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Seeking Answers for Older Adults with Depression

Nina Stone didn’t start to feel depressed until she was well into her 70s, but when the disorder hit, it knocked her for a loop. The 88-year-old St. Louisan became so depressed that for several months she found it almost impossible to get out of bed.

“I knew I wasn’t supposed to feel that way,” Stone recalls. “I couldn’t find the strength to get out of bed in the morning. I’d sit on the edge of the bed, shuffle into the bathroom, then into the kitchen to make some coffee. Then I’d get back in bed.”

She remembers being overwhelmed with sadness and often completely exhausted; although she spent many days in bed, she had trouble sleeping. She slept about two hours at a time, and never more than four hours a night. Some friends and family members wondered whether her moods were a normal part of aging—but Stone knew better.

“I knew something was wrong,” she says. “I felt like I wasn’t really living at all. I was just hanging around.”

So, Stone consulted the Yellow Pages, looking for a psychiatrist who specialized in working with older people. A few minutes later, she called Eric Lenze, MD, a Washington University psychiatrist at Barnes-Jewish Hospital.

After an appointment with Lenze, Stone became part of a clinical study that is evaluating the effectiveness of combining a pair of FDA-approved medications to treat depression in older adults. As a result, she was soon taking the antidepressant drug venlafaxine XR, commercially known as Effexor XR. Stone says she began feeling more like herself again in about four weeks.

“It has done wonders for me,” she says. “I was a miserable old lady, but now I feel like a new person.” In the depression study that involves Stone, every volunteer receives an antidepressant drug for 12 weeks.

If depression symptoms persist, study patients start taking an additional pill—either aripiprazole, sold as Abilify, or a placebo. The study medications venlafaxine and aripiprazole are often used in combination to treat depression in younger adults, but Lenze says the drugs need a closer look in older adults when the goal is not only to improve symptoms but to continue treatment until the depression is completely gone.

Identifying Depression in Older Adults

Lenze says although depression is as treatable in older people as it is in younger individuals, sometimes doctors don’t recognize clinical depression as readily in their older patients. When elderly people become sad and seem depressed, there is a tendency to attribute their mood to grief, disability or other problems frequently associated with aging.

Depression also may look more like a cognitive problem related to aging or a disorder related to the other medications that many older people take. A strong relationship exists between physical and mental well-being in older adults, according to Lenze.

At around age 60, many people begin to experience age-related medical and cognitive problems. “Depression is a very disabling and impairing disorder,” Lenze says.

“It can cause problems with memory and attention, and can greatly increase the disability that comes with other health issues. It even can increase the risk of death, either from suicide or by making age-related illnesses, such as heart disease or cancer, more deadly.”

For some people, depression is a condition that begins early in life and simply continues into older age. But for others, new-onset depression attacks as they face the many new stresses and challenges related to older age, such as grief, social isolation or disability.

It is not unusual for depression to appear in older adults after they’ve had a disabling medical event, such as a heart attack, stroke or hip fracture. Lenze says becoming disabled is a major risk factor for depression in older adults, regardless of what the disability is.

“Brain changes occur as we age that may put some older adults at risk for depression,” Lenze says. “But the news isn’t all bad. Depression doesn’t get more common as we age, and it’s certainly not an inevitable result of aging.”

He says when depression does appear in an older adult, it’s very important for that individual to receive treatment. That’s why Lenze is involved in learning the best ways to treat depression in older adults. He says it doesn’t necessarily follow that just because a certain drug or therapy works in younger people, the same approach also will help older adults.

Studying a Drug-Free Approach

One complicating factor in treating older patients with depression is that they often take other medications, and they may not want to add antidepressants to the blood pressure medicine, anti-inflammatories and other drugs they take. So in addition to studying medication to treat depression, Lenze is studying a technique known as mindfulness-based stress reduction.

“We’re teaching older adults techniques that help them remain engaged in the present moment,” Lenze explains.

“It’s very similar to meditation and involves monitoring your breathing and becoming aware of sensations in your body. In recent years, there’s been an explosion of interest in mindfulness-based treatments for anxiety and depression. We want to learn whether this approach not only will relieve depression and anxiety but also help improve cognitive function.”

Older adults can suffer from the snowball effect of health conditions. Depression and anxiety often contribute to cognitive problems in older adults, and cognitive impairments can lead to greater levels of disability. One possible mechanism in the brain triggering this cascade of problems involves changes in the hypothalamic-pituitary-adrenal (HPA) axis, which is tied to stress hormones.

The aging brain is less able to control the activity of the HPA axis, so older people may be more vulnerable to chronic anxiety and depression. That, in turn, may contribute to memory problems or other cognitive difficulties.

The hallmarks of the problem are continual, repetitive worrying about the same problem and difficulty letting go of negative thoughts. Helping people live more in the present moment by teaching them mindfulness-based stress reduction may make it easier to let go of those negative thoughts and ruminations about health concerns, disability, grief and other problems that can contribute to depression and anxiety.

Lenze says as we age, we lose some of what he calls our cognitive reserve. “We have more cognitive reserve when we’re younger,” he explains. “Older folks don’t have as much reserve, so when depression strikes, it can cause them more problems with day-to-day functioning.” In other words, where depression might make a 40-year-old sad and unable to experience pleasure, the same condition in a 70-year-old might lead not only to sadness but also to symptoms that mimic dementia. So the goal of treatment is not only to alleviate depression but also to improve cognition.

Avenues to Find Help

Lenze and his team of researchers are looking for signs of cognitive improvement in studies of mindfulness-based stress reduction and also noting cognitive performance in patients taking antidepressant medications.

The research team is still recruiting study participants over age 60 who are clinically depressed. “It’s not uncommon for us to meet with an older person and have that individual tell us they are worried that their mind is going,” Lenze says.

“Of course, the fact they’ve called and are aware they are having problems may be a sign they don’t actually have dementia. We have seen people with bad memories get much better once their depression has been treated.”

Nina Stone never felt like her mind was going. In fact, she didn’t feel like she was anything. After treatment, she says she is herself again. “I would tell anyone who thinks they might be depressed not to wait,” she says. “Get help right away. Life is too short to be miserable.”

For more information on the medication study or the mindfulness study at Washington University, contact Research Patient Coordinator Jenny Anger at 314-362-5154 or send her an email.
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