Dear Dr. Koepp, My mom has recently become depressed. She's 94 and lives alone. She's seen her internist and is on 10 milligrams of Lexapro. My family and I aren't sure what we should be doing (if anything). Where should we go from here?

I'm Dr. Regina Koepp. I'm a Board Certified Clinical Psychologist and I specialize with older adults and families. I created the Psychology of Aging Podcast to answer some of the most common questions I get about aging. Questions about mental health and wellness, changes in the brain like with dementia, relationships and sex caregiving, and even end of life. Like I say in my therapy groups, no topic is off topic. We just have to have a healthy way of talking about it. So if you're an older adult or caring for one, you're in the right place. Let's get started.

May is mental health awareness month? May is also Older Americans month. It's almost like the universe knows that May is my favorite month. So may is my birthday. Then there's mother's day, my anniversary's in may and now with mental health awareness month and older Americans month in May. All of my worlds are joining together, my career, my work, my family life! Because May is mental health awareness month and older Americans month and because this is the Psychology of Aging Podcast, the next few episodes will focus on older adults and mental health. Part of mental health awareness is staying mentally well and so to help older adults stay mentally well during COVID, I have a free guide on helping older adults stay mentally well during COVID and it's called, you guessed it, the COVID-19 wellness guide for older adults. So I'll link to it in my show notes. It's free and has lots of great recommendations and resources for helping older adults stay mentally well during COVID

So today I'm going to be talking about older adults and depression. The reason I'm starting with depression is that depression is the most prevalent mental health condition among older adults. To start this conversation, I want to share with you a letter that I received from a listener. Dear Dr. Koepp, My mom has recently become depressed. She's 94 and lives alone. She's seen her internist and is on 10 milligrams of Lexapro. My family and I aren't sure what we should be doing (if anything). Where should we go from here? So that's basically the letter. Here's my thinking around this. It can be really hard to know how to help an older adult who may be depressed, especially an older adult over 90. People have concerns about stepping into much like maybe they're overstepping and impeding on the person's autonomy or the opposite. There's fear around giving too much space and it's a difficult balance to strike. Do we step in or do we back off? This is one of the most common questions I get working with older adults and families.

Here's where I suggest the family start. The first place to start with a new onset of depression symptoms and older adults is with the primary care provider. And ideally that primary care provider would be a geriatrician. So a geriatrician is a primary care provider who specializes with older adults. And this is important because there are some sensitivities in older adult bodies that geriatricians are particularly thoughtful about. The primary care provider or the geriatrician could do lab work and a medical workup to rule out any medical causes of the new depression symptoms. The other place I would encourage this family to start, and hopefully the geriatrician is doing this as well, is to have a cognitive screening done. And I, and I suggest this because sometimes with an onset of depression symptoms in older adults, there's potentially a dementia disorder happening.

On the other hand, what's tricky about working with older adults is that while a medical condition can be causing what looks like depression symptoms, on the other hand, depression symptoms can be causing what looks like a medical problem. And so this is where it gets tricky to tease apart. Is it medical, is it mental health, is it both? This is where teamwork makes the dream work and also helps with understanding a diagnosis. This is also where older adults can end up in the pinball machine of healthcare. So they could end up with going to the neurologist and the neurologist might say, well no, you need to be seen by a Geropsychiatrist. And the Geropsychiatrist might say, well, you need to get your lab work done by your primary care provider first. And so the older adult is ping ponging back and forth and back and forth. And then sometimes in the pinball machine of healthcare, they get pinged around so much that they end up falling into the hole, right. And, and then not getting treated at all. And then it's frustrating and overwhelming and they don't want to go back into that system. If you're caring for any older adults, they might be relying on you to help them navigate that system because it's very overwhelming and frustrating, especially if you're dealing with depression or medical problems.

After I read this letter, I was really curious about what the signs of depression were that the family was noticing and they're 94 year old loved one. I thought this would be a good opportunity to provide some information and education about what to look out for with older adults. And then I'll also be sharing what you can do to help. So here's the list of the signs of depression in older adults.

