A Change of Perception

Jack and Gretchen Pennybacker

Jack and Gretchen Pennybacker found relief and treatment for Jack’s depression at the Fuqua Center for Late-Life Depression.

by Sylvia Wrobel

Depression hits the elderly often—one in four people over 65—and it hits them especially hard. Many times, they don’t realize what’s wrong.

Affected people, their families, caregivers, even health professionals, may wrongly attribute symptoms of depression to memory problems or to aging itself.

Emory’s Fuqua Center for Late-Life Depression is on a mission to change the perception that depression is a normal part of aging. It’s not. The center helps older patients with depression get the diagnosis and treatment that can vastly improve quality of life and independence.

Jack Pennybacker experienced intermittent bad moods throughout his life, but in his mid-60s, these moods suddenly turned black. His general practitioner prescribed a popular antidepressant.

A year later, Gretchen Pennybacker noticed signs that her once brilliant husband’s memory was slipping. A popular Loyola University mass communications professor, Jack retired, thinking it would help. It didn’t. These were supposed to be the golden years. They weren’t. Dealing with Jack’s worsening memory, irritability, and withdrawal, Gretchen sold their house in New Orleans and moved to Atlanta where family could help her with what clearly lay ahead.

The move to a townhouse in a strange city further disoriented Jack and required an exhausting vigilance of Gretchen. She didn’t know where to turn. When she described her predicament to the director of a nearby life-enrichment services program for older people, the director handed her the telephone number for Emory’s Fuqua Center for Late-life Depression. The center sent a bus to take Jack to Emory’s Wesley Woods campus, where a geriatric psychiatrist and gerontologist worked to understand his various medical conditions.

Like many seniors, Pennybacker had accumulated a personal pharmacy, including drugs for cholesterol, congestive heart failure, and cardiac arrhythmia. He was so overmedicated that he fell asleep during his exam. Medicines for depression and dementia were adjusted. Drugs with the most potential for side effects, beta-blockers and blood-thinners, were no longer needed once surgical ablation resolved his arrhythmia. A continuous positive air pressure face mask addressed previously undiagnosed sleep apnea, which his new doctors believed had caused him to be sleep deprived for years, possibly contributing to depression and memory loss. His wife no longer had to sleep in another room because of his restlessness.

For several weeks, Pennybacker also attended a daily support group, which the former professor referred to as his seminar. For the past five years, however, the Pennybackers have returned to the Fuqua Center only once every six months to see a psychiatric clinical nurse specialist.

Gretchen Pennybacker knows that Jack’s dementia cannot be fixed, only slowed. She increasingly serves as her 80-year-old husband’s memory; his beloved crossword puzzle books are increasingly made up of words he learned years ago, his amiable jokes not always quite on target. But even if Alzheimer’s is relentless, treating Jack’s depression has given the couple back years of a fuller, gentler life filled with grandchildren, restaurants, the symphony, and theater.

She has been given, she says, more time with the Jack she used to know.

Treating the common cold of psychiatry

Unfortunately, the Pennybackers’ story is not unusual. Because severe depression affects so many people—one in 10 Americans each year, of all ages, races, ethnicities, and socio-economic backgrounds—it is sometimes called the common cold of psychiatry. Common it may be, but the nickname doesn’t do justice to the pain suffered by patients and the bewilderment and hurt their withdrawal and irritability causes family and friends.

Risk rises with age and, markedly, with loss of function, hospitalization, or the need for health care services at home. Additional risks for late-onset depression (in which depression appears for the first time in old age) include widowhood, physical illness, an education level less than high school completion, and heavy alcohol consumption. Half of younger people who experience an episode of major depression never have a recurrence. However, in older people, the chance of relapse is 80%.

In the elderly, depression may exacerbate and interfere with treatment of diseases with which it commonly co-exists, including Alzheimer’s (about 30% of these patients are depressed), Parkinson’s (about 40% of these patients are depressed), stroke, heart disease, cancer, and hormonal disorders.

Depression may, in fact, be the first clue that these diseases exist. It decreases the likelihood of independent living and increases the likelihood of homelessness. It is a major factor in the disproportionate number of suicides in people over 65, most strikingly in white men in their 80s.

McDonald and Eve Byrd

McDonald and Eve Byrd

The good news, says McDonald—Fuqua Professor and chief of geriatric psychiatry at Emory—is that depression is treatable, with or without co-existing conditions. In fact, when a person has a combination of depression and Alzheimer’s or Parkinson’s, depression is the most treatable of those conditions. Appropriate treatment can take people who feel hopeless and give them back old interests and pleasures. For those who have withdrawn, it can re-engage them with family and friends. For patients with fading memory, lifting the fog of depression often can improve not only mood but also the ability to concentrate and function.

