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| Sunday, 25 April 2004 |
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Features |  |
| News Business Features Editorial
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Depression and physical health in the elderly Compiled by Carol Aloysius
Q: What causes depression in elderly persons? A: Physical illness and depression in elderly people usually occur together. This may be for several reasons e.g. depression resulting from physical illness or vice versa. Q: How does early detection of symptoms of depression in such patients help? A: Recognising early symptoms can lead to better management of persistent and severe depression and in turn facilitate the physical recovery of the patient. Q: Is treating older patients with depression more difficult than treating younger patients? A: Yes. Managing older patients with depression is definitely more challenging especially because older people are more vulnerable to adverse treatment effects. Q: Do all or most older people with physical illness run the risk of becoming depressed? A: No. Q: What are the risk factors? A: Illnesses such as myocardial infarction, stroke and Parkinson's disease. A past history of depression is also significant. Other factors include recent bereavement and cognitive impairment. Q: Is it true that more women are at a higher risk of becoming depressed after a physical illness? A: Yes. Studies have proved that women are more vulnerable to depression. Q: What are the symptoms of depression in old people? A: Symptoms of depression in old age may be less obvious than in younger persons. For example, depressed mood is less frequently a core complaint in older people. On the other hand they could complain of various somatic and hypochondriacal symptoms for which insufficient cause is shown. Negative feelings about self worth and the future are also more prominent in older persons. Older persons are also more likely to complain of insomnia. This should be distinguished from the reduced sleep requirement which often accompanies normal ageing. Further, many older persons with depression have excessive feelings of anxiety, suffer from lethargy and have psychomotor changes particularly agitation which is common in depression late in life. Older people are also less likely to express their feelings verbally. Q: Are older people more prone to suicidal feelings? A: Yes. Although they seldom express suicidal feelings, the actual risk of suicide is much greater, than in younger persons with depression. Q: What are the risk factors for suicide in old age? A: Feelings of helplessness and hopelessness, guilt, any self harm gesture and recent onset of alcohol abuse. Physically ill patients who "turn their face to the wall" may be trying to passively kill themselves because of undetected and potentially treatable depression. Q: Any other symptoms related to depression in old age? A: Most elderly persons are not satisfied with life, have reduced activities, get bored often, are low in spirits, prefer to stay at home rather than going out and doing new things, and afraid that something bad is going to happen to them. Q: How can these conditions be treated? A: At present the tendency is to ignore the symptoms of depression and treat only the physical symptoms. Hence a more holistic approach is needed when treating an elderly patient. The whole patient must be considered and not just the depressive or physical symptoms. As I mentioned earlier, medical studies recently have shown that there is a very high risk of deaths among diabetic, myocardial and stroke victims if their depression is not tackled along with their physical illnesses. Though drug treatment is often the first option in older depressed patients, the use of psychological approaches and electroconvulsive therapy (ECT) must also be considered. Q: What kind of approach do you advocate? A: I believe that the Community plays an important part in recognising depression in an elderly person at an early stage and bringing it to the attention of the doctor. Children need to understand and recognise these symptoms in their parents. This is why the community outreach program of the Centre for Community Mental Health at Kalubowila Teaching Hospital has organised school programs to create awareness about depression among school children. Let me quote the WHO on this. It says, "the most common medical problem of the 21st century is depression, it adds that community awareness is the "greatest tool to overcome this widespread phenomenon at national level." ############### The 'silent' killer Dr. D. P. Atukorale, discusses questions on a common disease. High blood pressure (Hypertension) is the pressure of the blood against the walls of the arteries. Blood pressure results from two forces. One is created by the heart as it pumps blood into the arteries and through the circulatory system. The other is the force of arteries as they resist the blood flow. The higher (systolic) number represents the pressure while the heart contracts to pump blood to the body.
