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CHRONIC CONFUSION: DEPRESSION
Depression in the elderly is also called ‘pseudo-dementia’, i.e. false-dementia; this is because the symptoms and signs of depression can be very difficult to separate from those of some of the dementing illnesses. Depression is common in old age, and the elderly have the highest rate of successful suicide attempts. Depression often accompanies physical ill-health and, as we have seen before, old age is also a time of loss, making coping with the burdens of everyday life that bit more difficult.
All of us have days where we feel sad, but for most the mood passes. It becomes a problem when the melancholic outlook on life persists and begins to intrude into the person’s daily activities. Common feelings in depressed people are those of worthlessness and a hopeless outlook to the future. Sleep becomes disordered and there is early morning waking with an inability to get back to sleep and a subsequent feeling of a poor night’s rest. Gloomy thoughts intrude and ideas of suicide begin to form. The person may worry about their general health and consult their doctor about many trivial complaints (hypochondriasis), or they may begin to feel that their body is rotten and that they are decomposing internally. Many slow down and lose the will to do anything, even speak. The person may refuse to eat or drink and thus put their life in danger.
The condition gets confused with dementia because when various questions are asked to try and establish a diagnosis, to get an idea of orientation and memory, etc., often the person does not answer, hence scoring badly. The important difference is that the depressed person, if given enough time or if they wanted to answer, would give the correct answers; as it is though, they appear confused. Some people have a long history of depression; others have their first attack in old age. Making the diagnosis is the first step, and the sooner the better. Most people with depression do go to their GP but often do not complain of feeling low. The astute GP will realize that something is wrong and begin to ask the right questions. In difficult cases the person should be referred to a psychiatrist. There is still great stigma attached to psychiatric disease, which is odd considering that a significant proportion of the population will suffer from it during their lifetime. As psychiatric units cease to be housed in vast institutions and become part of the general hospital or community facilities, hopefully this feeling will fade. There has been a tendency for GPs to diagnose depression but be reluctant to prescribe anti-depressants for the elderly age group. This is now recognized as poor management: good clinical practice is the use of anti-depressant drugs when the diagnosis is made.
In a few the depressive illnesses will be part of a reaction to bereavement or disability or other stressful life events. Most of these cases will be monitored by the GP and psychiatrist and a few will need treatment with counseling. In the other cases antidepressant drugs are needed as well as the other support networks (day hospitals, self-help groups, counseling etc.) The drugs are very effective and have minimal side-effects, except in the very old and frail. Most courses of treatment are given via the GP or on an outpatient basis. Sometimes however the condition of the person is so severe that treatment has to be started on an inpatient basis. This is certainly true when (electroconvulsive therapy) is used. Many people who do not understand this form of therapy or who have never seen it given are very opposed to it. However, it is an effective, safe and necessary form of therapy in severe depression and can be life saving. A mild anesthetic is given and one electrode on the side of the head gives a minor shock, often just enough to cause a slight twitch. The only side-effects are of mild memory loss surrounding the in some people. Most treatments (both drug and ) are given voluntarily. Occasionally, however, the depression is so severe that the person does not recognize that they are seriously ill and they have to be admitted to hospital under one of the sections of the Mental Health Act. This is usually done by a social worker and the GP.
Recovery from depression can be extraordinary, although some people relapse and may need further courses of treatment. Because it is common and treatable great lengths must be taken to ensure that no one is labeled as ‘demented’ when in fact they are suffering from depression. Occasionally the two conditions of depression and dementia coexist; as the depression is treated the dementia does not go away but is usually noted to be less severe.
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