University Place Positive Aging Series Suzanna Waters-Castillo, "Late in Life Mood Disorders" 6/18/2010  UP 445   cc >> Good morning and welcome to this installment of the Positive Aging Lecture Series. On behalf of Oakwood Village, the SAIL Organization, Supporting Active Independent Lives, and Continuing Studies at UW Madison, we're delighted to have you here for the presentation today about late in life mood disorders. Our speaker is Suzanna Waters Castillo. Suzanna received her bachelor's degree, her master's in social work, and her PhD from UW Madison. She's a faculty associate in the Department of Professional Development and Applied Studies in the Division of Continuing Studies at UW Madison. Dr. Castillo conducts research and teaching in her specialties of cross-cultural care, late-life mental disorders and care management systems. As an educator, she teaches academic courses to students and continuing education to professionals in health and human services. Dr. Castillo is a nationally and internationally recognized lecturer on these topics. And I owe her a debt of gratitude because she was very instrumental in helping to shape the content of our lecture series this summer, and I'm thrilled to have her as a colleague and have her participating in the series. So would you please join me in welcoming Suzanna Waters Castillo. 

(applause)  >> Thank you very much for that warm welcome. And I must say I'm very happy to be here. Get this set up right. And it's wonderful that we have so many people that are interested in this important topic. And before we begin today, I just want to tell you a little bit about my own interest in this topic. I am working with a group of professionals who, like myself, have expertise in geriatric psychiatry. And we have formed the Wisconsin Geriatric Psychiatry Initiative to educate professionals in the field to better understand the depressions, anxiety, the dementias, and other related issues in mental illness. There has, in the past, been little research that supports skill-building for professionals regarding late-life mental disorders, but that has changed significantly in the past 10 years. And, consequently, when we speak to professionals, students, and other interested parties like yourself, the information we provide you with is current information that's based on, is evidence-based, best practice, based in research, current research. So I share that with you as part of the hope that is emanating in this field at this time. 

I also want to tell you that in the Division of Continuing Studies we will have available to the public and professionals a web portal on topics in geriatric psychiatry much like the one I'll be presenting today. And there will be a consumer section with articles to read, some media such as eBooks to download, people to contact and so forth. And if you are interested in learning more about that, I will be at the back of the room at the end of the seminar today and I can give you my card, you can send me an email and our website will be previewed July 29th. We are sponsoring the Summer Institute on Late-Life Mental Disorders where physicians, psychologists, nurses and social workers, other professionals that are working to improve geriatric mental health will be present. So I welcome you to stay in touch with us. So let me just get a sense of my audience here today. Are there any retired or current professionals who have worked in the field or mental health or medicine or nursing? Let's see a show of hands. Okay, very good. How many of you have worked in the field of gerontology or geriatrics, any specialists here? Okay, one. And ma'am, what is your expertise? >> (inaudible) >> Yes, okay, very good. 

And others are interested parties? Okay. Well, welcome, I just like to acknowledge everyone, and thank you very much for being here today. The purpose of my presentation is to provide you with very, very current information about late-life mood disorders. And this is a topic that should really be a week long topic to talk to you about. But today I will be focusing primarily on late-life depression and accompanying anxiety. There are bipolar disorders and other elements related to depression, but depression is the most prevalent of the mood disorders in older adults. I'm going to give you some of the epidemiological information about the prevalence of geriatric mental illness, and then we'll get right into the characteristics. Research has told us that there are some very unique aspects about late-life depression that is different than midlife or early adulthood in terms of depression and anxiety, and we're going to explore that together. One of the issues in terms of improving treatment outcomes in late-life depression and anxiety is providing providers and people like yourself who may have a problem with depression or anxiety or has a family member, a neighbor, with the information that you need to support them when you go with them to their primary care provider. So the idea here today, my purpose is to give you the most updated information that hopefully will be somewhat useful to you when you work with your healthcare providers. 

So let's get started. The good news. Aging is not a disease. (laughter) Aging with the proper support can be a very fruitful time of life. And part of that fruitfulness comes from all of us working together. It takes a village to support you when you are feeling depressed, when you may have some stressors that go beyond simply feeling blue or sad. Happiness is not restricted to the young. And we certainly know that. However, the media has portrayed older people far too often being sad, not being pleased with life, we go through periods. There's an ebb and flow often associated with a physical illness or some type of a significant loss in our life. 

But, as you know, you are all good adapters. And one of the keys to life satisfaction as people age is successful adaptation to the changes that are going on in your lives. The most recent such study about happiness and aging was published last month in the proceedings of the National Academy of Sciences and highlighted in the Times and it drew on Gallup poll data. University psychologist Arthur Stone, the study concluded that people in their mid to late 50s are happier and less stressed than those in their 20s. And respondents tends to be more content at 85 than they were in their teens or early 20s. So that is very good news. Keep in mind on your bad days. Depression, though, and anxiety are not normal aspects of aging. And current medical and psychosocial research provides evidence for improved best practice that is changing the way doctors, nurses, and social workers work with us as we age and our moods. And these mood disorders can be effectively treated. 

