Deep into the abyss of depression, he disappeared on the night of Guru-purnima near the bank of river Chenab. The details of the 75-year-old man’s life are few but thought-provoking.
Ram Prasad was a son of a laborious marginal farmer. He lost his mother soon after his birth. He studied till class second and starting working at a vegetable shop. He was very honest and hard-working. He assisted his father in farming. At the age of twenty-one, he got married and later had three sons.
Ram Prasad worked very hard and provided education to all his three sons. The eldest son was an accountant, the second one was into poultry business and the third was unemployed. All the three sons were married and had children. Ram Prasad lost his wife almost thirty years ago and he did not get married again. Most of his friends from the same age-group had also expired.
Since last several months, Ram Prasad’s family observed a change in his behaviour. Ram Prasad lost his self-worth and suffered from a constant feeling of worthlessness. He seemed to be very lethargic and had become short-tempered. He would sleep during the daytime, an activity which he never did earlier in his life. He would be irritated over minor house-hold issues. At times he was aloof, apathetic and restless. All the activities which he liked like listening to the radio or visiting the village “haat” no longer pleased him. He was also obsessed with the thought of death and would often question his unemployed son that how would he and his family manage their life after his death.
He developed a fear of death so much that he would keep money in his almirah and remind his son almost every day that in case of any medical emergency, they shall find the money in the almirah. The family members also observed that he was always anxious and was consuming excessive “khaini”(tobacco) throughout the day. He would consume it six-seven times in an hour.
His family took him to the nearest primary care center where he was prescribed iron and calcium supplements and referred to a psychiatrist. The psychiatrist got a psychometric evaluation done for Ram Prasad through a psychologist. Ram Prasad was diagnosed with very severe depression & death anxiety. Medicines were prescribed and counselling was provided to Ram Prasad and his caregivers. The psycho-education to the family included the understanding of age related depression & anxiety and management techniques to overcome depression. They were also counselled on how to take care of Ram Prasad so that his condition does not deteriorate further. The psychologist also raised a red flag by stating that Ram Prasad was at high risk for suicide and the family should never leave him alone. A management plan was shared and the family was requested to visit the hospital regularly for counselling. After taking medicines for few weeks, Ram Prasad abruptly stopped his medication as he felt that it was too costly. His condition deteriorated each day.
One day his neighbour,BabuLal, an old man, asked him for help. He was very poor and in great need of a vessel to store water. Water was very scarce in their village. Ram Prasad, who was very kind, gave a drum to a neighbour to store water. Later next day, when his daughter-in-law found this, she went to the neighbour’s house and brought the drum back. This infuriated Ram Prasad as he considered himself to be the decision-maker and head of family. He was hurt and extremely agitated. In a rage of anger he left from his home. It was Guru Purnima, Friday, July 27th. His last location as confirmed by the telecom company was near the banks of river Chenab. Till date neither Ram Prasad nor his remains have been found.
EARLY WARNING SIGNS OF GERIATRIC DEPRESSION
Geriatric depression is a term used to define mental & emotional disorder affecting the elderly population. We all feel sad & disappointed but a perpetual depression is not considered a part of normal ageing process. It may be a sign of a mental disorder that affects us during old-age and may remain undiagnosed as the family members consider this as a behavioural symptom of getting old. However this must not be neglected as the symptoms may deteriorate rapidly and may cause severe depression and anxiety. This condition may lead to death-anxiety or end-of-life anxiety.
Our body, including brain, the master organ, degenerates as we grow old. The process of ageing is quite complex. According to medical research, ageing occurs due to the oxidative damage to the mitochondria, cell-death, Ultra-Violet radiation, pollution etc. Ageing happens to be the most common cause for death in human-beings.
Every person has their own philosophy related to birth, death & rebirth. Each individual integrates the concept of birth and death and accepts and integrates it his/her “self”. The thought of death sometimes is very intimidating, especially post retirement, when a person feels isolated after death of spouse or close friends of the same age-group. The fear of death aggravates the death-anxiety. The bodily processes like respiration, digestion, circulation etc grow weak as we age and even minor ailments like fever may trigger a fear of death.
