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The Boomers Rock Radio Show and the host Tom Matt, conduct interviews with many professionals on topics relating to boomers. This particular podcast talks about the importance of generativity. Learn more about this topic and many others on the Boomers Rock Radio Show!
The Importance of Generativity Podcast - with Dr. Deborah Heiser
Aging Well: A Challenge That Can Be Met
BLOGGER: Michael B. Friedman, LMSW
Sadly, in our society, the idea of aging well is virtually a contradiction in terms. Age is so identified with disability that when older people who are not disabled say they are “old”, they are quickly assured that they are not.
“You’re only as old as you feel.”
“Age is a state of mind.”
In our society, whether you are 65, 70, 75 or 80, if you’re still active, and enjoying life, you’re not regarded as “old”.
In fact, however, you are old when you reach a particular age. The Older Americans Act says 60. Medicare puts it at 65. Social Security is 66, phasing up to 67. Whatever the number, if you’re lucky, sooner or later you will be old.
When you are, you may be in poor health. You may not be able to get around easily or at all. You may have significant memory impairment. You may need help dressing, eating, going to the bathroom, or paying bills.
But chances are that you will still have most of your capabilities. The vast majority of people 65 and older are under 80, in decent health, and mostly independent. Even at age 85, fewer than 50 percent of people are disabled and in need of help for basic functions.
So it is a mistake to equate age and disability. It is a mistake to believe that it is normal for old people to be incapable of leading active, involved, satisfying, and personally meaningful lives.
Friends and family remain an important part of the lives of old people. Love, intimacy and — yes — sex can be central parts of their lives. Many older adults continue to work. Careers that are valued for their personal fulfillment and for their contribution to society can continue past ordinary retirement age. Work that generates an income and makes it possible for us to support ourselves and our families and to have daily contact with people we enjoy can also continue well past retirement age and provide both pride and pleasure.
Those who do retire often find so much to do that a common complaint is, “I don’t know where the time goes.” Whether it’s little projects in the house, playing golf, developing an artistic skill, taking care of grandchildren, volunteer work or being active in governmental, political, religious, communal or philanthropic organizations, there’s plenty to do in old age.
Of course, age does take its toll. Psychological adaptations are necessary when we retire, when our own children grow up, when our physical and mental skills diminish, when we have chronic illnesses, when the deaths of friends and family mount up and when we face mortality. In addition, the chances of becoming disabled and needing help increase with age.
To oversimplify, there are two populations of older adults — those who retain most of their capacities and are fundamentally independent and those who are significantly impaired. Both populations can age well or badly.
Aging well for those who are not disabled is easy enough to understand. The key is staying active and involved and avoiding what the developmental psychologists call “despair.” Ambitions from youth need to give way to a more realistic sense of what is possible in the limited time left. Satisfactions are found more in the moment and/or from pride in the past and from contributions to the future of those who will survive us.
Can people who are disabled and dependent also age well? This is a matter of considerable controversy. Many people look at this kind of experience from the outside and decide that it is a truly awful way to live. Some people living in a state of disability and dependency who are unable to be the people they once were hate it and wish for death. But most seem to want to live, and it is possible for them to find satisfactions in contact with and knowledge about those they love and in activities that they find interesting and pleasurable. For those with limited memory, there are still satisfactions in the moment.
For both “healthy” and “disabled” populations, aging well depends heavily on social conditions as well as individual choices and attitudes. Having enough money to lead a life you find satisfying, having family or paid caregivers to help you stay in the home you choose, having access to good health care, being connected with a community that accepts responsibility for people who need help, and living in a nation that makes support and services available to sustain a decent human life in old age — these are all critical to aging well.
The elder boom that began this year will result in a vast increase in the number and the percentage of older adults. Whether they age well or badly will depend not just on biological fate but also on personal, familial and societal preparation. Are you ready? Is the American society?
Boomers Rock Radio Podcast
Host: Tom Matt interviews Dr. Deborah Heiser about Motivation and Depression
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ARE YOU PSYCHOLOGICALLY READY TO RETIRE?
BLOGGER: Michael B. Friedman, LMSW
Work is a central part of the lives of most people. It is source of personal identity and self-definition. It is a source of day-to-day structure and of social interaction. Work can be a source of self-esteem. Earning a living adequate to take care of yourself and your family is an important source of pride and self-worth. If you have been lucky enough to have a personally meaningful career rather than just a way of making a living, work may also have resulted in a sense of importance, of achievement, and of making a contribution to your community, nation, society, or even humanity. Work of this kind results in recognition and admiration that many people come to crave.