However, there has been, I think the best word really is neglect, and lack of information in terms of treating older adults with depression and anxiety. Part of it has to do with many people believe that as people age and go on in their years through their 60s, 70s, 80s, and into their 90s, that depression and being anxious is a normal part of growing old. In fact, I remember talking with someone not too long ago and I was telling them about my presentation here today, and he laughed and he said well, everybody is depressed when they're old, aren't they? (laughter) And no, they're not. They are not. The majority of you aren't, and you'll see that in my statistics coming up. But there still is very much in society overall a great stigma about having mental illness. And there's often an association that the person will lose their mind, go crazy, that people will see it as a moral failing. And so we struggle with that in our society at large. And then there is the issue about ignorance, really simply not having current information about the nature of mental illness and aging, effective treatment, and where, really, to go. Where are the best places to go for help. 

Why it's important. Well, it certainly is important to discuss this because, as I said earlier, when an individual is confronted sometimes with a diagnosis or the thoughts about having a particular disorder that's related to our mind, there's often great fear associated with that. And some of that fear not only comes out of projections but associated with those projections are lack of information. And the issue that I'm primarily concerned with and my colleagues is untreated late-life depression and late-life anxiety rakes a terrible cost on the individual's health, stress on the family overall. And untreated late-life depression and anxiety can lead to isolation and suicide. And I'll talk a bit about that later on. And we know, I'm going keep saying this, mental illness in late life can be effectively treated. Now, you're going to probably see a slide like this over and over again throughout this series. But we know that our population is really exploding, and you can see the numbers of people in millions over the next 30 years that are going to be 65 plus. So this is enormous change in society. 

And I do believe, for the most part, it can be very beneficial to society because so many of you are vital and have so much to offer middle-aged adults, younger adults, children, and teenagers. So we want to keep mental well-being at the forefront. The number of older adults with mental illness in the United States will double in the next, what would that be, we're in 2010, the next 20 years. And that's quite significant. And that has to do with my generation as well as your generation, the baby boomers. And this is a very important statistical fact because professionals in the field need to ready themselves and be prepared to develop insight and treatment methods. Now, one of the problems that professionals in the field of geriatric mental health face today is many do go untreated, and the primary individual that is seen for treatment is primary care provider. Now some primary care providers are very well-equipped to treat late life mental illness, including the mood disorders like depression and anxiety. However, others are not. You can see the numbers in terms of older adults with mental illness. 

Those that received treatment only, it looks like about half. So we know that there are a great number of people living in the community and more in institutions like nursing homes, hospitals, that are not effectively treated. So we have a lot of work to do and part of the problem is that there is a tremendous shortage right now, and if we look at the projections going to be of professionals that are skilled and trained in geriatric mental health. And that is why in Wisconsin we have started the Wisconsin Geriatric Psychiatry Initiative to educate nurses, social workers, occupational therapists, other physicians, and psychologists very specifically about what people that are aging need in terms of mental healthcare. We see that there are more geriatric social workers, very significantly less geropsychologists and even less geriatric psychiatrists. In Madison we are very, very fortunate, Madison and Stoughton, we have my colleagues Art Walaszek, Tim Howell, Tim Juergens, Jeremy Peacock and also another geropsychiatrist out at the Stoughton hospital. There are actually six in Madison. So we have rich resources here. However, throughout the state of Wisconsin that is not the case. And in the United States as a whole, what does it say here, it looks like currently there are about 2400, and we're going to have less in the future. 

So we need to not only educate ourselves but you as well so you can advocate for your own needs. Let's just get to the basics of mood. When we talk about mood disorders we are talking about an emotional state, anxiety or depression, primarily. And that it becomes sustained and then it becomes a state in the individual's life where you simply don't function well. And, as I said earlier, we're going to talk about the depressive disorders and there are some that are very unique to older adults and anxiety disorders and the combination whereby you may have late-life depression and accompanying anxiety which is called comorbid anxiety. Now, these are, I don't know, can you see this over here? I just want to make sure because I do walk around when I talk. We see the prevalence of the mood disorders that are most common as we age right here. Number one are depressive symptoms where not quite, an individual is still somewhat managing. They may not have a very good appetite. They may not be sleeping well. 

Not feeling really sad, maybe experiencing some agitation. They also may be becoming a little bit withdrawn. But it is not sustained over time. It is not longer than two weeks. Those are symptoms and they can be very, very distressful, just the symptoms, and need to be treated. And you see the prevalence is quite high. We're talking about people living in the community, 10% to 25%. So you say why is it 10% to 25%? Some researchers when they do this start studying the mood disorders at age 55, some do it at age 60, and some start studying it at age 65, so we have a range here. Adjustment disorder with depression. That's 4%. 

