Over my 30-year career working with older people, it has been exciting to see the increased interest in and awareness of dementia care.  It feels like there is less stigma associated with the condition and people are much more likely to talk openly about either having dementia themselves or someone in their family being affected.

However, the ‘D’ which is still not talked about enough, especially in relation to ageing is ‘Depression,’ arguably just as prevalent and as life changing as dementia, but less recognised, under-diagnosed and under-treated.

It is hard to understand why this might be the case.   Some of the reasons might be that many of the signs of depression can look and feel quite similar to some signs of dementia including memory loss, cognitive difficulties, reduced motivation and sleep problems.  This results in less experienced professionals explaining these symptoms and mood changes as being because s/he has dementia, rather than being understood as a distinct other illness – depression.  The other more worrying reason might be that there is a general acceptance in our culture that somehow being sad is a ‘normal’ part of getting old.  To some extent this is understandable, because there are many losses and changes associated with ageing which are likely to make people less happy.  If our spouse has died and we have also lost many of our closest friends, if we are no longer living in our own home and we are less mobile and independent, life will undoubtedly feel very different.  However, we know there are many older adults still living life very fully into their 90s and beyond, including those in the very best care homes, where new friendships are formed and there are many things to look forward to in the day.  We should therefore not see sadness as inevitable, and most importantly, know that depression is not just an everyday passing sadness, but a debilitating and distressing illness which needs urgent attention.

An interesting piece of research by the British Geriatrics Society and The Royal College of Psychiatrists in 2018 highlighted some examples of best practice as well as some of the gaps in relation to recognition and treatment of older people with depression.   Staff training in understanding depression was highlighted as an important need.   My own experience in care homes over the years is that there are many people who express suicidal thoughts, “I want to die”, and the overwhelming reactions to this are what I would describe as the ‘cup of tea’ response – kindly meant, but essentially an awkward brush-off for staff who feel ill-equipped to know the right thing to say or do.    There are many possible helpful treatments for depression – both talking therapies and pharmacological.  It seems relatively rare for older adults to be offered any formal counselling in care homes settings – is this because there is some ageist assumption that it is ‘too late’, or maybe it is related to cost or lack of therapists interested in this area, although I would doubt the latter?  

Almost all the studies and informal evidence highlight the importance of addressing loneliness and lack of social stimulation as an associated cause of depression.  If we have things to do in our day, people to talk to and interests to pursue, our mood is likely to improve.  Physical exercise is also strongly associated with lessening the symptoms of depression.  Many care homes do run exercise classes on a weekly basis, but should there be something physical offered every day?  If someone is clinically depressed of course, the big ‘Catch 22’ is that they are less likely to be motivated to take part in any of these activities, even though, if they did, they are likely to feel better.   There is again an important staff training component here in knowing how to get beyond a person saying ‘No’ to every suggestion and finding the right carrots to encourage someone to get more involved.  For some individuals this might be the presence of a cat or dog, for others it might be the invitation from a handsome man or an attractive woman, and for others it might be a large glass of wine!  Knowledge of individuals is a critical part of finding what might help.    For some people with a clinical depression, carefully prescribed and monitored anti-depressant medication might be an important intervention, but it is never the whole solution.  

Let us hope that in the years to come, the big ‘D’ of ‘Depression’ in older people will be as talked about as its often unwanted companion, ‘Dementia’.   We can live well with a dementia, but it is very hard to live well with depression if it is left unrecognised and untreated.

SALLY KNOCKER
Consultant and Trainer
MCM

Further resources

Dealing with Depression Guide

https://independent-age-assets.s3.eu-west-1.amazonaws.com/s3fs-public/2020-10/Advice-Guide_Dealing-with-depression_2020_0.pdf?VersionId=vxhoM8Loi5fGpK482Ii

A range of resources available from the Canadian Coalition for Seniors’ Mental Health:

A range of contacts and resources from Beyond Blue in Australia:

https://www.beyondblue.org.au/who-does-it-affect/older-people

NHS self-assessment for depression

https://www.nhs.uk/mental-health/conditions/clinical-depression/overview/

British Geriatrics Society and Royal College of Psychiatrists Study

https://www.bgs.org.uk/sites/default/files/content/attachment/2018-09-12/Depression%20among%20older%20people%20living%20in%20care%20homes%20report%202018.pdf

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