Gerald Johnson* has no regrets about his life. At 90, he has lived a long, and for the most part, a happy life, rich with friendship and blessed with good health. He is spry and still drives his vintage Jaguar. The problem is that he doesn’t want to go out anymore-not even on a crisp fall day with the sunroof open. “I can’t bear to drive around my neighborhood anymore. Everywhere I go I pass a house where one of my friends lived and they are gone. I am the only one left.”
Diagnosed with Major Depression, Mr. Johnson is at risk for suicide. And he is not alone. Suicide is five times more common in late life than other ages, and the highest subgroup for suicide in late life adults is white males, according to Mark D. Miller, M.D. Miller, a geriatric psychiatrist is the medical director of Late-Life Depression Prevention Clinic at the Western Psychiatric Institute and Clinic in Pittsburgh and is also associate professor of psychiatry at the University of Pittsburgh School of Medicine. He has recently co-authored a book, Living Longer Depression Free: A Family Guide to Recognizing, Treating, and Preventing Depression in Later Life. Miller’s passion for working with late life adults developed as a child. He grew up in a small coal-mining town in Pennsylvania. His parents were killed in a car accident when he was 10 and he went to live with his grandparents. The town’s young adults had all left to find work and so he found himself being raised by older people in a community of older people. “I took a shine to them,” he says.
Suicide in Late Life
Why are white males at the highest risk for suicide in late life? According to Miller, when males think about suicide they use lethal means, such as jumping from a bridge or using firearms and, therefore, they are more likely to succeed. Women are more likely to overdose and they often fail. Among the factors related to suicide, a sense of hopelessness is critical. For someone who is hopeless in late life, often the support network is inadequate. Today, children move away from home; they try to bridge this distance by connecting by telephone, but this does not fill the void created by the losses of spouse, friends and coworkers. Health concerns also tend to accumulate with age. People who are less able to walk are less able to do what they like and less able to take care of themselves. Sometimes oncoming dementia is depressing as older people realize they are losing their mental abilities. The medical burden only increases with time.
Risk Factors for Depression in Late Life
At any age, suicide is directly correlated with depression. A psychotic may be suicidal, but for the vast majority of cases, suicide comes secondary to depression. This means that we can prevent suicide if we treat the person adequately. According to Miller, people who are suicidal in late life are more likely to have had a depression before, more likely to have had suicidal ideation before and even to have made a suicide attempt before. “So, if you had one in your lifetime, it puts you at risk to have more later. Depression is a risk factor and prior suicidality is a risk factor.” The other big risk factors are a history of certain personality characteristics or personality disorders, especially Borderline Personality Disorder, and alcohol and drug use.
But late life people who do not have a history of those risk factors are not home free. They still have the potential to become depressed because of their life circumstances. Miller suggests, “One of the things that we have found out over the last 10 years is that people that have their first onset of depression over age 60 are more likely to have had small strokes accumulating in their brains. When we look at MRI scans and we see the so-called white matter hyperintensities (WMH). We see more of them for people who are depressed for the first time after 60. They also correlate with other risk factors, like smoking, hyperepidemia, and other factors that give you cardiac disease or cerebral vascular disease. We believe that the more ‘hits’ the aging brain takes from small vascular changes, that there is an increased risk for depression, because it disrupts some of the neural circuitry needed for maintaining mood in the brain.” Late life people often suffer from an accumulation of risk factors that add up to more severe risk for depression than any one risk factor by itself. Aging increases the likelihood of such risk factors as losses, diabetes, little strokes and thyroid dysfunction that potentially add up to a Major Depression.
Red Flag-Watch for Changes
“A red flag is if you meet someone for the first time and the caretaker says that the patient was fine two days ago and now seems to be confused. That patient may be in delirium.” That is a medical emergency, cautions Miller. ” That patient is at risk from something that is really awry and has caused abject confusion. It could be something metabolic or a drug reaction, or withdrawal from a drug that was stopped. Oftentimes, there is an underlying dementia that may not have been recognized before, that needs to be recognized because this person is obviously at risk for self-injury, making bad judgements, or perhaps driving and wrecking the car.Clearly if you get someone who is confused but it is short term, within the last couple of days or hours, that patient needs to be evaluated by a doctor or in an emergency room-quickly–that day. The electrolytes need to be checked to make sure that something isn’t really wrong. It could even be a harbinger of mortality–it could indicate that the brain is shutting down. If you work with geriatric patients you learn to watch for those things. You watch for changes.”
Hope for Late Life Boomers
As boomers age their experience in late life is likely to be different, suggests Miller. As a cohort, they are better educated than the current late life cohort. For that reason, they should be better able to recognize the signs of depression and be more attuned to getting depression treated. Boomers have moved around more. This should create resilience in late life and help protect them from social isolation. They have been required to develop better skills at making new friends. They are more technologically savvy and have the potential to be more creative in staying connected with loved ones. In short, Miller says, “I’m optimistic about boomers as they enter late life.”