So, when you retire, there’s a lot to make up for. Are you ready? How will you define yourself? What will you say when someone asks you what you do? How will you feel about not earning a living and perhaps being dependent on government or family for support? Are you confident that your savings will hold up? How will you structure your days so that they don’t get away from you without doing what you wanted to do? Who will you chat with? How will you get recognition and respect when you are no longer a “star”?
Keep in mind that with increased life expectancy, retirement will not last just a couple of years before you die. If you retire in your mid-60s chances are you will still be alive and able to be active at 85—another 15 to 20 years. That’s a lot of years. Some of you will be vital into your 90s and have 25-30 years of post-retirement life. This creates both a great opportunity to take on new roles and a great challenge not to miss out on the potential satisfactions of late life.
One danger is that without work, days can slip away unnoticed. Sleep a bit late, read more of the newspaper while having breakfast than you ever did before, take a walk or exercise a little, sit down for lunch, do errands such as shopping, visit a doctor to check out your aching joints, have a drink at 5 preferably not alone, dinner, a book, a favorite TV show, and before you know it it’s time for bed. Some people seem to be happy to live this way, but many get bored and disenchanted or feel they are wasting their lives.
Do you know what you will need to be satisfied with a life without the work you will retire from?
Here are a few possibilities.
For some people, having fun in recreational and social activities and being close with family and friends are enough. Family particularly can provide opportunities for close relationships, for teaching the young, and for being helpful—all of which contribute to a sense of self-worth. Not that these are easy achievements in families, which often fester with angers and disappointments and do not respect old family members.
Recreational activities—whether it’s playing golf or poker, fishing with your buddies, quilting, following your favorite baseball team, reading, listening to music, or almost anything—offer opportunities to cultivate personal skills as well as to enjoy the company of others. Keep in mind that retirement can be very lonely. Work comes with opportunities to be sociable that don’t exist when you are home by yourself.
For many people it is important to do something meaningful. Meaning, like beauty, is in the eye of the beholder. Some people find meaning in artistic activity. Others find it in working for a cause as a volunteer. For some getting paid is critical for economic or psychological reasons. For some meaningful old age is found in taking courses to pursue neglected interests or to develop new skills. Many people find satisfaction in work as part of religious, communal, or political organizations. So much needs to be done to repair the world that there is always room for another hand.
If you are a person who is much admired in your world and if, like most such people, you enjoy the admiration, enjoy being recognized, enjoy being respected, or enjoy being in charge, engaging in “meaningful” activity may not be psychologically enough. For many people, having-been an “important” person is not nearly as satisfying as being one. Taking pride in the past, tempering your personal ambitions, and taking pleasure in watching and contributing to the unfolding of younger people—which are critical components of aging well—can be hard achievements for people who in fact have much to be proud of.
The transition from work to retirement generally is not easy psychologically because so much of who we are and of our sense of meaning and value comes from work. Expect at least a small emotional roller coaster.
The Importance of Creativity in Old Age
BLOGGER: Michael Friedman
“I have two driving forces in my life — to be creative and to be helpful. If I had to choose one, I would choose to be helpful.”
Bernie Kessler — a retired psychologist and an active, avid, very skilled photographer and photography teacher — said this to me recently when we got together during his recovery from heart surgery and the infections and subsequent surgeries that nearly killed him after the original “successful” surgery. Bernie is 84. He knows he will not live forever. But he also said, “I am not depressed. I am grateful to be alive.”
Creative and helpful! An important insight, it seems to me.
Of course, any pair of key components of living well is bound to be too simplistic; there’s always more to it. But sometimes simplistic insights are illuminating. Freud, for example, identified love and work as the fundamental goals of human life. That rings true. But for those of us who are older, particularly for those of us who are aware that death is closing in, finding ways to shape and to express ourselves through artistic and other creative processes, and finding ways to pass on what we know to the generations of our children and our grandchildren, are increasingly important.
It is not that love and work become irrelevant to older people. They do not. But something happens as we become older that changes the nature of intimacy and changes our long-term ambitions. Love and work become a bit less central. Articulating ourselves and leaving a legacy become, or can become, as Bernie put it, our “driving forces.”
Bernie, of course, is an unusual person. He is highly educated, financially successful enough to be able to live comfortably and married to a caring woman for 63 years. He has a daughter who shares his interest in photography and visits regularly, a network of friends who have been there for him during this very difficult time and connections with several arts organizations where he has exhibited and taught regularly. For him, being creative and being helpful are possible.
