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Depression is a serious concern for anyone, and no less so when a person has diabetes. Studies have shown that if you have both diabetes and depression, you are more likely to have high blood glucose, diabetes-related complications, and a shortened life span. While this may be because seriously depressed people typically don’t take as good care of themselves, researchers think that the link may go beyond that. Fueling their suspicions are the facts that the incidence of depression is higher among people with diabetes than in the general population and that being depressed raises the risk of developing Type 2 diabetes.
Depression is also common among older Americans, and as the U.S. population ages and the incidence of diabetes continues to rise, the number of people dealing with both diabetes and depression is expected to rise, as well. Consider these numbers: In the next 20 years, as the baby boomer generation ages, the number of Americans age 65 and older is expected to double. In roughly the next 50 years, according to Centers for Disease Control and Prevention estimates, the number of people between the ages of 65 and 74 who have diabetes will triple and the number 75 and older with diabetes will increase by a factor of five. Currently, it is estimated that 8% to 20% of older people living independently (not in nursing homes) are depressed, and it is known that people over 85 have the highest suicide rate of any age group. All of these statistics point to the need for effective treatments for depression in older people.
Depression is not just the normal sad feelings that occur at times of loss, stress, or disappointment. A person who is depressed typically feels deep sadness, feels very little pleasure in life, and may even contemplate suicide.
While the stress of coping with any chronic disease can contribute to depression, researchers are studying what unique aspects of diabetes might account for the high rate of depression among people with diabetes. They are exploring whether, for example, there may be biological factors such as changes in hormone levels that contribute to both diabetes and depression. In the meantime, however, it is known that identifying and treating depression in people with diabetes is possible and important for their overall physical and emotional health, as well as for their diabetes control. This article examines some of the particular stresses that diabetes and the process of aging cause for older people, the link of these stresses to depression, and what can be done to help.
Physical causes and effects
People with diabetes have the added stress of knowing that the longer they have lived with the condition, the higher their likelihood of developing diabetes-related complications, such as kidney and eye disease. The aging heart also becomes more vulnerable to the negative effects of diabetes, and many people with diabetes develop cardiovascular disease as they age. It is thought that diabetes complications such as heart disease may also lead to biological changes that cause or contribute to depression, although how they do so is not known.
Some of the bodily changes that occur with aging can have a negative effect on diabetes control. For example, many older people experience hormonal changes that make it difficult for them to notice symptoms of low blood glucose. This raises the likelihood that mild hypoglycemia will turn into moderate or severe hypoglycemia, which is particularly dangerous in older people. Not only can hypoglycemia lead to a fall, but severe hypoglycemia may trigger a heart attack or stroke. Many people also eat less as they age, which also raises the risk of developing hypoglycemia.
While most older people adapt and thrive in the face of these transitions, some become emotionally overwhelmed and experience persistent sadness. Add to this burden the emotional challenges of diabetes such as fear of complications, resentment over the lifestyle changes that are required to manage it, and stress on relationships, and it is easy to see how diabetes can make a person even more vulnerable to depression. Indeed, one study that looked at the effects of depression and diabetes together found that having both conditions resulted in a higher incidence of disability and complications than did having either condition alone.
Moreover, modern families are commonly dispersed geographically, often leaving older — and younger — people feeling isolated and disconnected from needed support. This environment can make an older person feel out of place and alone in facing the challenges ahead, leading to feelings of hopelessness (“It will never get better”) and helplessness (“There’s nothing I can do to make it better”), both of which are attitudes that underlie depression. Add to this the environmental stresses of diabetes, such as the need for frequent medical visits and the high cost of treating it, and it is clear how having to cope with diabetes may contribute to depression.
Signs and symptoms
Recognizing depression in someone else
When assessing mood disorders in older people, health-care professionals often use the Geriatric Depression Scale, a tool specifically designed to screen older people for depression. It consists of anywhere from 5 to 30 yes-or-no questions, such as the following:
1. Are you basically satisfied with your life?
Of these five questions, a “no” in response to the first question and a “yes” in response to any of the others is worth one point. A score of two or higher indicates that a person may be depressed. However, depression shares many symptoms with other conditions, including dementia. If you are concerned about an older friend or relative’s mood or behavior, share your concerns with that person’s doctor, if possible. In some cases, a primary-care doctor may decide to refer a potentially depressed older person to a psychiatrist for further evaluation.
Treating depression in older people
When prescribing antidepressants, many health-care providers start a person on a low dose of medicine and slowly increase it to an effective dose. This helps to lower the risk of serious side effects. How long a person continues to take antidepressants once an effective dose is reached is a decision to be made by that person and his physician. However, some studies have suggested that older people are more likely than younger people to have a recurrence of depression if their medicine is stopped altogether. For this reason, physicians often continue to treat older people with a low dose of antidepressants even after they report feeling better. Having a depression care manager on your health-care team to provide education, emotional support, help with solving problems, and reminders to take any prescribed antidepressants can also be an effective way to prevent a recurrence of depression.
As mentioned, psychotherapy is also helpful for dealing with depression. Some therapists focus on thoughts, others on feelings, and still others on interpersonal relationships, day-to-day problems, or issues from the past. The key is to find someone with whom you feel comfortable sharing your thoughts and feelings so that honest communication can take place. While it is often believed that older people prefer medication to psychotherapy, research shows the opposite is true: Older people are accepting of therapy and at times even prefer it to treatment with medicine.
There are also some things a depressed person can do to counteract his depression. Regular physical activity, such as a daily walk, has been shown to improve mood. People who feel depressed because they’ve become weaker and less able to function independently may want to visit a physical or occupational therapist to build strength and endurance and to identify safe ways to stay active. Spending more time with friends and family and doing activities that used to be pleasurable, even if a person doesn’t feel like doing them, can be helpful as well: Sometimes emotions respond when behaviors are changed first.
Since the physical and mental health of older people are inevitably linked, any treatments for physical or mental health problems should be coordinated and integrated with each other. Many experts recommend that older people receive regular comprehensive assessments by their primary-care providers, which should include assessments of their mood, gait and balance, ability to think and plan, ability to function independently, and quantity and quality of personal relationships. Having this information allows a physician to tailor a person’s treatment to his needs. For example, if a person is having problems remembering or planning ahead, his diabetes treatment regimen may need to be simplified, or a caregiver may need to take over certain tasks.
How to get help
The most important steps are to notice when changes occur in your or a loved one’s emotional or mental state, to explore whether they might be due to depression, and to reach out for information and support.
Depression and diabetes are both potentially disabling illnesses, and older people are at high risk for both. But with appropriate interventions and ongoing care, both can be controlled and hope restored for a better quality of life.
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