That's much more of an experience of depression with a specific situation in your life. The loss of a spouse, the loss of a dear friend, your occupation, financial status. Major depressive disorder, we'll talk specifically about what that is. And it's much higher in nursing home residents. Some studies have shown up to 50% of nursing home residents have a major depression. Now, general anxiety disorders, out of all the anxiety disorders, which there are several, are our most prominent in older adults. And that is about 7% of the population. And anxiety with depression is found in 48% of the individuals that have been diagnosed with a major depression. So almost half of the older adults who have been diagnosed with a clinical depression have an anxiety accompanying that and an anxiety disorder. And they can both be treated. 

So little comparison here for you. So you see in young through middle-aged adults, and here you have an example of what I'm talking about where you have 55 and older, these social scientists, you see the prevalence varies by age. And if you take just a simple quick look at this, you see the prevalence for depression, that includes major depression, being much lower in older adults. And any disorder still being lower in older adults. But we do see the increase over younger adults in cognitive impairment with the dementias. So if someone says to you all older adults are depressed. Say, no, the prevalence rates are higher for adults 18 through 55. And they'll think you're a lecturer at the University of Wisconsin. So this gives you insight in terms of really how effective human beings are at adjusting and coping as we go through life, however some things hit us hard as we age and that's where those dynamics start changing and a mood disorder like depression or anxiety starts hitting home. What is unique? Well, geriatric mood disorders, the depressions and anxiety, have a very different way of presenting, and we'll talk about what those are, than for the 18 through 54 crowd. 

Many older adults, in fact most older adults take multiple prescribed and over-the-counter meds that account the multiple medical conditions, and this makes treatment challenging. And we all have fairly complex lives by the time we're 70 years old with our children, our past life experiences, how we accommodate and manage change and stress in our life. And that we are changing people over time. The good news is that there is something called neuroplasticity. How many of you have heard that term or read about it in the newspaper? Neuroplasticity? Let's see a show of hands. Very educated crowd here. Well, neuroplasticity in simple terms refers to the ability of our neurological system to regenerate and develop neurological pathways that are new and we form them even as we age. Previous thinking and research suggested that there was an extreme limit, and once we became older, we didn't have the ability to regenerate some of these neurological pathways. But we now know that that's not the case. So that's also good news for everyone to know. 

We know that people are faced with a lot of chronic conditions, and they're dealing with the changes of late life. And this is particularly important for providers to understand. We are not simply a neurological system, a physiological process, we are human beings with knowledge, insight, capabilities and families, education, occupation, etc, that have allowed us to achieve the age that we are and to celebrate that. And that needs to be brought home to providers as well. Very, very important. Depression in late life. And this is a great photo that shows that. Now, if you are going to a healthcare provider to talk to them about depression, for a relative, yourself or a neighbor, you may want to take a picture of yourself where you have not been depressed to give them an idea of the changes that have taken place. One picture is worth a thousand words. Let me quote someone here, a scholar, and this is one of the best quotations about geriatric depression I found. 

"We do know that people with geriatric depression present with more extreme weight loss, hypochondriacal preoccupation, trouble falling asleep, agitation, and preoccupation with guilt." This is far different than the 18 through 54 group. So you need to be aware of that, in terms of yourself, your family members, and when talking to your doctor. hypochondriacal preoccupation, that's constant thinking about health problems. And we'll talk more about how that's often reflected. And let me remind you that these unique characteristics are based on research studies that have identified that over the years that there are different ways that as we age we present our changes in mood. Passing sadness is not depression. The blues. And depression is not a moral flaw. It is a serious medical illness. It is a medical illness. 

It's not about social moral experience in life. It doesn't mean someone is a bad or wrong or ineffective individual. It is a biological disease with psychosocial components. And when I'm talking about psychosocial components, I'm referring to behaviors that then we exhibit as a result of the changes in our moods. And in late life, depression and anxiety do present differently in the clinic and at home. One of the most fascinating aspects and very atypical presentation in late-life depression is people don't often feel sad but they will withdraw. There is often expressions about incompleteness in life, experience of wishing you had done certain things differently, the experience of feeling guilty, perhaps, about something in your relationship with children, spouse, former employees, how you did your job and so on. Another unique feature of late life depression are gastrointestinal complaints that are not substantiated after tests being done by a physician. The experience of just not having hope. And sleep difficulty, often early wakening. 

So this is the kind of list that your physician needs to have when you're talking to her or him about depression. Also, what's very interesting about depression, it can mimic dementia. Alzheimer's dementia, it can mimic that. People may have low motivation if you have depressive symptoms or are depressed. You also have difficulty making decisions. Your cognitive process becomes affected by a depressed mood disorder and an anxious mood disorder. You have difficulty concentrating and loss of memory. Now, this is reversible with proper treatment so that we know if a medication is successful, this is not dementia, it was a depression. These are some of the responses I've recorded. Before I became an academic I ran a geriatric care management agency and also was a care manager, worked with many older adults, this was in the state of California. 