What about those who may not have creative talents, who may seem to have nothing to teach, who spent their lives doing jobs they hated, who barely have enough to live on, whose families are not intact, who have few friends or who are not connected with community organizations?
If their isolation is extreme, old age is likely to be terrible. But most people have something to contribute to their families and communities, and most people have interests they can cultivate. Yes, some people create and some appreciate, but appreciation of the excellence of others is an opportunity for expertise that is satisfying in itself and can be passed on. Knowing batting averages, the plots and characters of TV shows, which celebrities are doing what with whom, the results of political polls — all of these are opportunities for personal development and to share knowledge. And virtually everyone is able to share their history, which is a great service to younger people smart enough to be interested.
The American society is wonderfully diverse, with a highly-developed sector of organizations that reflect the beliefs and interests of people from a multitude of backgrounds and life experience. Participation in these community groups, whether religious, cultural, recreational or political creates opportunities to cultivate new skills (including creative skills), to make a contribution and to leave a legacy. You don’t have to be a Bernie Kessler — a person of creative brilliance — to find the satisfactions of creativity and helpfulness in old age.
But Bernie is instructive, because even in the aftermath of illnesses that nearly killed him and have left him visibly weakened, he has lifted his art to a new level. While I was visiting with him, he showed me photographs he is readying for a new show. It is called “Silent Places,” and the photographs are simple black and white renditions of furniture in otherwise empty rooms. They are stark, without visual flamboyance, but filled with a sense of transcendent meaning that takes us beyond their visual surface. This work captures, I think, what the philosopher of art Arthur Danto has called “the transfiguration of the commonplace.”
Bernie’s new photographs are mature work that he probably could not have done when he was younger, despite the considerable beauty of the work he has produced over the years. I don’t mean to suggest that young people cannot produce works of transcendent meaning. Obviously they can and do. I only mean to suggest there are new opportunities for creativity and self-definition in old age.
Bernie Kessler is just one illustration of the possibility of new discovery and of the cultivation of a meaningful legacy in the final stage of life.
Dementia Caregivers: How to Build Meaningful Relationships in Spite of Memory Loss
BLOGGER: Michael B. Friedman, LMSW and John Zeisel, Ph.D.
Being the caregiver for someone you love who is gradually losing mental capacities is about as tough as it gets in human life outside of wars, disasters and profound poverty. Parents who were once your source of nurturing and knowledge; who worked hard to take care of their family; who had interests in politics, religion, sports, movies, celebrities and more; who had fun with their friends; who may have been among the best in their field. Parents who lose their mastery and become unable to manage their own affairs or to care for themselves in the most basic ways — parents who become dependent on you to take care of these things for them — can be, and often are, a source of great sadness.
Spouses and lovers who were your soul mates, your partners in life, the people with whom you shared your most important, moving, pleasurable and challenging moments — spouses who gradually lose their capacity to be with you as companions and confidantes can also be a source of great sadness.
On top of this, the time, energy and resources that it takes to be the primary caregiver for these people who are so important to you, can sap your own strength. You can feel that it is more than you can stand.
Changing your expectations of the person with declining cognitive capacities can make a big difference, helping you to be less frustrated and irritated by his or her inability to do what they once could and especially to be with you in the way they once were.
Focusing less on the past and on a wished-for future can make it possible to connect emotionally in a new way and to get the most out of the moments you have together. Our relationships are often oriented toward a collective future: retiring together, traveling together, getting old together. It can be daunting to maintain a relationship that does not have the kind of future we always assumed it would. But it is not impossible to have relationships in the moment that are emotionally satisfying even if we are terribly sad about what they, and we together, have lost.
Understanding that the person we love is still there, despite their inability to access memories without help, can also make a difference. Reminiscing together — even if it is mostly one-sided — can be a gratifying experience, especially when the person’s eyes light up with recognition. Talking about and engaging in old interests, listening to favorite music, going to a baseball game or even getting the feel of it on TV, watching old movies, taking a walk in the old neighborhood — all these can be sources of satisfaction in the moment. Even if the explicit memory of these experiences slips away because of the complex ways in which dementia affects the brain, the emotional connections remain.
Discovering the possibility of being together in silence can be deeply moving and meaningful as well. When we put aside our dashed dreams long enough to be open to the rich emotions alive in that silence, just being together can release an unspoken emotional exchange.
