By Prof Saroja Krishnaswamy

MALAYSIA: COMPARED to 50 years ago, there are now many more people over the age of 65, and even more are becoming centenarians. Currently in Malaysia, the life span for females is about 75 and for males 72. It is expected that there will be a doubling of those over 65 in the next 30 years in the US [1].

Two issues become increasingly important as people age. They are the older person's well-being, both physical and psychological, and the ability of the older person to be well integrated in the family, community and overall society.

Mental health problems over the age of 65 are becoming increasingly frequent, with cognitive impairments being the most common.

About 5 per cent of those over the age of 65 suffer from dementia, which is the most severe cognitive impairment.

Other psychiatric disorders have been under-diagnosed and this accounts for why the reported frequency is much less in the older as compared to the younger population.

The most common disorders of old age are depressive disorders, estimated to be about 15 per cent of the elderly in the community.

The core symptoms of a depressive disorder are the same as in the younger age group, for example, reduced energy, sleep problems (especially early morning awakening), weight loss and somatic complaints often described as hypochondriacal.

Often complicated by physical ill health, depression in the elderly can be difficult to diagnose and can increase mortality and morbidity due to existing illness.

Therefore it is important to identify risk factors early so that they can be treated or alleviated so that the risk of getting depression can be reduced.

Risk factors contributing to depression

Many old people are quite resilient in the face of adversity due to coping strategies learned from past experience and behaviour.

There has been evidence to suggest that the cohorts who survived the world wars have less mental illness, and it has been postulated that the adversities they went through have become protective.

Evidence backs the notion that support systems and personal traits are important and can buffer one during adversity.

However, there is only so much that a person can take and multiple adversities or too frequent ones or very severe ones become too heavy a burden and can cause a person to succumb.

These adversities can be considered risk factors and the common ones are as follows:

1. Death of relatives and close friends are considered as losses and older people would be facing more deaths with their elderly relatives and friends as compared to younger people.

2. Poor health and physical illness associated with pain and disability curtails activity and makes the elderly more dependent on others, contributing to a sense of uselessness.

3. Loss of status, loneliness and social isolation often arise when the aged have lost their position in society and in the family and often do not have a sense of being needed.

4. Development of chronic mental illness at a younger age can result in residual deficits that can be exaggerated in the aged and become a problem to caregivers and some mental illnesses can also become more intractable with age.

5. Social and economic problems are really devastating in the aged when they are not employable and have no other support.

6. Presence of other psychiatric diagnoses e.g. alcohol and other substance abuse which occur in about 10 per cent of the elderly often complicate the current presentation and may be masking underlying depression.

7. Other biological factors, especially degenerative changes which can result in neurotransmitter deficiencies, that can contribute to depression.

8. Environmental (especially housing which is not conducive to the elderly) and other factors, e.g. poor roads, lack of bus services, which make access to conveniences difficult for the elderly. Poor housing can be dangerous and increase home accidents, leading to fractures, immobilisation and even death.

9. Cultural factors (acceptable meanings given to illness by patient and family), and illness factors are confused for general ageing. Acceptance of death and disease as attributable to old age may hasten death unnecessarily.

10. Side-effects of drugs due to age related changes in drug handling and drug interactions, especially if they are on treatment for physical ailments. Hypertension, diabetes and obesity are common problems.

11. Poor treatment of other coexistent illness in old people can impair recovery of mental health problems. Illnesses causing pain and discomfort need to be adequately treated, and pain killers and other treatments should not be spared. Adequate doses of medication need to be used, as often, because of fear of side-effects, drugs are used too cautiously.

12. More frequent illnesses are prevented by closer follow-ups. Inability to attend clinics results in delay in detecting relapses or other new illnesses.

13. Neglect of optimum functioning e.g. prevention of vascular dementias if strokes are prevented with early management. Current developments in the prevention of strokes are very encouraging and more therapists need to be aware of the cutting edge developments in medical and surgical areas so that all the elderly can benefit from them.

14. Sensory deficits and cognitive defects - a lot of active work needs to be done by the therapist to work around these deficits and also to delay development of these deficits.

15. Encourage autonomy, including retraining in living skills and safety at home. Active rehabilitation would be needed in these areas for independent living.

16. Lack of practical support and information, including social and legal rights advice to patients and their supporters and caregivers. Practical support for those who cannot live alone should be timely, and with access to medical resources.

Depression in caregivers who need to look after the elderly is quite well documented and so caregivers need support and advice so that their needs are also taken care of.

Day-care and support groups will be needed and this will lessen the burden of the caregivers during the day, as well as be an opportunity for socialisation and development of other skills for the elderly.

Conclusion

A multidisciplinary team approach is needed and each member of the team could be confronted with different psychosocial problems when dealing with the elderly. The health worker dealing with the elderly has also to take into account the family context, local customs and culture and the social and health services available.

The key would be early detection of risk factors and this means the elderly would have to be viewed holistically and health workers need to keep this in mind at all times.

This article is contributed by The Star Health & Ageing Panel, which comprises a group of panellists who are not just opinion leaders in their respective fields of medical expertise, but have wide experience in medical health education for the public.

The members of the panel include: Datuk Prof Dr Tan Hui Meng, consultant urologist; Dr Yap Piang Kian, consultant endocrinologist; Datuk Dr Azhari Rosman, consultant cardiologist; A/Prof Dr Philip Poi, consultant geriatrician; Dr Hew Fen Lee, consultant endocrinologist; Prof Dr Low Wah Yun, psychologist; Datuk Dr Nor Ashikin Mokhtar, consultant obstetrician and gynaecologist; Dr Lee Moon Keen, consultant neurologist; Dr Ting Hoon Chin, consultant dermatologist; Prof Khoo Ee Ming, primary care physician; Dr Ng Soo Chin, consultant haematologist.

For more information, e-mail starhealth@thestar.com.my. The Star Health & Ageing Advisory Panel and AsiaOne provide this information for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader's own medical care.

The Star Health & Ageing Advisory Panel and AsiaOne disclaim any and all liability for injury or other damages that could result from use of the information obtained from this article.

This story was first published in The Star on Oct 5, 2008.