She's in her eighties and suffers from congestive heart failure and crippling arthritis, among other problems. She's also been depressed off and on for many years. Her daughter, a good friend of ours, takes her to the weekly doctor's appointment, this time after a hard night of pain and insomnia for her mom.
The 82-year old didn't want to get out of bed that morning and pushed away any help. Yet she could barely crawl to the bathroom, dressed with great difficulty and had no interest in eating.
At the doctor's office, the physician asks how she's been feeling lately.
"Oh, I'm fine."
Her daughter sighs and explains exactly what's been going on.
"Oh, she always exaggerates. Really, I'm doing just fine."
The doctor knows better than that and asks our friend about home care. That's what the daughter does. There's no money for the level of daily, sometimes nightly assistance her mother needs, and insurance only covers an hour's visit a day.
There's no basis for admitting her to the hospital today so the doctor adjusts medications and asks the daughter to watch her carefully. Of course, that's all the daughter's been doing, on top of her job and managing her own depression. Despite what her mother says, she needs more and more attention.
Back home, the mother lies down and doesn't want to move. She doesn't eat and drinks very little water or any fluid. In two days, she has trouble breathing and no energy to do anything. Dehydrated and wrenched by that deep coughing I've heard from someone with fluid building up in the lungs, she's readmitted to the hospital.
"I'm fine," a nod of the head, an indifferent stare, or no response at all. Or it could be an angry dismissal: "Leave me alone There's nothing wrong with me!" Those are the answers I used to get when I was helping my mother in her later years or when visiting the elderly parents of friends.
Despite her denial, our friend's mother is one of the lucky ones. At least her depression has been recognized and diagnosed, and she's been taking medication - though therapy is a step she won't take. Depression often goes unrecognized or ignored, or it may be considered a natural part of aging.
But depression is not a natural part of aging and is just as treatable when you're 80 as when you're 20. Nor is it true that most people with serious illnesses get depression. They may well feel upset, resentful or "depressed" in the everyday sense of the word, but they don't have the diagnosable illness of depression. These false beliefs, though, are part of the reason that the problem is under-treated, or not treated at all.
And then there is the "I'm fine" problem of refusing to talk about it. Many elderly people, like those of any age, may not even realize what's happening or may believe that what they're experiencing is nothing out of the ordinary. Of all the pains and problems that an elderly person might not mention to a doctor or might flatly deny, depression is probably first in line.
Given what the research studies of recent years are reporting, that silence can ensure that recovery will never occur. Those studies also associate depression with a higher risk of death generally.
But the data don't stop with those general findings. The studies are clear about specific diseases as well. There's evidence that depression in the elderly is a risk factor for stroke and coronary heart disease. It also increases the likelihood of death for someone with congestive heart failure - even when that disease is carefully treated and well-managed.
I have often read that the link between depression and other diseases has to do with lifestyle problems. Depressed people in general fail to eat properly, don't sleep well, don't exercise or socialize - or do any of the things that nurture healthy living. This sort of behavior increases the likelihood for heart problems, diabetes or other conditions. That's doubtless true.
But recent research suggests that the connection goes a lot deeper than behavior. As far as heart and cardiovascular problems are concerned, the disease pathways are similar to those for depression. Vascular problems are linked to serotonin, just as depression is, because that neurotransmitter not only affects mood but also the expansion and contraction of blood vessels. Both are also related to the sustained release of stress hormones.
It goes on. There are neural connections between parts of the brain linked to depression and the branch of the nervous system that controls heart beat, breathing and other basic functions. Some researchers believe that depression directly reduces heart rate variability, an important sign of heart failure. Depression is also linked to areas of the brain damaged during dementia.
The authors of these studies call for more aggressive research, comparable to what has been done for cancer and heart disease. They believe an all-out approach is necessary both because of the impact of the illness on so many systems of the body and because it is so common and widespread in the world's population.
Most of us don't have access to research, except for an occasional headline in the news. At the level of daily living, the middle aged children of elderly parents live with the more mundane struggle of caring for a beloved mother or father who seems to have lost interest in everything and perhaps even given up the will to live. When they suffer from physically debilitating illnesses as well, a parent's need for help with common tasks of living can become an exhausting burden for family care-givers, triggering their own depression.
My mother once lived in a community of older people, and every day she talked to friends and neighbors who were as depressed as she was but living independently. No matter how upbeat they might seem, most of the residents felt at times that they were all waiting to die. One day when I stopped by, my mom told me of the suicide of an elderly man living two doors down from her.
"He planned it," she said. "He wrote a note ahead of time to a friend. Told him what to do. Then he used a rifle."
"That's horrible - what drove him to do that?"
She looked grim just then, and the childhood image I had of her when she was deep in depression came back to me.
"At least he had the guts to do it," she said.
My mother never seemed to be suicidal, and that was the one time I ever heard her even suggest that she'd been living with that thought. Many years later, when she was terribly sick - she was in her mid-90s - she clung fiercely to life. She felt triumphant when she survived one close call after an operation.
"I had a heart attack in there," she told me. "But I beat it again." She was beaming - it was the second time she had lived through a moment of attack when her heart had briefly stopped. I had never seen her so happy.
The problem was that she no longer had any interest in living happily except at those moments of cheating death. Whenever I suggested therapy of discussion about depression with her doctor, she became resentful.
"I took courses with Alfred Adler in college," she'd say. "I know myself very well, and I'm not depressed."
Do you have elderly parents suffering from depression? What is their attitude about the illness? Have they been diagnosed and treated? How has your parent's condition affected your own life?