Tuesday, 27 October 2020

When signs of dementia could actually be depression: Forgetfulness. Confusion. Irritability. They're seen as early indicators of brain decline. In fact, it's often a hidden mental illness that can be treated with therapy

 Paul Garnett felt 'incredibly embarrassed' explaining to his GP at the age of 71 that his depression was out of control. 'I felt so ashamed of myself — a man who couldn't cope,' he says, recalling the difficult months that led to the appointment with his doctor.

'Everything felt so bleak once I'd stopped working,' recalls Paul, now 73. 'I had this morbid feeling that I'd achieved nothing in my life. I was eaten up with self-loathing.'

Though he'd experienced mental health problems since his 30s, Paul had always managed to continue working.

'I felt I had to be the strong one and I was able to keep my feelings buried,' says Paul, who lives in Manchester.

He'd had a difficult childhood, and then his wife had suffered a series of devastating miscarriages. His GP had prescribed anti-depressants — and these had helped.

Paul Garnett from Droylsden, Manchester. Paul, 73, suffered severe depression since he retired two years ago

Paul Garnett from Droylsden, Manchester. Paul, 73, suffered severe depression since he retired two years ago

But after retiring at 70 from his job as a retail manager, Paul's coping mechanisms started to unravel. He began drinking more and stopped eating regularly.

'Sometimes, I couldn't stop crying; or I'd become angry and verbally abusive with my family — the people who loved me most,' he recalls. 'My behaviour was out of character.'

Paul isn't unusual. One in five people over the age of 65 experience depression or anxiety, according to NHS England — about the same rate as the rest of the population. With older patients, though, there are concerns that doctors ignore depression or misdiagnose the disease as dementia.


This year, it's likely that the pandemic has pushed up rates of depression among older people, according to the charity Independent Age.

'With Covid-19, we've seen an increase in mental health problems such as depression,' says Deborah Alsina, the charity's chief executive, as it launches a report about mental health in later life.

'For many, the pandemic added to the stress, loneliness and anxiety they were already experiencing,' she says.

The charity found that 75 per cent of older people have experienced anxiety or low mood at least once since turning 65, and one in ten felt like this regularly or all the time.

Paul's wife persuaded him to get help and he was referred to an Age UK mental health assessor who arranged a programme of talking therapy that has transformed his life

Paul's wife persuaded him to get help and he was referred to an Age UK mental health assessor who arranged a programme of talking therapy that has transformed his life

'This is an urgent problem,' Deborah says.

Indeed, data from the Office for National Statistics showed that the mental health of two in five of the over-70s — that's 2.9 million people — worsened during lockdown.

And there is increasing concern, experts say, that not only is the impact of depression and anxiety often far worse for older people, they are also less likely to be treated for it.

'When younger people are affected, they generally become lethargic and withdraw from life,' explains Dr James Warner, clinical director of older adults mental health services at Central and North West London NHS Trust.

'However, with the elderly, depression reduces them to a state of extreme agitation.'

There is evidence that retirees are particularly vulnerable to depression and anxiety through loss of identity and self-confidence when they stop working.

'Older people also face isolation and multiple bereavements, as well as a higher risk of chronic pain disorders,' says Dr Warner.

'Men and women who have managed all their lives — bringing up families, working — can become indecisive to the point of paralysis, wringing their hands in despair, the total absence of pleasure in their lives etched on their faces.'

Worse still, the over-65s face an additional problem when it comes to getting treatment: ageism.

Only six per cent of people referred for counselling are over 65, despite this age group making up 18 per cent of the population, according to a survey of over-65s for Age UK and NHS England published earlier this year.

And this is despite evidence which shows that older people who are referred for talking therapies respond well — and often do better than younger patients.

Indeed, data from the NHS IAPT (Improving Access to Psychological Therapies) programme for 2019/20 shows that people aged 65 and over had an overall recovery rate of 64 per cent, compared to 50 per cent for those aged 18 to 64.


Depression and anxiety in later life are often dismissed as a 'normal part of ageing, with older people regarded, wrongly, as beyond help', says Alistair Burns, a professor of old age psychiatry at the University of Manchester. Another issue is that some older people may not be comfortable discussing their problems, suggests Caroline Abrahams of Age UK.