But what about the really difficult times? Dad has wandered away again. Is he safe? Mom says she doesn’t recognize you and yells for the police when you visit. Your wife curses you for cheating on her. Your husband demands sex with the home health aide. Your friend seems lost in himself and does not respond to your presence at all. What can you do?
There is no magic wand guaranteed to make bad times go away. Even if by changing our own behavior we reduce their anxiety and agitation, sometimes the people we care about remain disengaged. Some people’s disappointments and angers run so deep that moments of peaceful, loving exchange seem impossible. Some of us who are caregivers can’t stand another minute.
But these terrible times do not beset all people all the time, not by a long shot. It may seem impossible for the person you care about to get meaningful satisfaction out of a life so different from the life she or he lived before cognitive decline. It may seem impossible to have a meaningful and satisfying relationship with a parent, a spouse, a partner or a friend with whom you can no longer have in-depth conversations. It may seem that they cannot possibly find life worth living.
But a great many can. People with significant cognitive limits can get satisfaction out of life, and it is possible for us to have meaningful relationships with them — if we learn to shift what we want and expect from them, see the person who is still inside, and develop the capacity to live in the emotional moment.
(Michael Friedman is Adjunct Associate Professor at Columbia University’s schools of social work and public health. John Zeisel, Ph.D., who is Founder and President of The I’m Still Here Foundation and of Hearthstone Alzheimer Care.)
[1] Sanders, S and Swails,P. “A Quest for Meaning: Hospice Social Workers and patients with End-Stage Dementia” in Social Work Vol 56, Number 2, April 2011. http://oberon.naswpressonline.org/vl=5971918/cl=20/nw=1/rpsv/cw/nasw/00378046/v56n2/s4/p129
[2] Zeisel, John. I’m Still Here: A New Philosophy of Alzheimer’s Care. Avery. 2010.
BLOGGER: Michael B. Friedman, LMSW
After a person has been diagnosed with Alzheimer’s disease or other dementia, subsequent emotional, mental, cognitive, and behavioral problems are usually blamed on the disease. Other possible reasons including behavioral disorders such as depression, anxiety, or substance abuse or ordinary human reactions to tough realities are very often ignored.
“Grandma seems terribly sad.”
“ Of course, she has Alzheimer’s”
“Grandpa has been nasty lately“.
“It’s the Alzheimer’s.
“ Uncle John doesn’t enjoy life anymore.”
“ Who would? He has dementia.”
“ Mom isn’t eating much or isn’t taking her pills or isn’t getting any exercise.”
“It must be the Alzheimer’s”.
Not necessarily. In fact, blaming dementia very often gets in the way of understanding what is really going on and doing something about it that will help.
If there were a pill that would reverse, stop, or — better yet — cure Alzheimer’s, it might be useful to understand the emotional and behavioral problems of people with dementia solely in terms of the disease. But the best pills available now only delay the unavoidable decline in memory and other cognitive functions. That’s worth doing, of course, for the people for whom the pills work. But counting on the doctor to come up with medicine that will make a big difference usually is disappointing.
People with dementia experience many of the same emotions as people without dementia, but they are at higher risk than older adults without dementia for diagnosable mood and anxiety disorders, both of which can result in declines in cognitive functioning that are similar to the decline associated with dementia.
Unlike dementia, however, depression and anxiety can be treated effectively; and if they are, the loss of cognitive functioning that is caused by these disorders can be reversed. To be clear, treating depression and/or anxiety does not reverse dementia and the loss of cognitive functioning caused by dementia. But effective treatment for mood or anxiety disorders can result in overall improvement of functioning that can make a very big difference in a person’s life.
These days, of course, the first line of response to depression and anxiety is medication. However wise that is for people without dementia, it is unwise for those with dementia. Medication can be helpful, but it can also be dangerous. At the very least, doses must usually be lower than for younger adults.
Better is to begin with interventions that do not rely on medications. Some formal psychotherapies can be helpful, such as “cognitive-behavior” and “interpersonal” therapy. Exercise, interesting activities, and social contact with people they enjoy can also be extremely helpful.
Most important is to understand (1) that people with dementia are adults with meaningful life histories, personal interests, individual desires, and a need for dignity and respect and (2) that behavioral “problems” are to a significant extent in the eye of the beholder. People with greater understanding and tolerance of behavior, that most people find trying, are generally better able to help people with dementia to get the most out of life.
I don’t mean to make this sound easy. Some people with dementia are so profoundly sad and lost in themselves that they may be impossible to reach. Some people are “scared to death” by the slightest change in routine. Some people completely deny that they have any need for help. Some people are abusive towards anyone who tries to help them, evoking responses in kind from many — if not most — of us.