And these are the kind of responses I would hear from older adults, and it would be a red flag for me, particularly if when I went back to visit I would hear this again. "It's just too much trouble." "I just can't do this anymore." "I'm not well enough." "Just go ahead without me." "I just don't have the energy anymore." "I'm just going to stay back." "Everything is too frightening everyday." "I'm just too frightened about going out in the street, going into a theatre." "I just don't have a reason to get up in the morning." "It's just confusing for me." "I just don't know where to begin." "What can I do about this?" Also the experience of, "I just feel so awful about my relationship with my daughter or my son, and I'm so angry about that." When you hear repeated statements, very subtle sometimes, that would reflect hopelessness, guilt, unfinished business, despair, that may reflect the desire to withdraw, to be isolated, these can be red flags. And you need to have a conversation or just begin to say, how do you really feel about that? Often people will dismiss someone as oh, they're just very crabby. But when we hear these kinds of statements come up over and over again and particularly if there are some new ones that just the individual never talked about in the past, that they are not part of their normal typical response to life, that is very important to keep in mind. Something is changing. Or if, as I say, they ratchet it up and things become even more desperate, then you know that there is a big change taking place. Now there are two onset periods in late-life depression and late-life anxiety. You have early onset in early adulthood and that's often called chronic, and also you can have an acute experience with depression sometimes due to a situational experience. Then the late onset which someone may have never experienced depression, a clinical depression or heavy depressive symptoms. And the research tells us that that type of depression is most often related to a medical condition, a medical illness. 

And that's important to keep in mind because it can be treated. And must not be ignored. These are the most typical medical conditions that have depression associated with them. Cardiac, heart disease, that would include any type of cardiovascular illness, the various cancers, diabetes, having had a stroke, and then Alzheimer's dementia and Parkinson's dementia. And you can see the three that seem to have the highest percentage reporting comorbid depression with a medical condition are Parkinson's dementia, Alzheimer's dementia, and the cancers. So when someone gets one of those diagnoses, their physician needs to follow them to see if it's possible that they will develop a depression and treat them for it. Because it's so difficult having any one of these illnesses that the likelihood of depression can occur. And in part that's due to physiological changes in the system. In cancer, taking chemotherapy, that's a term called chemobrain that woman have experienced that have had breast cancer. So the research is beginning to identify that the physiological changes that occur with many of these illnesses can result in depression. 

So we need to be aware of that and know that. And here we have the most common to the least common depressions in late life. And I'm going to talk about each one of these. And as I said earlier, the most common are depressive symptoms. Okay? And it's more common than a major depressive disorder, and we saw this statistic earlier, from 10% to 25% of community-dwelling people have depressive symptoms, and they often, often go untreated. And what we find is an irritability, some type of just a low feeling, overall low feeling, just not having the energy, the cognitive process, the enthusiasm, and a kind of a restlessness, just feeling restless. And some kind of a vague unsettled feeling. Also people have the experience of talking about physical complaints more. A lot of older people, as I said, don't talk about being sad. They don't talk about feeling blue. 

They may have guilt. Some of the other things that I've talked about. I've talked about cognitive changes with depressive symptoms too, poor judgment where you may decide to go to an event and you hadn't really judged your ability to be there for the entire day, spend more money, let's say, than you perhaps should in a situation, just can't make decisions very well and not able to stay on track, not to stay attentive. If you have questions about this, talk to your physician, to a nurse practitioner. Minor depressive disorder, in terms of the disorders, is most common, and we have a large percentage of people, and if you look back at that one graph that I showed you earlier, about half of the community-dwelling older adults are treated for diagnosed depressive disorders. And that's a big concern. And it's also associated with medical illness and substance abuse. We're learning a lot more about the relationship between mood disorders and substance abuse in late life. Currently the recommendation by scientists that have studied the substance misuse, let's say, in late life is that past the age of 65 it is recommended that women take no more than two alcoholic drinks per day and men have no more than one alcoholic drink per day. Now that's over a week's timeframe. 

And part of that has to do, I didn't make that up, it's in the literature, I'm reporting scientific evidence to you. >> Excuse me, do you have that backwards maybe? >> Pardon me? >> I'm wondering if you have that backwards? You said two for women, one for men. >> Yes. >> That doesn't sound right. >> I mean it's one for women and two for men, thank you. (laughter) Oh, dear, sorry, women. (laughter) Everybody is much happier now. (laughter) Now the men know they can have two drinks a day. >> But it will interfere with their medications. >> Either way it will interfere with their medications and that's the issue. 

