New Book on Depression Puts Focus on Older Adults
Other issues, like dementia, can complicate a diagnosis
(Editor’s note: The following is an excerpt from Depression in Later Life: An Essential Guide, by Deborah Serani, published this summer by Rowman and Littlefield. Serani is a psychologist and adjunct professor at Adelphi University.)
Case Study: Davina
Dennis from across the hall in my office building came in one afternoon and asked if I’d take a look at his 81-year-old mother, Davina, who moved in with him a few months ago.
Dennis told me that she’s not herself these last few months. Dennis and his wife, Gail, think she’s depressed and so does her general practitioner. The reasoning behind this, they feel, is that Davina recently stopped driving and seems to be having some difficulties adjusting to the new living arrangements. A prescription for an antidepressant, Zoloft, was filled, but before beginning the medicine, Dennis wanted a second opinion.
I agreed to see his mother, but wanted Dennis and his wife to be part of the consultation. So I sent Dennis home with some informational papers for his mother to complete ahead of time, suggesting that if she cannot, that he can do so for her.
On the day of the appointment, I welcomed Davina into my office and watched as she slowly walked with her walker to a sturdy chair. Her hair was a soft puff of white and styled short. She was dressed and groomed well, wearing a black velour sweat suit and supportive black sneakers. Davina’s eyes were at half mast, heavy lidded, until she placed her glasses on. Then they popped open.
Davina told me that she was an elementary school teacher for 33 years, and married for 56 years. She had four children and seven grandchildren and can name them all, but has trouble recalling their exact ages. Davina goes on and shared that her husband, Larry, died from a stroke on May 29, but she can’t remember the year. She took his passing very hard, but manages to fill her days with reading, playing on the computer, watching television and spending time with her grandchildren next door.
Living, Health Questions
Davina disclosed that once she started having trouble walking and driving, her son thought it’d be wise to sell her home and use some of the money to build an addition to his house for her. Which is what they did. She reported liking the arrangements, having her own living area far enough away, but also being close enough should she need help with things.
Davina speaks well and doesn’t need me to repeat any questions or comments made to her during the consultation. When asked about her physical health, Davina said she takes Zocor for high cholesterol and Lopressor for her heart, but can’t remember the exact dosages. She has weakness in her legs, especially in both knees and has been told she needs knee replacements.
“Do you know why you’re here to see me today, Davina?”
“Dennis thinks I’m depressed.”
“Do you think you’re depressed?”
“Some days. I think about things and get depressed.”
“Oh, this and that.” She paused. “Missing Larry. Feeling old.”
“What else do you think about?” I asked, wanting to know more.
“Not too much else. I try not to think about things too much,” Davina replied.
“Well, I’d like to talk to you today about some things. Would that be OK?”
A Small Test
“But before we start, I want you to remember these three words: Rabbit, pencil, bedroom. Can you say them for me?”
“Rabbit, pencil, bedroom,” Davina repeated.
Davina and I completed the Geriatric Depression Scale, The Beck Depression Inventory, The Beck Anxiety Scale and the Mini-Mental State Exam. At the end, I asked Davina to tell me the three words I wanted her to remember.
“Rabbit, pencil, bedroom,” I reply.
Davina narrows her eyes. “Yes. I remember now.”
After a brief moment to score the tests, I invite Dennis and Gail in to join us. Dennis and Gail both agree that Davina seems sad and lethargic. They talk with Davina in the session about how she doesn’t want to do a lot of the things she used to do. Dennis tells his mother that sometimes she’s irritable and snappy. Gail reminds Davina how she hasn’t wanted to talk on the phone with Linda, Ken or Greg (her other children) or interact with the grandchildren like she used to.
Trying not to make Davina feel broadsided, I stop and ask Davina how she feels about listening to all of this.
“OK,” she said. “I’ve heard this from them before.”
Long List of Concerns
Dennis and Gail continue to share their concerns and the list is a long one. They report that Davina doesn’t like go out as much anymore, and when she does, she nervously insists on going home early. Gail says that she seems confused a lot of the time and sometimes forgets to lock up her side of the house, leaving the front door open all night. When Gail reminds her of what she needs to do, Davina gets upset, and sometimes cries. Dennis shares openly and with great concern that Davina isn’t understanding how serious this is.
“I do,” Davina responded. “I just don’t see what they’re saying. I’m fine.”
I take out the Beck and the Geriatric Depression forms.
“Remember these?” I lift them up for everyone to see. “We filled them out a little while ago.”
“Well, it shows here that some of the things you think and feel suggest depression, Davina.”
I try to be gentle and wait for her to process the information.
“You got scores in the moderate range for depression. You have some anxiety too, but it’s on the milder side.”
“You can have both?” Gail asked.
“Oh, yes, it’s not uncommon for depression and anxiety to buddy-up sometimes,” I replied.
“Does the Zoloft take care of that?” Dennis asked.
“It does, but I have a bit more to share with you all.” I paused a beat and looked at Davina. “How do you feel learning this?”
“Well, if it says so, then it must be true,” she said.
Not satisfied that Davina understands me, I explained the symptoms of late life depression and go over some of the questions we completed. I do this to review her memory of the experience and to educate everyone in the room about late onset depression.
Another Issue: Dementia
I go on further and illustrate that while simple forgetting and confusion are part of depression, there are some things here that warrant further inspection. I shared that Davina obtained a score of 15 on the Mini-Mental State Exam, which suggests a moderate impairment of cognitive functioning.
Davina could not identify the day or date, had trouble drawing an object, counting backward from 100 by sevens and other recall issues. I recommended more in-depth testing by a neurologist, who’d perform relevant medical and lab tests related to brain functioning. And also a neuropsychologist, who’d test Davina’s executive functioning, and further assess her mood and anxiety states.
“You’re thinking Alzheimer’s?” Dennis asked, upset.
“Alzheimer’s!” Davina snapped back, upset. “Oh, I don’t have that. What are you talking about?”
“There are many different kinds of issues related to how the brain works. And as we age, our thinking can slow down a little. It’s natural. But there are some things that concern me. Thing that concern Dennis and Gail. And I’m thinking maybe you may feel confused sometimes and it makes you feel upset. Or nervous. Maybe even depressed,” I said.
Davina is agitated but is listening.
“I can’t say what’s going on because more information is needed, but early identification and treatment can be very helpful.”
Depression Only ‘Half the Story’
We continued talking a bit more before the consultation ended. Before they left, I urged them to start making appointments, and to keep me in the loop as things progressed. As I closed the door, I realized that Davina’s general practitioner was right about her having depression. But it was only half the story. Davina appeared to also have some form of dementia.
It was easy to Monday-morning quarterback his decision to prescribe Zoloft from the vantage point I had now, but it was also easy to miss Davina’s entire diagnostic picture. Why? Because so many of the symptoms of dementia can overlap with the symptoms of depression …and vice versa. And this is why a comprehensive, multi-professional assessment ensures a proper diagnosis of late life depression.