But many people could be helped to overcome emotional problems that co-occur with, but are not caused by, dementia.
In an ideal world everyone with dementia would be able to get a sophisticated assessment to distinguish between the effects of dementia and other disorders and then to get the treatment that would be most likely to be effective. But in the real world there is a terrible shortage of physicians who understand the subtle differences between dementia and depression and other disorders. In the real world there is a terrible shortage of geriatric psychiatrists and other mental health professionals. And in the real world, paid and family caregivers usually do not get training and support to help them be more skillful with and tolerant of the people they care for.
Our nation needs major changes in policy to address these shortfalls. In the meantime, however, we need to understand that there are ordinary emotional causes for the sadness, disengagement, and anger experienced by so many people with dementia and that we caregivers can do much to meet human needs often neglected because of a frightening diagnosis.
Grandma is sad? Grandpa is nasty? Maybe they are clinically depressed and could benefit from treatment. Maybe she’s lonely and he feels he’s being treated like a child. Maybe it’s something else. But be careful not to jump to the conclusion that it’s because of the dementia.
Elderly Depression: Is Melancholy an Inevitable Outcome of Getting Old?
BLOGGERS: Michael B. Friedman, LMSW and Lisa Furst, LMSW
Depression is dangerous and one of the most significant impediments to aging well.
People with depression[i] usually experience a profound sadness and sense of hopelessness that goes far beyond ordinary unhappiness. They often experience terrible psychic pain, which some people report is harder to bear than severe physical pain.
People with depression often experience a profound disinterest in life. What has made them happy and kept them vibrant no longer does. Life may have no meaning for them.
People with depression often find it difficult to carry on ordinary life functions. They may have trouble sleeping or sleep too much. They may have no interest in food or may stuff themselves in futile efforts to counter their bad mood. They may find it difficult to concentrate on work, day-to-day tasks, or social interaction. They may ruminate about relatively minor matters and be unable to make a decision or forgive themselves for errors or discourtesies. They may feel that doing anything takes too great an effort. They may always expect the worst and give up without trying. They may be angry much of the time, easily irritated by small aggravations. They may often think about death, even about taking their own lives.
People with depression have lower life expectancy than those without. The combination of depression and a serious, chronic physical illness, such as diabetes and heart disease, results in greater risks for disability and premature death than for people with the same physical conditions without depression.[ii]
People with depression are also more likely to be socially isolated and caught in a vicious cycle in which depression feeds isolation and isolation feeds depression[iii].
Most people who complete suicide are depressed.[iv] And the sense of hopelessness inherent in depression makes many people reluctant to seek or accept help.
Obviously, depression makes it hard to live well at any age, including old age.
The good news for older adults is that, contrary to common belief, depression is not a normal or inevitable outcome of aging. But the ageist expectation that it is frequently results in failure to take steps to overcome it. ”There’s nothing to be done. They’re just old.” This attitude too often robs older people of opportunities to enjoy life.
In fact, each year major depressive disorder affects fewer than 5 percent of adults 65 or older who live in the community.[v] The rate is higher among older adults with serious chronic health conditions, those who need home health care and those who are institutionalized.
A much higher proportion of older adults who live in the community — perhaps 20 percent — experience symptoms and forms of mood disorders, such as dysthymia or sub-syndromal depression[vi], that are not as severe as major depressive disorder but may have nearly as much negative impact[vii].
So, a significant proportion of older adults suffers from depression. But, it is important to note, 75 to 80 percent of older adults do not experience depression in any given year. Depression — to say it again — is not normal in old age, an encouraging fact for those who may feel hopeless about their lives.
Depression often can be treated effectively or overcome through other means such as meaningful relationships, activities, or spiritual experience. Unfortunately, it often goes unrecognized.
One reason for this is that it may not look like “depression”. Frequently, it is expressed through physical symptoms such as headaches, “stomach” problems, aches and pains, fatigue or insomnia.
Depression also can be hard to recognize because it does not necessarily involve having a depressed mood. There are two “cardinal” symptoms of major depressive disorder — profound sadness for two weeks or more and loss of interest and pleasure in activities that have had the greatest personal meaning. It is necessary to have one, but not both, of these symptoms to be diagnosed with major depression. It may seem strange, but there is depression without sadness[viii].
