely to be depressed than younger people, the size of the baby boom population will demand new strategies to care for them.

Experts have long seen that generation as a "silver tsunami" that will require extra resources, and the mental health needs of this age group are the often-neglected underside of the tsunami, said Stephen Bartels, director of the Centers for Health and Aging at Dartmouth College.

By 2030, there will be as many as 14 million American seniors with mental health or substance abuse disorders, up from 5 million to 8 million today, according to the Institute of Medicine. Depressive disorders, along with dementia-related behavioral and psychiatric symptoms, are the most common maladies facing that group. Some experience depression for the first time in older age; others have chronic conditions.

"Depression is underrecognized and undertreated in older adults," Bartels said.

Misconceptions

Depression in seniors is often misunderstood. "The public thinks, 'Well, if I was losing my ability to walk or losing my vision or hearing or people that I love, that it's normal to be depressed when you get older,' and that's just not true," Bartels said.

The most important misconception about seniors and depression is the assumption that a person who has never had it won't develop it, said George Alexopoulos, a professor of psychiatry at Weill Cornell Medical College.

When Judy Young, a retired psychiatric nurse and psychotherapist, experienced her bout of depression - it was her first - she was 65.

Depressed older adults can have different symptoms from those of younger people. Rather than seem sad, they might be unable to experience pleasure. They're also more likely than younger people with depression to lose weight and to feel worse in the mornings. Delusions can be more frequent. Social withdrawal, irritability and loneliness can be more prominent as well, said James Ellison, director of the geriatric psychiatry program at McLean Hospital in Belmont, Mass.

Whereas some gradual cognitive slowness may be normal with aging, the despair and withdrawal of depression can spark a rapid, functional decline, including problems with concentration. Depressed seniors are more likely to fall, which often leads them into a nursing home, Bartels said. Poor sleep coupled with memory loss can impair reaction times in such tasks as driving and cooking.

If you suspect a decline in function due to depression in yourself or loved one, Ellison recommends that you consult a health-care professional. Assessment by a clinician will usually include a screening test such as the Geriatric Depression Scale, which asks yes-or-no questions about feelings and beliefs, such as "Do you often get bored?" and "Do you feel your life is empty?" The results of such a test will help a clinician determine what additional evaluation or treatment should be pursued.

"Perhaps the most important questions you can ask are whether the person has been getting less enjoyment out of activities … and whether a person has felt down or blue more days than not in the last few weeks," Ellison said.

An aging brain

Just as seniors show big variations in their skills and abilities - one 80-year-old might play tennis and another might be reliant on a wheelchair - the internal process of aging differs for each of us. Our physical reactions to life stresses and our predisposition for depression also are unique to each individual, Alexopoulos said.

The changes that occur as the brain ages make some people vulnerable to depression, according to research done by Alexopoulos and others. These are mainly changes that impair connections between the part of the brain responsible for adaptive behavior and the part involved with processing pleasure, fear and aggression. The stress of living with disabilities, accumulating as we age, may trigger depression in some people whose brain changes have made them vulnerable.

Up to 40 percent of those who experience their first bout of depression in later life suffer from executive dysfunction - an inability to plan and follow through on tasks.

"Executive dysfunction is probably the most toxic impairment of mental abilities," said Alexandre Dombrovski, a psychiatrist at the University of Pittsburgh. It has consequences for managing day-to-day life, finances, medical needs and self-care.

He said seniors with executive dysfunction end up in nursing homes or assisted living more often than those who suffer from pure memory or language impairments. Dombrovski said that seniors with cognitive challenges such as executive dysfunction are also at elevated risk for suicide.

Some depressed seniors may seem to have dementia. Symptoms overlap: The loss of motivation in dementia and the lack of energy in depression appear similar. Dombrovski said a medical or neurological evaluation is the best way to tell the difference.

Communication

Talking about depression can be uncomfortable for older people. Many of the World War II generation feel they have to pick themselves up by their bootstraps: These seniors identify symptoms not as signs of depression but of weakness or failure in their ability to care for themselves, Bartels said. "For that reason, we need to be more proactive in reaching out to people with depression," he said.

Baby boomers, sometimes called the Prozac Generation, might be better at articulating their problems, but they still battle with stigma.