You have to watch yourself. And women we know we have a lighter body weight, we metabolize the medication we're taking differently. And this is news to a lot of people. How many of you knew that actually that men no more than two a day, women no more than one? Oh, my goodness, so women know this better than the men. (laughter) Is this is little denial maybe, I don't know. But this is important information to share with your friends as well. Post-stroke depression, non-dysphoric is the technical name for it. And what it's associated most commonly with are depressive thoughts without the sadness. And again the research tells us that most commonly people experience and talk about hopelessness and worthlessness and may speak about dying or wishing to die. And that's more common than in a minor depression. 

And what really happens is the emotional, the part of the brain that processes our emotions is interrupted due to a stroke, and that's why there is a different expression when people have a stroke and have depressive symptoms. So that's what the doctor needs to look for. When we look at vascular depression, we're talking about a depression that may be associated with post-cardiac surgery. Also, other types of severe vascular disease that is not effectively maintained or managed. And this is very common. Vascular depression is also very common with Alzheimer's type dementia. And as you can see, cognitive decline, I've stated that there, and it is difficult to treat with an antidepressant. There is another type of depression common in late life and it's called executive dysfunction depression. And, again, this is associated with cognitive changes that are occurring in the frontal lobes of our brain which are right in back of our forehead. And this the part of the brain that is very sophisticated. 

It is part of the brain where we think up new ideas, and then we make a plan, let's say we decide that we are going to call our children and we are going to have dinner together at a certain restaurant and that you are going to send them directions. Excuse me, this thing came out, I'm wired here. And when you do not have executive problems, you do not have a difficulty in thinking about the problem and acting on it. You will send out cards to everyone or you'll call them on the phone and you'll drive to the restaurant and meet everyone there. However, when you're beginning to have difficulty with the ideas acting on them, then we call this executive dysfunction, and there is a depression that is often associated with that. And can you see why. It's threatening to our identities, we know that there are some major changes occurring in the way we live our lives, and this needs to be treated as well. These are some of the more specific characteristics of executive dysfunction depression. We often lose track. We don't track ideas as well. 

We don't express them as sequentially as we need to. As I said earlier, we just don't execute our plans as effectively. We don't always detect when we take a mistake in terms of let's say following through on a recipe and putting in all of the ingredients. Our actions may be out of order. (music playing) Could somebody turn that off, please? We have problems with fluency in our speech, it may be somewhat mumbled and people often show just kind of a general overall apathy. So you can see, just take a look at these, this is a serious form of depression. Here we have depression of the Alzheimer's type. And 20% to 40% of people with Alzheimer's type dementia have depression. And this is unique compared to depressive symptoms. People significantly express that first term, anhedonia is a technical term but it really means a lack of pleasure. 

In other words, the things that you enjoyed in the past just aren't any fun anymore. And you just don't know why. You have sleep problems, often lack of desire to eat foods you enjoyed in the past, withdrawal, kind of an agitation, just this restlessness I talked about earlier, and kind of apathy comes and goes. It's not constant. And this is something every healthcare provider should look for and it can, again, be treated. Major depressive disorder. We know that this is the least common. And this is associated with medical conditions. Very important to keep in mind. And we know that there is also a lack of pleasure, and often the comments ongoing about physical health complaints over and over again, they can't seem to find a solution. 

Sleep problems. Energy problems. Again, appetite. These are constant across many of these depressions. And functional impairment. We're talking about not being able to get up and get dressed in the morning, not grooming yourself properly. And I'll give you an example of that. I worked with an older woman in her early 80s who was very active in her yard, in her garden, she mowed the law, raised her flowers, was involved in her church, took wonderful care of the way she dressed, all over she's just a delightful person. And I would do my usual monitoring visits, this was when I was a care manager. I started to notice that she would come to the door with stains on her shirt or on her blouse. 

And I would go again, and her name was Sarah, and I noticed that Sarah's makeup just wasn't on properly. And at the second visit after I first noticed, this was a major change, major change in her appearance, and she spoke much more softly. And she had always had a lot of energy but she also seemed to be slightly agitated. And I conducted a geriatric  depression scale with her and sent that depression scale off to the physician, and the physician notified me, and she and I went in to see her physician and she was reluctant to talk about her feelings. However, he asked her about her health, and she explained that she was having these stomach problems and she felt very tired and she had lost her appetite, she loved to cook. And he weighed her and she had lost, over a couple months, about six to seven pounds, which was unusual for her. And so he recommended an antidepressant that also was an appetite stimulant. And he said we're going to focus on your appetite. And over a three-month period her mood started to improve, her appetite improved, and he kept her on the antidepressant long enough and the mood clearly lifted for her. And she moved away from a major depression into a normal mood. 