In older adults, depression may be missed because it involves cognitive difficulties that get diagnosed as dementia. This common misdiagnosis is terribly unfortunate because successful treatment of depression can restore cognitive capacities that have been lost due to depression — even in people with dementia.[ix]
Finally, depression can be hard to spot because many people with depression are able to hide it. From the outside they may seem unchanged, even though they may be suffering terribly on the inside.
So depression is dangerous, and it often goes unrecognized and untreated, depriving older adults of opportunities to get the most out of life. What can be done about this? We will address this question in our next post.
In the meantime, if you or someone you care about needs help, call 1-800-273-TALK.
And to find a geriatric psychiatrist in your area, refer to the website of the Geriatric Mental Health Foundation, http://www.gmhfonline.org/gmhf/find.asp.
This article was co-authored with Lisa Furst, L.M.S.W., Director of the Training and Technical Assistance Center of The Geriatric Mental Health Alliance of New York and co-author of Depressed Older Adults: Education and Screening
[i] PubMed Health. “Major Depression”. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001941/
[ii] Katon, W. and Ciechanowski, P. “Impact of Major Depression on Chronic Medical Illness” in Journal of Psychosomatic Research 2002. http://meagherlab.tamu.edu/M-Meagher/%20Health%20Psyc%20630/Readings%20630/Ultization/Depress:Anx%20PC/Katon%2002%20Dep.pdf
[iii] Alpass, F. and Neville S. “ Loneliness, health and depression” in Aging & Mental Health 2003
http://www.informaworld.com/smpp/content~db=all?content=10.1080/1360786031000101193
[iv] Centers for Disease Control and Prevention. National Center for Injury Prevention and
Control.(2007). WISQARS injury mortality reports, 1999-2007. http://www.cdc.gov/ncipc/wisqars/
[v] Byers, et al. “High Occurrence of Mood and Anxiety Disorders” in Archives of General Psychiatry, May 2010. http://cumberland.pa.networkofcare.org/library/High%20Occurence%20of%20Mood%20and%20Anxiety%20Disorders%20Among%20Older%20Adults.pdf
[vi] Surgeon General of the U.S. “Depression in Older Adults” in Mental Health: A Report of the Surgeon General. U.S. Department of Health and Human Services, 1999. http://www.surgeongeneral.gov/library/mentalhealth/chapter5/sec3.html
[vii] Beekman, A.T. F., et al. “Consequences of Major and Minor Depression in Later Life: A Study of Disability, Well-Being, and Service Utilization” in Journal of Psychological Medicine, 1997. http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=25569&fulltextType=RA&fileId=S0033291797005734
[viii] Gallo, JJ. and Rabins P. “Depression Without Sadness: Alternative Presentations of Depression in Late Life” in American Family Physician, September 1999. http://www.aafp.org/afp/990901ap/820.html
[ix] Friedman, M. et al. “Cognitive Camouflage: How Alzheimer’s Can Mask Mental Health Conditions” in Social Work Today, Nov/Dec, 2009. http://www.socialworktoday.com/archive/112309p16.shtml
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Elderly Depression and How It Can Be Overcome
BLOGGERS: MICHAEL FRIEDMAN, L.M.S.W. and LISA FURST
Although depression is not a normal outcome of aging, it is dangerous and one of the most significant barriers to aging well. [i] Fewer than 5% of older adults have major depressive disorder in any given year[ii], but as many as 20% have significant symptoms of depression.[iii] It is frequently unrecognized and untreated[iv], resulting in much unnecessary suffering and lost opportunities to age well.
Fortunately, depression in old age can be overcome. How? There are four general, not mutually exclusive, approaches—(1) lifestyles that promote mental health in old age, (2) getting professional help, (3) developing skills to manage disturbing moods yourself, and (4) getting help informally from family, friends, and community resources such as clergy.
Mental Health Promotion: To vastly oversimplify, the keys to avoiding depression in old age are being physically healthy (a mix of luck and self-care), being physically and mentally active, being involved in personally satisfying activities and relationships, and achieving a sense that you have had a life of meaning and value.[v]
Once depressed, however, maintaining such a life can be very difficult. Despair can dissolve a sense of achievement in life and create the conviction that there’s no point trying to stay well, active, and involved.
Professional Interventions
Screening can be a first step towards dealing with a depressive disorder. It should be routine in primary and specialty health care and in settings where older adults live or congregate, such as senior centers[vi], but unfortunately it is not.
The most common screening instrument, the PHQ-9,[vii] is filled out and scored by the person being screened, but diagnosis by a professional is needed to confirm a positive finding.