'People who grew up in an era when there was a real stigma associated with mental illness find they cannot be open about it — an essential pre-condition to people getting help,' she says.

Indeed, a YouGov poll of more than 2,000 British adults published in November 2018 found that nearly one in four (24 per cent) of over-65s felt uncomfortable about friends and family knowing they had depression, compared to just seven per cent for arthritis.

'The bitter irony is that talking therapies are most effective in the over-65s,' says Dr Amanda Thompsell, chair of the faculty of old age psychiatry at the Royal College of Psychiatrists. 'Yet the stigma around mental health and fear of being thought less of by family and friends is deterring them from seeking help.'

Earlier this year, a government campaign aimed to persuade GPs — and their patients — that providing treatment for mental illness in older age should be a priority.

'Anyone out there who is feeling down needs help and should get it from the NHS,' Professor Burns wrote in a letter to every GP in January.

The message to people such as Paul is 'seeking help is a sign of strength, not weakness', she adds. 'We need to challenge the idea that older people should have a stiff upper lip towards mental illness.'

June Cooke, 85, a former cleaner and great grandmother of six, from London, says she had experienced severe depression and bipolar disorder most of her life — but it was only when she had a breakdown aged 76 that (with the help of her three daughters) she was referred for medication and counselling.

'Nobody talked about mental illness when I was young,' says June. 'I thought of myself as 'crackers', or that if I talked about suicidal thoughts, my children would be taken away and I'd be put in a mental institution.'

June received treatment, including talking therapy, at the Central and North West London NHS Foundation Trust and says: 'I think this is the happiest I've ever been.'


the Royal College of Psychiatrists estimate that 85 per cent of older people with depression receive no help at all from the NHS.

What worries experts is that, generally speaking, attitudes within healthcare have not changed since 2009, when a pioneering study published in the journal Current Gerontology revealed ageist attitudes among GPs.

In the study, 121 GPs had been asked to consider a plan of treatment for two case studies with identical symptoms of depression, one aged 39 and the other, 81.

The majority of doctors planned appropriate diagnosis and treatment only for the younger patient, taking for granted that the symptoms of the older patient were caused by physical health problems, such as increased disability and incidence of chronic pain, and were therefore inevitable.

The reason such attitudes prevail, according to the mental health charity Mind, is that many GPs still believe misery is the price of ageing.

'We regularly hear from people who say their mental health problems are dismissed by their GPs as merely a part of getting older,' Vicki Nash, head of policy at Mind, tells Good Health.

And, in some cases, patients' symptoms are misdiagnosed as dementia (see right). The problem here is that symptoms including irritability, tearfulness, lack of motivation and problems with memory are common to both illnesses.

However, there are also clear differences. People with dementia lose cognitive function, failing to recognise the people around them as well as the date, time and year. Those with depression may not remember at first, but usually manage to recall this basic personal data once prompted.

Also, the severity of depressive symptoms usually varies throughout the day, while dementia symptoms stay the same, according to retired GP Dr Keith Souter.

Professor Burns, supported by Age UK, is calling on GPs 'to think twice before offering medication as a first-line treatment option for depression and anxiety in older people — and instead refer more patients for talking therapy'.

Paul's story highlights the need for the provision of such care — and the power it has to transform lives. Luckily for Paul and his family, his GP referred him to Age UK Manchester for talking therapy.

'Even after my first session, it felt like a huge burden had lifted from me,' he says. 'The counsellor provided a safe space for me to talk about things that I had never, talked to anyone about before.'

In 14 weeks of therapy, Paul also learnt coping mechanisms to use every day.

'It wasn't easy at first, and I still get the occasional bout of anger, but I now feel confident that I can manage it. I just feel so positive in everything I do.'


 It's wrong to think low moods are 'natural' in old age 

Commentary by Dr Max Pemberton 

When it comes to their mental health, older people are being routinely let down. Over the 16 years that I've practised as a psychiatrist, I've seen repeated examples of how poor the provisions are for this group.

Even after the recent surge of interest in mental health, with celebrities and the Royal Family raising its profile, the mental wellbeing of older people rarely gets a mention. The focus is almost always on youngsters.