Depression is very common in the geriatric population. It is very important for the family to identify the early warning signs of geriatric symptoms which are :
- Neglecting self-care, hygiene & clothing
- Feeling of anxiety
- Feeling of guilt
- Feeling of worthlessness
- Loss of interest in life
- Loss of interest in enjoyable activities
- Loss of confidence & motivation
- Loss in recent memory- Forgetfulness, misplacing objects or items
- Apathy- Loss of emotional expressiveness
- Excessive Lethargy- Sleeping in the day
- Increased usage of alcohol, tobacco or prescription drugs
- Problem falling asleep- Insomnia
- Restlessness
- Perpetual Sadness
- Change in appetite- Less or even more than usual diet
- Social Isolation & withdrawal- Avoiding people
- Fixation on death – suicidal thoughts
NEUROBIOLOGY OF GERIATRIC DEPRESSION
The causes of depression in old age can be various- health & related, retirement, loss of spouse and friends of same age, isolation, certain health conditions including dementia.
| Symptoms of Depression | Symptoms of Dementia |
| Mental decline is relatively rapid | Mental decline happens slowly |
| Know the correct time, date, and where you are | Be confused and disoriented; become lost in familiar locations |
| Difficulty concentrating | Difficulty with short-term memory |
| Language and motor skills are slow, but normal | Writing, speaking, and motor skills are impaired |
As per the medical research, the decline of neurotransmitters- dopamine, serotonin and norepinephrine cause depression in old-age. The genetics, socio-economic conditions, family environment and history of substance abuse play a significant role in the causation of depression in the elderly.
MANAGING GERIATRIC DEPRESSION, ANXIETY & SUICIDAL THOUGHTS
It is very important to identify the early warning signs of depression and death anxiety in the elderly at the community level. Our social system is such that post-retirement most of the people suffer from a feeling of worthlessness. Chronic medical conditions, stoke and substance abuse further aggravate the depression and anxious affect. A lot of suicides occur in the geriatric population and most of them are not reported. Depression and inability to cope up with stress happens to be the chief cause of suicides in India. Medication, psychological support & counselling, and reintegration to society post retirement is the need of the hour.
Elders sometimes take multiple medications and this puts them at a high risk. Side-effects of certain medications may cause depression in the elderly and the same should be reported to the physician so that the same can be addressed at an early stage.
Secondly, tobacco consumption along with alcohol and substance abuse(ganja, bhaang, opium etc) is significantly high in rural India. Old-age is marked by mild cognitive decline which gets aggravated due to the substance abuse. We must lead a active healthy life and exercise moderately to keep fit in old age. If we pursue a new hobby then it relieves the stress as well as new cells in the brain get generated. Diet, proper nutrition, proper sleep wake cycle along with exercise are a must for having good physical and mental health. People living on the hills and cold area often suffer from mood disorders like Seasonal Affective Disorder(SAD). Spending time in the sunlight boosts serotonin levels which improves our mood and increases our resilience to fight with depression which is caused by seasonal affective disorder(SAD).
According to Wg.CdrH.S.Riar, 79 year old retired air force fighter pilot, one must avoid alcohol and tobacco abuse right from young age to keep cognition intact during the advanced years of age. Both alcohol and tobacco cause damage to the brain cells thus impairing the brain function across all cognitive domains- attention, concentration, memory as well as mood.
According to Dr.S.K.Varshney (74 year old retired professor of Law, University of Lucknow, who authored more than 250 books in last two decades after the sad demise of her husband in the year2000)-“Life is music and dance. There is birth after birth, death does not exist. Life revolves on an axis of a pendulum from love towards law. We have to do our duty and be truthful to our partner. Guilt and not being grateful for all the achievements in life are the two biggest cause of depression in old- age. One must learn to keep fit and shun all evil to fight decay, disease, disaster and pre-mature death in old age. Health and happiness is the pivot of life on which we move. We should move steadfast to lead a happy and healthy life. Love, care & compassion is the source of all happiness in life therefore one must learn to love all “jeeva” and with that emotion one can save the life on the planet earth. Make earnest efforts, to get rid of negative thoughts which push you towards suicidal thoughts. Win over your weaknesses which make you a pessimist. With age one has to be more mature and wise enough to feel panic on trivial matters. Let your children take the initiative in most of the family matters as you have played your innings. The less you interfere in the family matters, the more you will be comfortable in your dealings. We stop looking ahead and brood in the past. One must find new opportunities and create new avenues related to your work and involve your family members and friends. This will prove your worth in the eyes of other people around.”
Early identification of geriatric depression results in better management of the disorder and lesser incidence of suicide in the elderly. Seek help today.
Devendra Singh,
Psychotherapist