Treatment can be effective.[viii] The most common forms of treatment are medication and psychotherapy. Both cognitive and interpersonal therapies have been shown to be effective[ix]. The combination of medication and psychotherapy appears to be most effective.[x]
Great care is needed regarding medication for older adults, keeping doses as low as possible to avoid potentially severe side effects but as high as necessary to have a therapeutic effect.
Although highly controversial, electro-convulsive therapy (ECT) appears to be effective for some people with severely disabling depression who do not respond to other treatment.[xi]
Increasingly, treatment for depression is provided by primary care physicians. They often do not have the time or training to provide sound treatment.[xii] Various models of care management within primary care settings have emerged to provide needed follow-up and psychotherapy.[xiii]
Many people with major depressive disorder need treatment by a mental health professional such as a psychiatrist, psychologist, clinical social worker, or nurse. Unfortunately, there is a great shortage of trained geriatric mental health professionals.
Self-management: Some people with depression, particularly those with recurrent depressive episodes, develop effective self-management skills, sometimes on their own, sometimes with the help of a mental health professional. These include self-observation skills that make it possible to anticipate depressive episodes, recognize them when they occur, resist the powerful urge to withdraw, remain active and involved with other people, control suicidal impulses, and know when to go for help.
It is very important not to confuse self-management, which can be effective long-term, with self-medication with alcohol and other drugs, which cannot.
Informal Interventions: Most people who seek help turn to non-professionals—to family and friends they trust and to respected figures in their communities, especially clergy.
People who are willing, and have enough time, to spend with a person who is depressed can be extremely helpful.[xiv] Talking—not about the depression but about anything of interest, having fun, socializing, or even taking a walk can counter depression.
Spiritual experience is particularly helpful to people who find comfort through faith or religion.[xv]
Informal interventions may not be enough for people with “moderate” or “severe” depression or during periods of profound hopelessness, psychosis, or suicidality. Then professional help may be essential.
Do these approaches to overcoming depression work for all older adults who are depressed? Of course not. There are some who reject any offer of help because they are in a state of denial, feel too hopeless to believe that help is possible, or are too weary to make any effort. There are people with depression who anger so easily or who are so unpleasant that they drive away all but the most saintly people who might be helpful. And there are some people who do not respond to any form of treatment.
But these are the exceptions. Yes, depression can be dangerous and is a barrier to aging well, but it is not an inevitable outcome of old age; and, when it occurs, it can usually be overcome.
Need help for yourself or someone you care about?
(Michael Friedman is Adjunct Associate Professor, Columbia University Schools of Social Work and Public Health. Lisa Furst is Director of the Training and Technical Assistance Center of The Geriatric Mental Health Alliance of New York and co-author of Depressed Older Adults: Education and Screening)
[i]Friedman, M. and Furst, L. “Elderly Depression: Is Melancholy An Inevitable Outcome of Getting Old?”Huffington Post, June 22, 2011. http://www.huffingtonpost.com/michael-friedman-lmsw/elderly-depression_b_879904.html
[ii]Byers, et al. “High Occurrence of Mood and Anxiety Disorders” in Archives of General Psychiatry, May 2010. http://cumberland.pa.networkofcare.org/library/High%20Occurence%20of%20Mood%20and%20Anxiety%20Disorders%20Among%20Older%20Adults.pdf
[iii]Surgeon General of the U.S. “Depression in Older Adults” in Mental Health: A Report of the Surgeon General. U.S. Department of Health and Human Services, 1999. http://www.surgeongeneral.gov/library/mentalhealth/chapter5/sec3.html
[iv]Wang, P. et al. “Twelve-Month Use of Mental Health Services in the United States” in Archives of General Psychiatry, June 2005. http://archpsyc.ama-assn.org/cgi/content/abstract/62/6/629
[v]King, A and Guralnik, J. “Maximizing the Potential of an Aging Population” in Journal of the American Medical Association, November 3, 2010. http://jama.ama-assn.org/content/304/17/1944.short
[vi]Berman, J, Furst, L.M. (2011). Depressed Older Adults: Education and Screening. New York, NY: Springer Publishing Company http://www.springerpub.com/product/9780826171023
[vii]McArthur Initiative on Depression and Primary Care.“Patient Health Questionaire”. 2011. http://www.depression-primarycare.org/clinicians/toolkits/materials/forms/phq9/
[ix]Klausner, E. and Alexopoulos, G. “The Future of Psychosocial Treatments for Elderly Patients” in Psychiatric Services, September 1999. http://psychservices.psychiatryonline.org/cgi/reprint/50/9/1198.pdf