And this is a very happy story. But these characteristics were all present. Her functional impairment was she wasn't mowing the lawn, changes in appearance, problems with sleep, energy, appetite, apathy, she just didn't have pleasure, but she was not feeling sad. It was a big red flag for me. Now, major depressive disorder, the onset is less common in late life. Higher in early and middle adulthood. Now it turns out that Sarah had also had a depressive experience right after she had a hysterectomy when she was age 48. Excuse me, this thing is coming off. When she was 48. And so, again, she fit this framework. 

And we know that about 5% of people 60 and older have a major depression. It may be under-diagnosed. These are probably not accurate in one sense. And it is more common in women. And we think, well why is that? One of the reasons is historically women go to physicians more, and women also have the ability to talk about what is bothering them physically and so forth in the doctor's office. And so we need to encourage men in our lives to, when they start feeling changes physically, appetite, diet, sleep is often a red flag, physical complaints, experience of worthlessness, etc, and that begins to go beyond two weeks, we need to start thinking it might be a good idea to talk to my doctor and nip this in the bud. And even if you think something is changing and you're not sure, talk to your physician. Very, very important. Why does this happen? Very important to understand this. Now, let me see here. 

How are we time wise? Can anybody tell me the time? >> 11:14. >> Pardon me? >> 11:14. >> 11:14. Okay, we can do this. The research tells us that there is some association with genetic factors, particularly with early onset, but it has been hard to substantiate. There is vascular risk with cardiac disease, with post-cardiac surgery, as I talked about, vascular depression with the dementias. We saw those high statistics, I think it was 20%-40% of people with dementia, Alzheimer's type, have a depression. Endocrine changes. That's all a part of changing. Menopause. 

There's some research to substantiate that. Serotonin, a neurochemical in our brain, also changes with age, particularly with cognitive changes. And we know that that can be treated with serotonin re-uptake inhibitors, SSRIs, which are the most common antidepressants and have a track record of effectively working in older adults. We know another indicator of depression in late life is poor social support. If you read in any of the papers, the researchers are talking more and more about the importance of a good, strong social support system. Whether it's younger people, people your own age, whatever the case. Because this contributes to healthy aging, and it contributes to adjusting to major losses in our life as well. However, some of us get hit hard and have multiple losses. Whether it's a loved one, roles that are lost, we're asked to move to another building, even down the hall. We lose our sense of purpose sometimes, and we just don't have the opportunities to contribute. 

All of those factors can play into having major experience of loss. And there's an idea, a hypothesis that says we become depleted, they call it depletion syndrome, and people just don't have any more resources. And when we see that happening to someone, that's when we need to begin to recognize there may be some depression here because the individual just can't pull out any more stops. Low engagement is an indicator also. Low engagement means not going out, whether it's just out in the hall to visit, calling someone on the telephone, taking a walk, sitting with a good friend. Engagement takes all kinds of levels. I'm not talking about running marathons. I'm not talking about long vacations. Social dynamics, where we stay connected. I'm talking about connecting with people. 

And when those connections start disappearing, that's a red flag because what happens is we're decreasing input, neurological input, physical input, that is so necessary for older adults to thrive, particularly if you have a physical or a psychological health problem. So we need that positive exchange to occur. And when an individual has a mood disorder like a depression and anxiety accompanying it, it often doesn't happen because people withdraw. The environment. Micro and macro changes in the environment can impact depression. Sensory changes, hearing, vision, taste, smell, touch, physical mobility. You know this but we need to keep that at the forefront. Lots of stress, environmental stress. We need to have the opportunity to have a connection with the existential, the spiritual and/or the religious. It is part of the process of aging. 

When we move through the generative process when we give back to society, to children, people often move on to the experience of wisdom and sharing. And that is associated, in many instances, with the experience of spirituality, participating with some type of a group, religious or otherwise, where we have that connection with a higher sense of self. And for those of you who believe in existentialism, it could be that as well. With the appreciation of nature, the world around you, and your connectedness to that. Some researchers believe that religious coping has a high association, a positive association with health and well being. And Duke University Aging Center has done significant research on this. We see cognitive changes as a source of late-life mood disorders. And one of the things that is directly associated with depression is distorted thinking where an individual continues to ruminate about life failures, about experiences of low self-esteem, and the individual just is full of them self. I remember working with an older woman who said, you know I just can't get away from myself. It's all about me all the time. 

And that is one of the best examples I can think of this distorted thinking where you're constantly ruminating about your life in a negative way. You may have unrealistic expectations, overreaction to some things, over-personalized. Again, it becomes all about you. Fear and anxiety become heightened so that we know that kind of cognitive change where there is this kind of cyclic activity in the brain needs to be interrupted. These are some warning signs and contributing factors. When someone moves from their normal form of behavior and starts having sleep problems. Persistent negativity. Constipation and GI problems that there isn't a solution to. Lots and lots of visits to the doctor all the time. That should tell the doctor that, other than a major acute or medical condition, that something psychological needs to be addressed. 

