Commentary: Late-life depression is common but not inevitable in ageing Singapore

SINGAPORE: While Chinese New Year is a time for joyous reunions, it can be a time of deep sadness for vulnerable seniors.

As Singapore’s population ages, late-life depression is becoming a serious but overlooked issue. According to the Well-being of the Singapore Elderly (WiSE) study conducted by the Institute of Mental Health, depression affects about 5.5 per cent of the elderly locally.

While many people associate depression with sadness, it can manifest in less obvious ways, particularly in older adults.

Recently, I received a referral from primary care services for an elderly woman suspected of having dementia. Her family described her as becoming more forgetful at home, noticeably quieter than before, and less engaged in activities. She used to enjoy morning walks or chatting with neighbours at the market, but for the past six months, she mostly stayed at home, rarely venturing out.

During our conversation, she remarked, "I don't want to go out. I'm old now, can't walk well, and all my friends are gone. No one remembers me anyway."

As the consultation progressed, she began to tear up, expressing dissatisfaction with life and feelings of loneliness. She believed other elders were better off than her. After a thorough assessment, she was diagnosed with late-life depression.

LATE-LIFE DEPRESSION CAN GO UNDIAGNOSED

This patient’s case is far from isolated. Late-life depression often goes undiagnosed because its symptoms such as fatigue, lack of concentration and sleep disturbances are easily mistaken for normal ageing or physical illnesses.

Moreover, when elderly individuals take multiple medications, some can induce depression-like symptoms, complicating diagnosis and treatment.

Late-life depression can also present as memory loss or confusion, which may be misinterpreted as dementia.

RISK FACTORS FOR LATE-LIFE DEPRESSION

Several factors contribute to the increased vulnerability of older adults to depression.

Long-term social isolation is a significant risk factor for depression. Older adults often face shrinking social circles due to the death of friends and relatives, retirement, or reduced mobility.

Deteriorating health also plays a crucial role. Chronic diseases such as diabetes, heart disease, or arthritis, along with long-term pain, not only affect physical health but can also make older adults feel helpless and pessimistic, triggering depressive moods.

Cognitive decline is another factor, as decreased cognitive function or early-stage dementia often accompanies low mood.

Changes in life roles can contribute to depression in the elderly. The loss of professional roles after retirement, reduced income, or increased dependence can make older adults feel like burdens to their families or society, increasing psychological pressure.

Lastly, loneliness and a sense of loss are significant contributors. The breakdown of intimate relationships or loss of loved ones, including pets, can plunge older adults into deep sadness and helplessness, further increasing their vulnerability to depression.

SUPPORTING SENIORS STRUGGLING WITH GRIEF AND LONELINESS

Due to the stigma surrounding mental health or misconceptions that depression is a “normal” part of ageing, many older adults are reluctant to seek professional help. If you suspect your elderly loved one has depression, adopt a gentle and patient approach.

Instead of pushing for immediate action, gradually introduce ideas for social engagement, such as short outings or arranging home visits from family and friends. Create a welcoming environment at home and, if appropriate, assist with technology to help them stay connected.

Identify and address specific barriers that may be holding them back, such as mobility issues or fear of being a burden. Offer to accompany them to community centres or senior day care centres, or arrange for befrienders to come to their home if leaving is challenging. Establishing a daily routine with small, manageable activities can provide structure and purpose, even on difficult days.

Active listening is crucial throughout this process. Provide a non-judgmental space for your loved one to express their feelings about loss and loneliness. Your presence and willingness to listen can be incredibly supportive.

If signs of severe depression or prolonged grief are apparent, gently suggest speaking with a healthcare professional. Offer to make the appointment and accompany them. Remember, your role as a caregiver is to provide support and encouragement, helping the older adults navigate through their grief and loneliness at a pace that feels comfortable and manageable for them.

MANAGING LATE-LIFE DEPRESSION

Late-life depression is treatable, and many seniors see significant improvement with proper diagnosis and management. However, treatment can be complex due to coexisting medical conditions and potential medication interactions common in older adults.

The most effective treatment plans typically combine psychotherapy, medication and lifestyle modification tailored to the seniors’ specific needs. Cognitive behavioural therapy has shown promise, helping patients challenge negative thought patterns often exacerbated by age-related changes and losses.

For severe depressive symptoms, doctors may prescribe antidepressants or short-term anti-anxiety medications, with careful monitoring for any drug interactions and side effects.

For seniors who are reluctant to seek help, caregivers can try different strategies. Framing therapy as a life review or reminiscence sessions can make it more appealing. My patient’s daughter encouraged her father to attend therapy by framing it as a chance to share his life stories and make friends.

For medication reluctance, involving the seniors in decision-making and explaining how the medication works can increase acceptance. In one case, a grandmother was more receptive to taking antidepressants when her trusted doctor explained their benefits.

Encouraging seniors to seek help often requires patience and persistence. If initial attempts are met with resistance, continue to express your concern and support, and be prepared to try different approaches over time.

Late-life depression is not an inevitable part of ageing. Through collective efforts by families, communities and healthcare professionals, we can ensure that every senior feels valued and connected. Helping them rediscover purpose and meaning in life is a responsibility we all share in building an inclusive society.

Associate Professor Ng Chong Jin is Head and Senior Consultant of the Department of Geriatric Medicine at Khoo Teck Puat Hospital.