"When I was growing up, we used to say 'the 'C-word.' We wouldn't say 'cancer' because it was a death sentence. It's the same with mood disorders, mental illness …. today," said Michael Bresnahan, a 65-year-old Boston-area resident who is recovering from bipolar depression that first struck him at age 55. "But you know what? It's treatable, and I always talk about it."

Depression often arises in older adults in tandem with another medical condition, creating an even bigger challenge.

A western Pennsylvania man who asked to remain anonymous for privacy reasons had a second serious bout of depression at the same time he was diagnosed with Parkinson's disease. At age 60, the retired engineer had just beaten prostate cancer, only to be stricken with the two illnesses. The man, now 68, wasn't sure which condition was more traumatic.

"I thought it was pretty hopeless (that) I was ever going to feel good again," he said. He credits the support of his wife and doctor and the right medications with helping pull him out of his worst lows.

Depressed seniors with diabetes were at a 78 percent increased risk of early death compared with other diabetics of the same age, possibly because the depressed diabetics were less likely to follow through on prescribed medication, diet and self-testing, according to a 2014 study led by UCLA researchers.

Senior depression exacts a financial cost as well: After adjustment for chronic diseases, doctor and hospital costs were 47 to 51 percent higher for depressed vs. non-depressed patients older than 65 in a 2003 study.

Treatment

"Depression is tricky," Dombrovski said. "There is no first-line treatment that helps everybody. Rather, there is a menu of treatments."

Choosing antidepressants poses several age-related challenges, Ellison said, because side effects that a younger person can tolerate may prove more harmful to a senior. Some antidepressants, such as citalopram, have been shown to put seniors at increased risk for cardiac-related events, for example.

Drug interactions are an issue in treating seniors, who are typically on five or more prescribed medications.

For late-life depression, drugs may work more slowly, taking almost twice as long as in younger patients, Alexopoulos said. It took many painful months to find the best medications to help the retired engineer in Pennsylvania. Patients with Parkinson's face a particular challenge with finding the appropriate antidepressant because the disease attacks dopamine-producing cells that control movement and motivation.

Support groups

Medication isn't always the answer: Judy Young, the retired nurse from New Hampshire, says that the antidepressant she's taking doesn't help much, but talking does. For her, participating in support groups and consulting with a psychologist have made all the difference in her mood.

Brief rounds of cognitive psychotherapy can work just as well as drugs for moderate depression in seniors, Bartels said.

The health-care system is not staffed for the onslaught of seniors with mental health needs: By 2030, there will be fewer than one geriatric psychiatrist per 6,000 people who need mental health care, according to the American Geriatrics Society.

Integrating depression care throughout the health-care system is one way to meet the demand. Because of stigma, many seniors prefer to see primary-care doctors for depression rather than a psychiatrist or psychologist. Research shows that elderly patients benefit when their primary doctors work with depression care managers - nurses, social workers and psychologists who monitor symptoms, drug effects and adherence to treatment.

A study that was published last year found that depressed patients age 60 and older who received standard primary care were twice as likely to die within about eight years as those without depression. But depressed patients whose doctors offered special depression management were no more at risk of dying that those without depression.

"All of the effort and thinking going on in integrating care …. can make a difference," said the study's lead author Joseph Gallo of the Johns Hopkins Bloomberg School of Public Health.

Beyond doctors' offices, researchers are devising what Bartels calls "high-touch, high-tech" ways to reach depressed seniors.

"High touch" approaches include training individuals who deliver meals to seniors or work in senior facilities to screen for and identify depression. Experts also hope that peers - retired professionals such as doctors, lawyers and teachers - might be trained to look for signs of depression and deliver interventions.

"High-tech" modes include telemedicine and mobile medicine: Talk therapy conducted via video has proved as effective as in-person therapy, Bartels said. Researchers are developing senior-friendly apps that can deliver cognitive behavioral therapy that helps analyze thoughts, behavior and action, and this approach has been successful for people with depression.

Thanks to the support she's received, Judy Young is feeling better. She takes each day as it comes, enjoying her 23-foot motor home and time in New Hampshire and Florida. She has a busy life coordinating her partner's enrollment in an Alzheimer's drug trial with a schedule of concerts, trips and visits with new and old friends.

"You have to be proactive about getting help for yourself," she said. "That's something that's difficult for all of us."