A messy appearance, isolation, pacing and fidgeting and lot, lots and lots of complaining, excessive irritability. I mean, we all get crabby, that's just part of life. We get irritable. All those calls that come into our house at 7:30, the computer-generated calls for some kind of a foundation or whatever, and I keep having to say to myself be polite, be polite, be polite. But sometimes I'm just so crabby. Chronic pain. We don't pay enough attention to chronic pain and sometimes it just reaches a watershed point. And that can also be a contributing factor, and often is, to late-life depression and anxiety. Now, these are risk factors and some of them are also, what we just saw here, warning signs. Widowhood. 

Isolation. Substance abuse, an individual may have never been an abuser of substances but because of being lonely, not having contact, losses. Less than high school education. People don't have the opportunity to hear information like what we're talking about today. Family history, to some extent, particularly if there's been a history of suicide. Unable to perform their daily grooming. Not being able to dial the phone. Not being able to, let's say, prepare your letters and put a stamp on the envelope. To get into the bus. Now these are all major changes. 

A terminal illness can be a risk factor. Multiple physical conditions that just wear a person down, remember it's like depletion. Vascular problems, vascular dementia, vascular depression, and they can be a very challenging cycle. But without treatment, people keep going to the ER without help, they have very costly ambulatory care, wind up hospitalized when it could have been prevented. Increased costs, fiscal costs for your family, yourself, and emotional costs, very high to everyone. There are greater numbers of prescriptions. There's a cascade effect where one thing leads to the next. Suicide risk with major depression, lots of suffering, and loss to society. You are all very important people and you have a lot to offer, regardless if it's to the person you're talking to in the park or here or out in the community. Now let's talk a little bit about suicide risk and aging. 

Older adults are significantly at risk for suicide, particularly older men. Part of that has to do with the pressure that men have carried with them all their life. Also your ability to manage without seeking help. And individuals that are divorced, separated and never married. More common in white men than African Americans or Latino men. More common in professionals. And a big red flag is the purchase of a fire arm. Now, if you have had a history of previous psychiatric treatment, a major depression or a bipolar mood disorder, etc, you need to stay on top of things and manage as best you can with family and others changes in your mood. Any history of attempts. Terminal illness and major losses. 

And people will sometimes talk about this. We have to take it seriously. Anxiety that is not treated. Insomnia, psychosis, and hopelessness. These all create what we call a perfect storm, if not interrupted. Well, until recently suicide was more common in older adults, but you know what, the data is telling us something different. Recently, the data has shown that there has been a peak in suicide among middle-aged men 45, I think, to 55. And this is the first time in the history of data collection in suicide rates. And it's surpassing that of older men. And there are a lot of ideas out there about why that might be. 

It's important to realize that 80% of people that have committed suicide did have depression that was a major depressive disorder. And so on. I've listed a 24-hour suicide hotline number for people to keep in mind. It's something that you can call information for as well. Now, we're going to talk a little bit about adjustment disorders which are different than a major depression or even a minor depression. And these are life stressors. And these are really a frequent experience for older adults. And it may also be that someone just can't adjust to a major change. It's very much situational. And it is also short-term. 

That's the good news. People in late life can be effectively treated for these adjustment disorders with medication. And, unlike major depression, there are often emotional symptoms associated with adjustment disorders. So that's important to keep in mind. And difficulty with daily functioning, getting up in the morning, preparing meals, going out, driving, etc. They are more common in mid and late life, no surprise, right? Got a lot of changes we're going through. Kids are leaving, people are changing in their relationship. Chronic illness. We see that 10% of all adults have had an adjustment disorder, and I think that's very low. They usually are about a three-month event. 

I mean they begin around three months of the experience of having to deal with the adjustment and end around six months. May have stronger anxiety component or depressive component but it's not the same as posttraumatic stress disorder, that's also adjusting to something but it's very different from that. Older adults are vulnerable because we have these unexpected things that happen out of the blue. And we have so many dramatic changes, and again that tells us how valuable our support systems are, our social support systems. How valuable the kinds of services that we receive are to us. How valuable it is to have a primary care provider that can respond to these changes. Anxiety and adjustment disorders in late life. What we see primarily in older adults are the generalized anxiety disorders, that is one, two, three, four, fifth point down and comorbid anxiety with depression. Now I want to move ahead and talk a little bit about bereavement, grief in late life. We've all experienced grief, and we know how painful it can be. 

However, there is a point where grief goes beyond the normal course and begins to affect our life in a way that can be very dramatic. And I just wanted to point that out. Now the people that study these kinds of emotional changes in our lives identify that really there are three stages to our experiencing grief. And we know we've had this. And the majority of people wind up experiencing the restitution phase. And that's where we begin to take on a new life. This thing is not working. I don't think my ears are big enough. I should have bigger ears. This keeps slipping off my ear. 