[x]Bartels, SJ et al. “Evidence-based practices in geriatric mental health care: an overview of systematic reviews and meta-analyses” in Psychiatric Clinics of North America 2003. http://www.ncbi.nlm.nih.gov/pubmed/14711131
[xi]Mayo Clinic Staff. “Electro-convulsive Therapy” on Mayo Clinic Website. http://www.mayoclinic.com/health/electroconvulsive-therapy/MY00129
[xii]Wang, P. et al. “Twelve-Month Use of Mental Health Services in the United States” in Archives of General Psychiatry, June 2005. http://archpsyc.ama-assn.org/cgi/content/abstract/62/6/629
[xiii]Oxman, TE et al.“Evidence-Based Models of Integrated Management of Depression in Primary Care” in Psychiatric Clinics of North America, 2005. http://www.public-health.uiowa.edu/ICMHA/outreach/documents/EvidenceBasedCollaborativeCare_000.PDF
[xiv]Vann, M. “Bail A Buddy Out Of the Blues’ in Everyday Health, June 2011. http://www.everydayhealth.com/emotional-health-pictures/bail-a-buddy-out-of-the-blues.aspx?xid=aol_eh-emo_5-_20110613&aolcat=AJA&icid=main%7Chtmlws-main-n%7Cdl5%7Csec1_lnk3%7C216211
[xv]Dein,Simon. “Religion, Spirituality, and Mental Health: Theoretical and Clinical Perspectives” in Psychiatric Times, January 10, 2010. http://www.psychiatrictimes.com/display/article/10168/1508320
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Are you one of the 2.9 million grandparents in America who are raising their grandchildren? Although there are many good reasons to do this, it brings increased responsibility, stress and sacrifices that you probably didn’t anticipate for your “golden” years. Kin caregiving becomes necessary in families of all backgrounds and socioeconomic statuses and for many reasons, from military service to parental illness or death to child abuse or neglect. Census data reveal a significant increase in kin caregiving recently, probably due to the recession. When called to provide care, you may be relieved that the children can be safe with you, but now you have a lot to do. You’ll need to take care of getting the children enrolled in school, apply for financial and medical benefits, make sure they are seen by a pediatrician, perhaps arrange for counseling, consider pursuing custody or guardianship. The list goes on and on. So how do you do this and still find time for yourself? Many grandparents respond to the children’s needs first and try to take time for themselves later. Many never get to it — an understandable choice, but ultimately you need to take care of yourself to be able to do the best you can for your grandchildren. How Can You Cope? Becoming a kin caregiver evokes many emotions, from the joy of having your grandchildren with you to feeling angry and resentful about your adult child being absent or about your losing so much — your time, possibly your job, your independence, sleep, your financial security.
How can you cope?
• Staying healthy is important. Don’t miss your annual physical or ignore symptoms that are new for you. Fit in some exercise. Walking is a lot better than nothing.
• Have some fun. Stay in touch with friends. Do things you enjoy.
• Find reliable people to talk with — a trusted friend or family member, clergy or a counselor. Alternatively, join a support group where you can talk with others in similar situations and learn about services and resources for you and your family.
• When you feel overwhelmed and that you can’t possibly get everything done, make a list of things to do, decide what has to get done now and what can wait, and schedule when you will do them. Literally, put them on your calendar.
• Talk with your grandchildren about what you’re finding difficult. They may be having a tough time emotionally, but they also may be able to help more than you think.
All of this is easier said than done, and you can certainly expect that there will be times when you feel that you just can’t take it anymore. That’s par for the course when raising children. Sometimes it’s wonderful to be with the kids; sometimes it’s enough to make you furious or bring you to tears. But sometimes caregiving can overwhelm anyone. You may not be able to do the things that really have to get done or lose patience more than you used to. You may feel hopeless or helpless or lose pleasure in everyday life. You may have trouble sleeping, more than the usual physical aches and pains, or be drinking too much. You may be withdrawing from the friends and support you need. These are all signs that your coping is running short and when you need to recognize that you need to take care of yourself in order to care for your grandchildren. Raising grandchildren can be very satisfying, and it is always a challenge. Take care of your kids and take care of yourself. That’s the best caregiving of all.
This post was co-written with Deborah Langosch, Ph.D., L.C.S.W., the Project Director of the Kinship Care Program at the Center for Trauma Program Innovation at Jewish Board of Family and Children’s Services in New York City.
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