Services for older people remain a Cinderella speciality — and it's clear that 'ageism' underpins this lack of consideration .

Ageism is also at the root of many of the assumptions and prejudices which lead to older people with depression being dismissed or ignored.

Depression in older people is more common than dementia, yet it is significantly under- diagnosed and undertreated. In fact, the symptoms of depression are frequently mistaken for dementia.

Mental health services for older people remain a Cinderella speciality — and it's clear that 'ageism' underpins this lack of consideration (stock image)

Mental health services for older people remain a Cinderella speciality — and it's clear that 'ageism' underpins this lack of consideration (stock image)

There is an assumption that the elderly are supposed to be down and a bit grumpy; their distress and despair is dismissed in a way that would never happen to any other group.

And although suicide rates generally are declining, they are still higher in older people than in the young. Yet there are scant services and resources to address mental health problems in older people.

Four in ten people over the age of 75 are suffering some signs of depression, but as few as 3.5 per cent of cases are referred for therapy. This is utterly disgraceful.

I have direct experience of this. In one service for older people's mental health where I worked, we did not have a single psychologist: we just had to prescribe antidepressants.

The number of older people on antidepressants has doubled in the past 20 years, according to figures published last year — and this is despite older people being far more at risk of side-effects and complications from taking such medications.

Their metabolisms mean that the side-effects can be more serious, too.

Antidepressants can cause chemical imbalances in the blood and reduce its ability to clot; they can increase confusion and make patients feel dizzy or lightheaded; they can also interfere with medications that are commonly prescribed in older people for conditions such as high blood pressure.

That's not to say that antidepressants aren't useful and that some patients shouldn't be taking them.

My worry, though, is that these pills are too easily dished out when psychotherapy would be a far better option. However, patients in this age group simply won't get access to this.

Once again, the poor provision of psychotherapy is pure ageism, based on stereotypical assumptions that older people 'won't change'.

Yet there is good evidence that the elderly respond just as well as younger people to talking therapies.

In fact, some studies show they respond better because they are more likely than younger people to attend sessions.

Senior citizens have just as much right to therapy as anyone else, and it's scandalous that they aren't being offered it.

Part of the problem is that GPs are not always in tune with how older people experience depression. More than half of older people with depression have no history of it, and this 'late-onset' illness often has subtly different symptoms to the depression that affects younger people, which can make it tricky to spot.

Older people tend not to complain of 'feeling sad', but rather find they have no enjoyment in life. They can become more preoccupied with physical health symptoms and develop anxiety or obsessive compulsive disorder (OCD).

In more than 70 per cent of cases, there is evidence of poor memory or thinking, symptoms which mimic those of dementia — that is why we sometimes call it pseudodementia.

As a result, the patient's true problem — depression — is all too easily missed.

It would be wrong to put all the blame on GPs. I've seen hospital doctors, too, overlook depression in older people. The problem is endemic.

I remember one patient I saw early on in my training, while working in geriatrics. She was sitting in a chair by her bedside, staring out of the window.

She was in her late 80s, frail and stooped. She had been on the ward for the past month after falling at home. She rarely spoke, and when people asked her questions, she stared at them, then shrugged her shoulders. Her memory was very bad and she frequently forgot what people told her.

She obviously had dementia, and it was decided on the ward round that it would be best if she went into a home.

Her husband had died four years previously and she had no family, so I phoned her GP to explain our plan.

Yet the GP was dumbfounded when I said she had dementia.

'I only saw her a few weeks before she fell and she was as fit as a fiddle,' he told me. 'She had a better memory than me!'

The GP was adamant, so after I put down the phone I went over to the patient and asked her basic questions about where she was and what the date was.

She shrugged her shoulders each time.

But it niggled me that she could have been so different when her GP saw her, so I phoned the old-age psychiatrist who, after an hour of assessment, confirmed the patient actually had depression.

She was transferred to the mental health unit, began treatment and, incredibly, over the next few weeks her memory improved and she went back to her own home.

It had a profound impact on me and was a valuable lesson in not jumping to conclusions — and, in particular, how easy it is to dismiss someone simply because of their age.

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