As reported by The Hartford Courant, July 4, 2006.

Elderly's Complaints of 'Aches And Pains' May Indicate Depression

By Kathleen Megan

Lately, Pearl hasn't been volunteering to do as much at the Simsbury Senior Center. Her knee has been bothering her, and she has an irritating skin condition that is worse in the hot weather.

She's been feeling frustrated with not being able to do everything she wants to do. And sometimes Pearl, who asked that her real name not be used, feels as if "it takes longer and longer to do less and less."

Rickie Bergquist, director of the senior center, noticed the change in Pearl right away and talked to her about it.

Over the years, Bergquist has learned to pay attention to changes such as increased sadness or withdrawal or irritability. Although years ago people may have seen such behavior as normal for elderly people, she knows they could be signs of a treatable case of clinical depression or anxiety.

"I know for a fact there have been four people I've been able to help because I pointed them in the right direction," said Bergquist. "I knew something was wrong, but I couldn't put my finger on it."

Pearl, who is 80, said she appreciates Bergquist's concern and will pursue help if she thinks she needs it. "I'm not sure I'm as depressed as people think I am," said Pearl.

Geriatric specialists say that depression is often overlooked in older adults. Only one in six elderly people with clinical depression gets diagnosed and treated for the illness, according to a study by the National Institute of Mental Health.

Even when patients turn up in their primary care physician's office, depression is missed in about half the cases, according to Dr. Charles Reynolds, a professor of geriatric psychiatry at the University of Pittsburgh Medical Center. That's because they often come in complaining of aches and pains.

"Patients may lack the appropriate vocabulary to express sadness," said Reynolds. "Although they may be in emotional distress, it may be expressed in the idiom of physical complaints. It may not be understood as a form of masked depression."

It may be true that the patient does have a backache, but the core illness - depression - may go unidentified. Often, declines in memory have more to do with depression than with cognitive problems. Dr. Harry Morgan, a geriatric psychiatrist in Glastonbury, said that a person with mild cognitive impairment - a kind of pre-Alzheimer's condition - can appear to have dementia if she or he is also depressed. However, once the depression is treated, the person returns to the milder condition.

Depression is also missed simply because there is an assumption that if an older person has lost a loved one or a house, or suffers from an illness or disability, depression is a normal response.

Morgan said that in this situation, patients are apt to say, "if you were in my shoes, you'd be depressed too." Many people have the misconception that older people can't be helped. This, of course, isn't the case, he said. Usually, a few weeks into treatment, a patient may still have some sadness but will also begin to resume old activities: watching TV or meeting friends at the senior center.

While the percentage of elderly people who are depressed doesn't vary much from other age groups, the prevalence of depression in certain settings is definitely higher.

Reynolds said that while 6 percent to 10 percent of elderly people overall are depressed, the rate is 20 percent of elderly people in hospitals and between 25 percent and 33 percent of people in nursing homes.

In a study two years ago of 634 adults living in low-income senior housing in Hartford, 38 percent had symptoms of clinical depression, 28 percent had major depression and 14 percent had generalized anxiety disorder, according to Julie Robison, an assistant professor of medicine at the University of Connecticut Health Center.

Why are the rates in senior housing so high? Robison, who worked on the study, said she's not sure, but that many residents have complex problems, including health troubles, difficulties with adult children and limited resources.

Without treatment, a good many elderly people can become so depressed they commit suicide. This is particularly true of elderly white men, who kill themselves at a rate six times that of the general population - 66 to 80 suicides per 100,000.

"When it comes to suicide, we think of the young people," said Dr. George Kuchel, director of the Center on Aging at the University of Connecticut Health Center. "But there are far more gestures than successful attempts. With elderly men, there are very few gestures. Instead, we see successful suicides."

Treatment for depression must take into account a person's biological and medical needs, psychological concerns and the support available from family and community.

In addition, a geriatrician must have deep knowledge of many physical illnesses and medications so as to know about side effects and interactions. In some cases, depression can actually be brought on by certain medications or illnesses.

"People who like very simple cases will not like geriatric care," said Morgan.

Experts say 75 percent to 80 percent of older people will get better with treatment that combines medication and talk therapy. Morgan said that about 65 percent get better with medication alone, while 60 percent get better with psychotherapy alone. Interestingly, he said, for the oldest, most frail patients, talk therapy is most effective, possibly because they have been very isolated.

However, Morgan also likes to tell the story of a treatment that humbled him. He had a patient for whom he had prescribed medication. When she returned a few weeks later, she was all smiles and Morgan thought the medicine must have helped.

"Doctor I never took the medicine," his patient told him. "My son bought me a dog."

Said Morgan, "It's many things that get people better."