(laughter) So most people go on to resolving, thinking about the person that they have lost and going on and loving that person but living life. However, there's something called complicated bereavement and this is about guilt. It's about the guilt of things other than the actions that you took to resolve the loss of that individual. And you begin to think about the thoughts of death other than the normal feelings that would deal with adjustment. And you begin to feel perhaps that you should have died instead of the other individual. You have more very serious preoccupation with worthlessness. You have changes. You slow down. Your speech may become very slow. You just have kind of a retardation of your walking, etc. 

You are not able to get dressed, do the things you need to do to groom yourself and get out. You may even have hallucinations that have nothing to do with the loss of the individual. Now many people have recounted hearing the individual talk to them that has just died, seeing them, etc, and that appears to be a normal part of grief. These hallucinations are very different apart from that. And if an individual knows someone that is going through this, this requires treatment and most likely an antidepressant. Risk factors, you see them up there. Substance abuse is one. Poor health status. Multiple stressors. Traumatic loss, etc. 

And already thoughts of suicide. And sometimes you just can't handle it, and then we need to reach out. You need a physical work up, simple cognitive evaluation, find out how you're doing with getting around, there are evaluations, social support, etc. Now, I'm going to go on and talk in the little bit of time that we have next, I'm going to talk a bit about treatment. Very important for anxiety. You see here that general anxiety disorder, you've probably seen the advertisements on television, right? Well, they're more common in older adults than they are in the younger adult population. So you have the statistics here to bear it out. Now how are doctors and other professionals treating depression and anxiety in late life? I'm just going to move forward here. Treatment. There are two forms and they have found to be effective. 

Pharmacotherapy, psychotherapy, what works? Well, when we're talking about pharmacotherapy, there is one primary form of therapy that seems so work well and it is the one that deals with serotonin in our bodies. And these are some of the, you've probably heard about one of the most common and one of the more effective ones for older adults is Celexa and Lexapro. Those two antidepressants, if monitored properly, in many cases can work for older adults, and the research is there to bear it out. In cases where an individual is very seriously depressed, talk therapy or psychotherapy can't be initiated necessarily right away. We need to work on the neurochemical changes that have occurred in the individual's body. Now obviously the physician needs to work closely with the family and monitor all of this and with the pharmacist. The pharmacist is one of the most important players when we're talking about pharmacotherapy for mood disorders of depression and anxiety. Here we have a statement about selective serotonin re-uptake inhibitors, and what we basically do is boost the neurochemical serotonin. It's a very important part of our cognitive and emotional functioning. So that that's what that medication does, and what doctors often prescribe are Lexapro or Celexa. 

However, everyone is unique. Talk therapy has, in combination with some of the SSRIs that I just spoke of, are equally effective. There are very specific approaches that are being used now. And they are not the kind, how many of you have heard of Woody Allen? His favorite kind of therapy still is Freudian psychoanalysis. Well, research has found that that is not the most effective form of therapy overall, particularly for people of our age. What they found is an approach called behavioral therapy, cognitive behavioral therapy, where the psychotherapist works with the individual to reconstruct how that individual thinks about themselves, particularly when an individual's self-esteem is very, very low. And it is a very pragmatic process. And the research shows that people your age enjoy this form of therapy because it really is about problem-solving and changing the framework in our mind about the way we look at ourselves. And the primary types are behavioral therapy. One of the most common types is problem-solving therapy. 

And the older woman that I talked to you about who was also taking the antidepressant that became better, worked with a therapist doing problem-solving therapy. And this was a perfect match for her because she was an individual that liked to help and solve problems. Cognitive behavioral therapy is a more specific name for, it is a type of behavioral therapy with a focus on the way we think not just the way we act, which behavioral therapy is. And I repeated that there, I'm sorry, interpersonal therapy and supported therapy are similar where we spend time just talking about what goes on in our life. So this isn't the kind of mind-probing therapy that people might know of. Now, we must be close to 11:30, am I right? What time do you have? >> 11:37. >> 11:37. We're going to close by saying treatment though needs to be multimodal. You have to not only be working with your primary care provider. Research tells us that when people are depressed, if they're going to anybody, they're going to their doctor first, and this is very important. 

We also need, in some cases, care management support from a care manager who might be a nurse or a social worker. We need somehow social support, but our care manager can help with that. We need to start engaging again. Physical activity of some type has been proven for cognitive problems and emotional problems to be particularly efficacious for people. A healthy diet and a positive environment. It is not simply medication but that usually jump starts that old brain of ours, and then we can begin with some of these talk therapy methods and so forth. And the research does bear out that this does definitely, positively change many older adults' life, and they can begin to re-experience pleasures that were lost previously. So I want to thank you very much for your presence. If you have any questions, I'll be in the back of the room with my card, and I can tell you more about our web portal with more detailed information, and I wish you good health and sharing this  information with others. Thank you so much for your time. 

It's been a pleasure. (applause)