Confounds, Damned Confounds, and Depression

[Content note: death, aging, dementia. It’s a cheerful post.]

As the Baby Boomers age, there’s simultaneously a large population of people to study and a vested interest in knowing a whole lot more about aging. This in turn, results in books like Depression in Later Life: A Multidisciplinary Approach, which I just finished. Eldercare and geriatric therapy is a field I’ve essentially never interacted with before grad school, so I’ve been reading whatever I can get my hands on.

One of the indications of depression in elders is executive dysfunction. Executive function is this collective name for the ability to anticipate the outcome of your actions,hold multiple threads  of knowledge in your head, and generally coordinate your behavior. Someone who anticipates a busy Tuesday and Wednesday, does their housework on Monday for a house party on Thursday is displaying executive function. Someone who forgets about the roast in the oven and sets the kitchen on fire because they went to start the laundry is exhibiting executive dysfunction. [Here’s the Wikipedia article  but, in a painful twist of fate, it’s horribly disorganized.]

So, elders with executive dysfunction might have depression. But, says you, this sounds like aging! This sounds like memory concerns. Couldn’t my grandma who forgot the roast in the oven have forgotten it? What makes this depression. Good point, says I. Let’s look at other commonly cited symptoms.

Hallucinations or psychosis can be a sign of depression in the elderly. Psychotic depression isn’t restricted to those with gray hair, but it’s more common as a component of depression in elders than in the young and middle-aged. Sure, fine, but paranoia and delusions are also a core sign of ongoing dementia! (And it’s hard to disentangle paranoia from pure hallucinations; when someone says there was a man trying to attack them, you usually can’t find that man to inquire if he was nice and well meaning or imaginary.)

Okay, but all that aside, there’s another piece of depression in the elderly. Declining social interactions! Of course, this could also come from dementia-driven or aging-driven means. I’m sure you can imagine that if your friend group began to die or move into assisted living situations, you might suddenly be somewhat less social. That the work of making new friends to replace ones you’d had for years or decades could be a little bit overwhelming, even unappealing. Alternately, dementia and Alzheimer’s come along with a less known symptom of irritability or outbursts of rage. This, you know, could result in either less social interaction by choice or by driving others away. Declining social interactions in your elderly client? Could be dementia…or it could be depression. Back to square one.

But what about insomnia? Insomnia is a common symptom of depression in young and old. This sounds like a more quantifiable sort of measure. “How are you sleeping, ma’am?” and bingo, we have a lead. Except (because there’s always an except), sleeping patterns change over the lifetime. Sleep research is generally terrible, but one thing we have established with a modicum of replication is that the elderly don’t sleep as much, and might not need to.

Okay, says you. How the hell am I ever supposed to determine what’s aging, what’s dementia/Alzheimers, and actually, why would I care outside of research interests? After all, if what you get is symptoms entirely indistinguishable from dementia and memory loss from aging—so indistinguishable as to make research bafflingly confounded—if what you see is an elder with psychosis and executive dysfunction and declining social interactions, isn’t it a walks-like, quacks-like duck situation?

Well, no. Because in one of those circumstances, in some of those people who show up in front of you with those ‘classic’ symptoms of dementia, in some of those cases the things are depression, and depression can be fixed.

And this was sort of stunning to realize. I been doing the opposite of what I described here. I sort of meanedered along assuming that if it looked like dementia, it was. In practice, this can, and probably does, have awful results.

Imagine (and I know some of you won’t have to imagine) you woke up one day with depression. You were stuck in this dark hole, and cut off from social connection and having trouble sleeping and struggling with memory issues. And then, everyone just sort of nodded sadly and conceded that this was tragic, but it was part of your inevitable decline. They never really considered therapy or treatment, because it was obviously an incurable, progressive, cognitive disease. Maybe, depression being what it is, you found yourself agreeing with them; that it was hopeless and probably not something you could stop.

And what if that wasn’t true?

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