Ageing, Loneliness and Depression
World health organization (WHO) defines “elder” as a person above the age of 65years. It is estimated that out of seven billion total population, 7.5% (525 million) is over 65 years in 2010. This figure was 6% in 1992. Worldwide, the proportion elderly population is growing compared with the total population. This is mainly due to the increased life expectancy of people with advances in health care services and reduction in young population due to low birth rates. Few decades ago, high elderly population was found mainly in the developed countries. However, currently this issue is more common in developing counties. It is estimated that in 2040, the elderly population may exceed the figure of young population.
At present, the life expectancy at birth in Sri Lanka is 74.9 years (males – 71.6 years, females – 78.5 years). The WHO estimates that the current elderly population in Sri Lanka is 9.4%. Therefore it can be predicted that by 2050, the elderly population in Sri Lanka may exceed the proportion of young population.
What are the problems of expansion of elderly population? Firstly, the elderly is a time period where physical and mental frailty is more. Therefore these people are more vulnerable to medical disorders such as hypertension, stroke, myocardial infarction and mental disorders such as Dementia and Depression. Secondly, there will be multiple issues related to inevitable loneliness.
Loneliness has become a major concern in elderly. This usually begins with retirement. The elder may lose his income, social status and important social contacts with the retirement. As a result the elder may feel loneliness, impaired self worth and he or she may feel difficult to fulfill his or her needs including biological needs such as food & shelter and social needs such as social care. Further, the proportion of young people is declining as a result of low birth rates. This might further aggravate the loneliness as there won’t be adequate caregivers for the elders. In addition, the youth who are the traditional caregivers in our culture, are migrating to the cities and abroad leaving the elders alone. This is inevitable with current economic trends.
Multiple adverse outcomes can be seen with loneliness. The physical care for the elder may be impaired such as nutrition, medical care for illnesses and safety concerns. So they have more risk for deterioration of health issues and more prone to accidents. Further, this makes the elderly more prone to certain mental illnesses such as Depression, Adjustment disorders and substance related conditions.
Depression is one very important mental health condition seen in elderly even-though loneliness is not the only cause for the depression. It is estimated the 27% of the elderly population is suffering from mental health condition worldwide (WHO 2014). Depression is one important contributor for the above figure with the worldwide prevalence of 10-14%. Rates of depression rise sharply with the advancement of the age.
Depression is a mental disorder affecting the mood of an individual. This is due to certain chemical changes of human brain. The affected individuals show certain clinical features such as low mood, lack of energy to work lack of pleasure. In addition, they may have poor sleep, poor appetite, lack of concentration, recurrent suicidal ideations, tearfulness and ideas of guilt and worthlessness. Depression can be seen in any age group and it is estimated that 10-20% of total population will get depression during their lifetime. As discussed above, elderly population is at more risk to develop Depression.
Elderly depression is a difficult condition to recognize. There are several reasons for this. Firstly, some of the classical symptoms of depression may be absent or difficult to identify in elderly depression. For example, “lack of pleasure” and “lack of energy” are difficult features to identify in elderly depression. In addition, affected individuals may show body aches and pains and other medically unexplained physical symptoms rather than classic features of depression. Some affected individuals show significant memory loss (Depressive pseudo-dementia) resembling another mental disorder called Dementia. So that, high level of public awareness and alertness is essential for early diagnosis of elderly depression.
Elderly depression has many health impacts. Firstly, it deteriorates physical health of the affected due to poor self-care and nutrition, increased vulnerability to medical illnesses such as hypertension and increased vulnerability to Dementia. Secondly, it increases the rates of suicide and deliberate self harm and self neglect. Sri Lanka is a country with high rates of suicide and high rates of elderly suicide. Thirdly, the affected individuals may show aggression and violence particularly towards care givers, further reducing the received care for them. In Sri Lankan context, depression may manifest as excessive alcohol use since verbal expression of depressive symptoms is rare in our culture. So alcohol related issues are common among depressed elderly. In addition, depressed individuals are more susceptible for abuse particularly physical & emotional abuse and for exploitation. Considering all, it is obvious that the elderly depression may worse the care giver burden and exhaustion for the care givers.
What should we do to minimize elderly depression? Firstly it is important to prevent the occurrence of elderly depression as much as possible. Even though there are certain un-modifiable risk factors such as genetic factors & personality factors, certain risk factors are preventable. These include physical and social neglect, loneliness, malnutrition, alcohol use and uncontrolled medical illnesses. Every measure should be taken to eliminate these modifiable risk factors.
Secondly, the caregivers should be well aware about the early symptoms of Depression such as alteration in sleep, self neglect, irritability and poor interactions with others. In such situations, early referral to a psychiatrist is very important. If so, the disease can be diagnosed early and prompt actions can be taken to minimize the advancement of the disease. Elderly depression must be treated with carefully selected medications and other non pharmacological therapies. Usually they need treatment for longer duration. Once treated, optimal care for the elder by the caregivers is essential as the recurrent rates are high.
In summary, it is evident that ageing will be a major global problem in near future. Elderly people are at risk of getting many problems including elderly depression. Every step should be taken to prevent this as much as possible. The caregivers must be well aware on how to detect elderly depression early and seek psychiatric advice early to minimize adverse outcomes.
Dr. Thusitha Athurugiriya (MBBS, MD-Psych)