The lower (diastolic) number represents the pressure when the heart relaxes between beats. The systolic pressure is always stated first and the diastolic pressure second. For example 120/80 means systolic BP is 120 and diastolic B.P. is 80. Blood pressure below 120 over 80 mm Hg is considered best for adults. A systolic pressure of 120 to 139 mm Hg or a diastolic pressure of 80 to 89 mm Hg is considered pre-hypertension and needs to be watched carefully. A blood pressure reading of 140 over 90 or higher is considered elevated or high. High blood pressure usually has no symptoms. In fact many people have high blood pressure for years without knowing it. That is why it is called the "silent killer". Hypertension is the medical term for high blood pressure. It does not refer to being tense, nervous or hyperactive. You can be a calm relaxed person and still have hypertension. A single blood pressure reading does not mean you have high blood pressure, but it is a sign that further observation is required. Certain diseases such as kidney disease can cause hypertension. In 90 to 95 percent of cases, the cause of hypertension is unknown. The only way to find out if you have hypertension is to have your blood pressure checked by a doctor or other qualified health professional such as a RMP or a staff nurse or a medico. You should get your B.P. checked at least once every two years or more often if necessary. Optimum B.P. with respect to cardiovascular risk is less than 120/80. However unusually low readings should be evaluated to rule out rare medical causes. Hypertension affects about 50 million Americans and one billion people worldwide according to the report. The relationship between blood pressure and risk of cardiovascular disease events is continuous, consistent and independent of other risk factors" the committee writes. The higher the blood pressure the greater the chances of heart attack, heart failure, stroke and kidney disease. The National High Blood Pressure Education Programme Coordinating Committee - a coalition of 39 major professional, public and voluntary organizations and seven federal agencies has issued the JNC VII guidelines. The new guidelines highlight four basic strategies: 1. Pay attention to blood pressure before it is high. The new classification. (a) Pre-hypertension describes people with blood pressure between 120-139 millimetres of mercury (mm Hg) systolic or 80-89 mm Hg diastolic "We have thought of blood pressures under 140/90 mm Hg as being okay" says Daniel W. Jones MD the American Heart Association representative on the JNC VII Committee "The evidence is now clear that those in the pre-hypertension range are at higher risk than those with lower blood pressures and are much more likely to move into the hypertension range where medication is required. But lifestyle changes can help those with pre-hypertension" 2. In people over the age of 50, systolic pressure is more important than diastolic. The guidelines say systolic pressure of 140 mm Hg or greater in that age groups should be treated regardless of the diastolic blood pressure level. For patients with stage one hypertension (systolic BP of 140 - 159 mm Hg) and additional cardiovascular risk factors, a sustained 12 mm Hg reduction in systolic pressure for more than 10 years will prevent one death for every 11 patients. Patients and clinicians should not be lulled into a false sense of security because of a "normal" diastolic B.P. Focused treatment at this age can mean great benefits later in life in the form of less cardiovascular and kidney disease which have a huge impact on quality of life. 3. Two (or more) drugs are better than one for most patients. Most hypertensive patients will require 2 or more antihypertensive medications to achieve goal blood pressure (less than 140/90 mm Hg or less than 130/80 mm Hg for those with diabetes or kidney disease). Using more than one drug to treat most patients will be key to improving blood pressure control rates. Patients and physicians need to begin the drug treatment process with an open mind to using as much medications as necessary to achieve goal blood pressure. For most patients controlling high systolic blood pressure has been considerably more difficult than controlling diastolic hypertension. Recent clinical trials have shown that two or more antihypertensive drugs may be needed to achieve optimum pressure. ############### Health Line Leg cramps Do you suffer from leg cramps? If the answer is 'Yes' Dr. Simone D. R. Goonewardene tells you what to do. Many of us experience leg cramps that keep us awake at nights. Common causes of leg cramps or "Nocturnal Cramps in legs" are due to Sodium depletion, or tired legs after exercise. It occasionally indicates disease caused by drugs, Hypothyroidism, tetanus, muscle ischeamia and myopathy. Precautionary measures to be taken are: Consult a doctor to treat the cause it known. Causes could be (a) physical or due to drugs. Physical: 1. Massage and apply heat to the affected muscles. 2. Stretch the calf muscle 3 minutes before retiring to bed in the night. 3. Stand one foot away from the wall facing it with the hand outstretched above the head with the palms touching the wall. Stand on your toes count to ten repeat for 3 minutes. 4. Rest on a chair for ten minutes with feet resting parallel to the floor. Place a cushion under the tendon achilles which is about 3 inches above the heel. 5. Rest the feet on a folded pillow while sleeping. 6. Avoid covering the feet and lower part of feet with a bed sheet. 7. Drink tonic water before sleep. Drugs: Quinine 300 mg or Biperidine 2-4 mg nocte ############### From our readers ..... : The pitfalls of a push button world In todays push button world stress takes a heavy toll on our adult life. A large segment of adults in urban areas in particular suffer adverse effects from stress related ailments and complaints like high blood pressure, heart disease, cancer and even certain accidents. It can lead to mental suffering like feelings of inadequacy, isolation or powerlessness. Modern living imposes severe strains and stresses both physical and mental. The mad rush to work in filthy over-crowded buses and trains, saddled with arrears on instalments and rent, trapped amidst blasts, political vendettas and many more keeps us pushing towards this chaotic state. Bad eating habits, lack of exercise adds to the mess. Exciting events in our daily life like weddings, examinations, can generate much stress as does tragedy and disaster. Admittedly a certain amount of stress is welcome and healthy too, since a little bit of anxiety, excitement and pressure can help us to activate us to perform better. But when one is overstressed and depressed it could lead to monotony, lack of motivation, addiction to booze or drugs and above all negativity. However a healthy level of stress or pressure makes us exhilarated largely motivated and mentally and physically alert. A totally relaxed person may very