Persistent sadness or crying a lot. So, I was recently working with somebody with Parkinson's and she's sharing with me that she's finding herself tearful, just experiencing bouts of tearfulness throughout the day for for weeks at a time. Feeling worthless or helpless. Feeling slowed down. Excessive worries about finances and health problems, weight changes, like especially due to changes in appetite. You might hear your loved one say I'm not hungry or they want to eat everything in the house. So they might have weight changes, like losing weight or gaining weight. There's also psycho-motor symptoms, we call them, like pacing and fidgeting or the opposite, like being unusually still. A person could experience changes in sleep, like sleeping too much or sleeping too little. So with older adults sleeping too much is kind of tricky. Sometimes I'll work with families, especially families with a loved one in their nineties or the loved one in the nineties is sleeping a lot during the day and sleeping a lot at night. And the family's wondering, " is this normal? Is there a certain time that the body is just slowing down or how much sleep is too much? How much sleep is too little? And that's where a team is really helpful. You can figure out with medical providers, is the older adult... Is this within normal functioning for how they're doing medically or is this maybe more like a depression? Difficulty concentrating. If there's any cognitive disorder that might be difficult to assess or figure out or tease apart physical symptoms like pain or gastrointestinal problems and then withdrawal from regular social activities. So it's important to know that in order to meet the criteria for a depressive disorder, the older adult only has to have five of those symptoms lasting for two or more weeks and the symptoms also have to affect how they are functioning, like how they're doing in friendships or relationships, how they're taking care of themselves or how they're engaging in activities.

Are they slowing down and that's a departure from how they were the month before and all of the medical problems are ruled out. Then you might think about depression. I want to say that the person doesn't have to meet full criteria for depression to get support and care. So I'd say even if she didn't meet the full criteria for depression, it's worth getting her checked out.

So I'm going to give you a personal example from myself. So after I had my first child, I had symptoms of postpartum depression. But what was tricky is that I didn't meet like full criteria for postpartum depression. I felt numb and I wasn't myself, but I was really productive at work. I was excelling at work and so I was highly functioning, but I wasn't myself. I didn't feel like myself. I felt off when I got pregnant with my second child, I was dreading the postpartum experience because of my experience. After having my first child, I never got assessed or evaluated after my first child because I thought, well, I didn't meet full criteria for depression. And then I had my second child. And to my surprise, I didn't have any of those postpartum depression experiences that I had after the first child. And then I realized, Oh my gosh, I could have received care, I should have received care, I should have opened myself up to that possibility because I, I think I was suffering for a year when I didn't have to. And it was only with perspective of having a second child and experiencing a positive postpartum experience that I realized, wow, I was really, really struggling that first year after my first child was born. So I'd say even if your loved one doesn't meet full criteria for depression, it's worth encouraging them to get checked out.

So now what should you do if you're concerned that your older loved one has depression or might be experiencing some symptoms of depression and not living their best life at this stage of life? So the first thing to do is to talk with them about what you've been noticing in a compassionate and concerned way. We have this kind of experience with older adults, something that we all do and I think it's related to ageism, which is bias and discrimination based on age, but it's our perspective that older adults are fragile. And so we sometimes don't have conversations with older adults and we fragilize them. I don't even know if that's a word, but we make them more fragile than they are in our minds. And so then we don't have conversations with them to talk with them about their concerns or what we're noticing because we fear that it will break them.

Now I want to give little caveat here that if the person has a dementia disorder, you do need to be mindful about how you approach topics. But if they don't have a cognitive disorder, be mindful of are you fragilizing the person, are you infantalizing the person by withholding a conversation? So another thing you could do if you're concerned that your older loved one might be depressed is to offer to help them get evaluated and treated. So as I mentioned earlier, the first step I would recommend is going to their primary care provider or their geriatrician to rule out any medical issues that might be causing depression symptoms or medications that could be causing depression symptoms. If medical concerns and medications are ruled out or properly treated, then you could get connected to a mental health provider, preferably a mental health provider who specializes with older adults.

