Australia is ageing. Currently around 13 per cent of the population is aged 65 years and over: by 2051 this will increase to about 27-30 per cent. Life expectancy has also increased with more Australians living beyond the age of 80 years than ever before. The majority is living independently with about two-thirds rating themselves to be in good health. Older people are mostly active, reporting high levels of life satisfaction and fewer pressures and worries than they had earlier in life. It is a myth that depression is a normal part of the ageing process.
Nevertheless, while there is much debate about how common depression is in old age, around 6-15 per cent of older people are clinically depressed. Untreated depression has many negative consequences. Symptoms such as feelings of worthlessness, insomnia, suicidal thoughts and agitation are very distressing and cause considerable suffering and loss of function. Weight loss that accompanies poor food intake may become so severe that malnutrition can occur.
Depressed elders also have difficulty in coping with chronic health problems - aches and pains seem more severe and disabling. Social and medical services are used more frequently but unfortunately the depression is often unrecognised and untreated apart from prescriptions of sleeping tablets, painkillers and other medications. Self-medication with alcohol is not uncommon.
Physical ill health is indeed the major cause of depression in late life. There are many reasons for this and include the psychological effects of living with an illness and disability; the effects of chronic pain; the biological effects of some conditions and medications that can cause depression through direct effects on the brain; and the social restrictions that some illnesses place upon older people's lifestyles resulting in isolation and loneliness. As a consequence, rates of depression are highest in the institutions full of frail, disabled elders - hospitals, hostels and nursing homes.
Premature retirement may occur in early old age and other people may take over the older depressed person's usual family and social roles. For some, the suffering is so intense that suicide is the outcome. Older men have long been at high risk of suicide, though fortunately rates have declined in recent years.
So what can be done about it? First and foremost it is imperative that a national strategy be developed for preventing depression in later life. The National Action Plan for Depression makes passing reference to older people but doesn’t provide any specific details, nor does the ageing section of the Commonwealth Department for Health and Ageing. This is a major gap in Australian mental health policy. Beyondblue, the national depression initiative, has no resource material on depression in old age, although in 2004 it did launch a prevention initiative called maturityblues, but little has evolved from that yet.
A policy of prevention needs to have a focus on mid life as well as late life because lifestyle changes during mid life may be the key to the prevention. There is mounting evidence that cerebrovascular disease may cause depression for the first time in old age, so controlling the known risk factors in mid life (for example, high blood pressure, smoking, diet, physical activity) might prevent depression in late life.
For older people with physical disabilities, social isolation and loneliness often compound the problem and increase the risk of depression. Lack of transport, often because the older person is no longer fit to drive, is frequently cited as a reason for non-attendance at the numerous social activities that are potentially available in most localities. Public transport is often unsuitable or inaccessible. While there are some excellent community transport schemes in Australia, they are clearly insufficient to meet the needs of the elderly.
Another factor contributing to the development of depression is chronic pain. This is often poorly treated, especially in the nursing home environment. It is noteworthy that around 20 per cent of elderly suicides have uncontrolled pain in the weeks before death. While palliative care services and pain clinics have an excellent reputation for pain management, their focus is invariably upon the terminally ill or a younger adult population. Older persons with chronic arthritic and other musculoskeletal pains are unlikely to receive such expert care.
But possibly the most important preventive measure is public education. Excellent educational strategies to destigmatise mental health have been launched by beyondblue and the Federal Government that have focused on youth and younger adults especially in the workplace and at school, but little effort has been made to extend these into later life. Is this just inadvertent neglect or an example of ageism? Whatever the case may be, it is essential to rectify this omission.
For several years, our Aged Care Psychiatry Department at Prince of Wales Hospital has been running annual mental health educational seminars for older people in eastern Sydney and they have been very well attended. They have shown us how receptive older people are to being informed about mental health issues. Clearly this needs to be applied at a broader community level.
Another issue requiring attention is the provision of adequate clinical care for older depressed individuals. While there are Australian clinical practice guidelines that outline the assessment and management of depression in the elderly (pdf file 429KB), the translation of guidelines into regular practice is often fraught with difficulty.
And it is not as if there are a lack of treatment options as a recent review article in the Medical Journal of Australia found. There is a wide range of effective treatments including medication, psychological treatments and lifestyle changes that are effective in treating depression in late life. But there are inequities in mental health service provision in Australia, with older people being less likely to see a private psychiatrist than younger adults and with public mental health services being unevenly developed around Australia. Some states such as Victoria and Western Australia have well developed old age mental health services but the other states lag as noted in the 2004 National Mental Health Report.
There is much to be done to improve our nation’s approach to depression in late life.
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