often not perform to the best of his ability. Eliminating stress and avoiding pressure altogether is futile and counter productive and would make our lives dull and insipid. In order to bring down stress to a healthy manageable level it is important to recognize ones symptoms of stress. Ask yourself as to whether you are taking on more than you can. Are your eating habits healthy ? Are you getting enough sleep and exercise ? Ask yourself what changes you could accommodate. Tackle one problem at a time, ensuring that it leads to the ultimate goal and thereby releasing that penchant for perfection. Some very effective stress remedies include physical exercise like weight training, aerobics, pilates and sports and jogging. Relaxation techniques like yoga and meditation. Yoga helps to improve your physical health and tone your muscles and internal organs and relieve the inner tension whilst meditation is an important element of yoga but a therapy in itself. Reserve time that is just for yourself, to read, write, watch movies, listen to music, do some gardening. Put your problems into perspective by volunteering, make the first move to be friendly, focus on being less critical of others, be they friends or relatives, and have a good laugh since laughter is the spiciest condiment in the feast of existence. Vimal Waidyasekera, Regina, Canada, Editor's note: Readers views on this subject are welcome ############### Dr. R. A. R. Perera, Consultant Psychologist, talks about a rarely discussed subject... : Psychological management of a dying patient The medical profession has largely ignored the needs of the terminally ill. Death is still a taboo topic, not widely discussed in society. Psychologists and psychiatrists have recently begun taking an interest in identifying the psychological and social problems experienced by the dying, and have tried to develop methods of relieving and preventing these problems. Despite this change in attitude, many of the issues entailed in the psychological management of the terminally ill - such as whether to tell the patient the truth, how to tell him, what help to offer relatives - remain baffling and complex. A person with an incurable illness obviously enters a psychological and social world, which is intrinsically alien and stressful. Not surprisingly, therefore, he may react to this situation with a range of emotions including anxiety, depression, guilt and anger. Anxiety: The patient's anxieties may include the existential fear of a state of non-being or a pervasive concern about what will happen to him after death. The most dominant fears however, relate to the process of dying itself: the fear of pain, shortness of breath, and other physical symptoms, which may not be amenable to treatment. The fear of abandonment by relatives, friends and medical staff, with consequent isolation and loneliness. There is concern of being a burden and a nuisance to others, because of progressive disability. These anxieties are entirely legitimate. Pain for instance, is often a symptom of terminal illness and can prove relentless. Depression: The dying patient obviously has much to mourn over - he is soon to lose his family, his friends, his social role and indeed his own life. The patient may become so depressed that he harbours suicidal inclinations. Guilt: Depression may be associated with a feeling of guilt, or guilt may occur as a disturbing emotional reaction in its own right. Guilt about abandoning the family, particularly young children, and abandoning friends for whom the patient feels an obligation. Anger: The patient may show intense anger. Why has he been issued with so cruel a fate/ this anger may be legitimate - directed towards doctors; for example, who have treated him inefficiently. This is irrational and unrealistic, and reflects the patient's sense of frustration, impotence or bitterness. Family problems: The most common difficulty was a failure in communication between patient and relatives leading to uncertainty about what information each had of the diagnosis and prognosis. This uncertainty might lead to a major disruption of the relationship and may prevent any intimate contact. A marriage may become strained due to irrational outbursts of the patient to his spouse. In some cases a patient may turn to a parent for support and comfort, thus seeming to exclude and reject the spouse. A previously independent man, who proudly occupied the role of family provider, may unwittingly resent the wife, who has taken over his role. Although any marriage is vulnerable at this most stressful of times, marital relationships which have been troubled previously are most likely to become disturbed. As with any psychosocial stress, the patient with terminal illness may come to use one or more of a number of defense mechanisms, to ward off distressing thoughts, feelings and fantasies. Denial: This often occurs at the time when the patient is first told about his condition. a period of numbness or shock ensues and the patient professes to have no knowledge about his medical state despite having been provided with information about it. Dependency: Obviously, a terminal ill patient must depend on medical personnel and others in order to receive appropriate treatment and care. The dependency may, however, attain exaggerated proportions with the patient foregoing any measure of responsibility for him. Regression: This is the most extreme form of dependence. The patient reverts to an earlier stage of psychological development, usually that of a small child or even an infant. Counter-dependency: These patients act in a stubbornly independent fashion, determined to cling to their own autonomy. They resist the offer of help and support even though they are clearly in need of it. Psychological management includes: Promoting the patient's self-esteem by encouraging him to see that he still has a role to play and that he is valued. Promoting his emotional comfort, by reducing unnecessary distress such as anxiety, guilt, shame and depression. Promoting key relationships between the patient and his relatives and friends so that they can be mutually supportive. Although patients may use denial to fend off the reality of their predicament, virtually all of them appreciate at one stage or another that their lifespan will be shortened. Active listening is a very important therapeutic measure. Among other benefits it lets the patient know that he is accepted and valued and that he is not abandoned. An appropriate use of humour is an important aspect of management. |
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| Editorial | Security Produced by Lake House |
Physical illness and depression in older people usually occur together
for various reasons. Recognising the symptoms of depression at the early
stage could help in better management of such patients, says Dr N.
Kumaranayake, Centre for Community Mental Health, Teaching Hospital
Kalubowila in this interview with CAROL ALOYSIUS.