In the grand scheme of things, it's hard to find mental health providers who specialize with older adults. We are few and far between and I'm hoping to change that with making caring for older adults inspiring and energizing and life-filled, but until then I have some resources for how to find mental health providers who specialize with older adults near your older loved ones. Head on over to my show notes and go to my website and learn more. What might happen though is you might be going back to that pin ball machine of the healthcare system, especially for older adults. You might be pinging and ponging and going up and down and all around with neurology and primary care and mental health providers and they all might have their own criteria for what they need. Like neurology might not see your loved one until Gero psychiatry rules out that there are any mental health problems interfering with their brain and so on.

You might end up with all of these systems, primary care, neurology and psychology or psychiatry all at once. If you do have all these teams treating your older loved one, it's a great idea to help facilitate releases of information between them so that they have permission to talk with one another about your older loved one's care. That's back to the teamwork that I was mentioning and that will help to really fine tune what is going on with your older loved one. Something that's so important to know here is that depression is highly treatable in older adults, so the CDC tells us that 80% of the cases of depression in older adults are in fact treatable. But here's the thing, older adults can't get treated for depression if their depression goes unrecognized and untreated, and when we don't recognize, and we don't treat depression in older adults, they suffer when they don't have to.

They also have more medical problems. They also are more likely to stay in the hospital. They're also more likely to take more medication for their medical problems, have more visits to the ER, and experience more loneliness and isolation than older adults who do have their depression treated. This is why I'm on this mission to help elevate our understanding of caring for older adults and especially as it pertains to mental health conditions. So one of the things that we can do to recognize and treat depression is to challenge a belief that many of us have that because a person is old, they're expected to be depressed, and that is a false belief. Depression is not a normal part of aging. I'm going to say that again. Depression is not a normal part of aging. Depression is not a normal part of aging. So there's a common misconception that when people age, they become depressed.

But as I mentioned, that's not correct. So let me tell you what the rates of depression actually are for older adults. So according to the CDC, only one to 5% of people, 65 and older living in the community, meaning that they living in their single family homes or wherever independently have depression. These rates do increase though when older adults are in the hospital or have a medical problem, but then they only increase to 11.5% and then when older adults require home health care assistance in their home, the rates of depression then are 13.5%. Okay, I do want to point out though that the rates of depression do increase the older a person becomes, like especially when we are going into the oldest old ages like 85 and 90, our rates of depression increase. So for folks 85 years and older, the rates of depression are 20 to 25%. And for folks 90 years and older, the rates of depression are between 30 and 50%. So you can see that the older we get, the higher our risk for depression. Some of the risk factors have to do with loneliness and isolation, medical problems, higher rates of grief and bereavement. So there are a lot of risk factors that put older and we call these folks in the 85 and 90 year old age ranges, the oldest old, um, that put these folks in the higher risk for depression category. With that said, just a friendly reminder that depression is highly treatable in older adults, even folks who are 85 and 90.

So I shared a little bit about what you can do if you're concerned about your older loved one who might be depressed. It's also important that we all work on shifting our own view that with age comes depression and we can help our older loved ones get connected to providers and resources that can help to treat suffering and ease pain. So please don't ignore the signs and symptoms that I mentioned earlier. Instead lean in and share your concern and help them get connected to providers. So head on over to my website and my show notes for how to do this. Another way that we can help older adults surrounding depression is that we can work toward preventing depression from happening in the first place as much as possible by focusing on wellness strategies that serve as protective factors. Protective meaning protects the person from developing depression, so my COVID-19 Wellness Guide for Older Adults gives lots of strategies for maintaining wellness during COVID, but they also serve as protective factors against depression. So head on over to my website and download that from the show notes. It will really help you out and your older loved one out too.

If you or someone you know is in crisis or struggling with thoughts about harming themselves or others, please reach out to the national suicide prevention line at +1 800-273-8255 there are people standing by and ready to help and yes, even to help older adults. If you liked this episode, be sure to subscribe so you'll be the first to know when new episodes are released and then leave a review. Subscriptions and reviews help people to find this show. In wrapping up, it's important to share that the ideas expressed in this episode are mine and mine alone, and that the information shared does not take the place of licensed medical or mental health care. See you next week. Same time, same place, lots of love to you and your family. Bye for now.