But, and this is what keeps McDonald up at night, to achieve these results, depression in the elderly must be treated adequately and it can be treated only if it is recognized.

Too often it isn’t. Depression in the elderly can look a lot different from the way it does in a college student, the mother of a newborn, or a 45-year-old man, all of whom are likely to be overcome by great sadness, to weep, to focus on feelings of worthlessness. Older persons with depression often say that they feel no sadness whatsoever. Instead, they demonstrate apathy; lack of interest, enjoyment, or motivation; withdrawal; in some instances a dementia that can verge on catatonia. These symptoms, especially when unaccompanied by sadness, may be wrongly assumed, even by clinicians and social services professionals, to be completely explained by other diseases, especially those involving memory and cognition, or to be a normal part of aging.

To further complicate things, some older people don’t have words to describe, or don’t like to admit, what they are experiencing. Or frequently, they think what they are experiencing is a normal part of aging. They may feel guilty or ashamed. Geriatric psychiatrists like McDonald are often in the strange position of having to persuade patients that they actually have a biologic disease for which effective treatments are available.

Reaching out to the community

For Evelyn Ramirez, the past six years have been the best. The 70 years before that, she says, were nothing but misery. As a young rural mail carrier in Thomaston, Georgia, she sobbed furiously between stops. Tranquilizers local clinicians offered didn’t do much. The first time she tasted alcohol, however, that sweet moment of relief, she knew she was on her way to full-blown alcoholism. She blames depression for the failure of her three marriages and for her previous poor relationships with her children. She tried to kill herself. She grew up depressed, lived her entire life depressed, and expected to die depressed.

Six years ago, however, shortly after moving into a one-room apartment in one of the government-supported, high-rise senior-living towers in which the Fuqua Center provides outreach services, Ramirez attended a presentation on late-life depression by Emory psychiatric clinical nurse specialist Sherry Dey. Call us if you want to talk, Dey told the group. Within days, Dey and McDonald were sitting on Ramirez’s couch. Everything was about to change.

Today, always smiling, with friends and a renewed relationship with children and grandchildren, Ramirez has become an advocate for recognition and treatment of depression, talking to medical students and other groups about her experiences.

Fuqua Center staff members offer a full continuum of geriatric psychiatry services not only at the Wesley Woods campus but also throughout the community. They cover 21 residential facilities for older adults, half of which are low-income facilities. For some patients, like Ramirez, these services can be life-changing, even life-saving.

“We were founded to be a community outreach and education service aimed at improving community awareness about depression and improving access to services,” says Fuqua’s executive director and nurse practitioner Eve Byrd. She logs hundreds of hours and thousands of miles every month, developing and strengthening partnerships with organizations that serve older adults across Georgia.

Every year, Fuqua provides training for depression screening to more than 2,000 people. It conducts more than 100 educational programs annually, tailored for nurses, social workers, and other health care specialties. It also provides continuing education to primary care physicians, who care for the great majority of the elderly. Another way the center helps is by coordinating a large listing of community resources across Georgia and four surrounding states. This continually updated referral network (www.fuquacenter.org/ReferralNetwork) covers everything from psychiatric specialists and facilities to pastoral counselors.

Cathy Berger, director of the Atlanta Regional Commission’s Area Agency on Aging, says the difference the Fuqua Center has made for Georgia’s older citizens has been nothing short of astounding. Her own organization—which plans, coordinates, and implements programs to help keep people healthy, active, and in the community as long as possible—incorporated mental health as a major component of its work, mainly due to the Fuqua Center’s efforts.

“The Fuqua Center has been enormously important in the training of thousands of people who work with the elderly and in connecting hundreds of age-related services to mental health resources,” Berger says, “but their biggest impact may well be the way in which they have brought depression and mental health issues in the elderly to the forefront in Georgia.” EH


J.B. Fuqua

Where the center got its name

Raised by his grandparents on a small tobacco farm, J. B. Fuqua later wrote that he was “proof that any obstacle can be overcome if you are willing to educate yourself and work hard.”

His ticket off the farm was a homemade ham radio and Morse code learned from a mail-order leaflet. After a globe-hopping stint as a radio operator in the merchant marine, Fuqua worked as an engineer in a radio station, then convinced three investors in Augusta to fund his plan to build a radio station. It was the start of an extraordinary career in which he launched more than 40 companies and served in the Georgia State Legislature.

But he seldom spoke of his biggest obstacle: a lifelong struggle with severe depression. Treated with “everything that came along over the past 50 years,” he found electroconvulsive therapy to be “little short of a miracle.”

Fuqua recognized that depression in many older people went unrecognized and untreated because of poor access to geriatric psychiatry services and a lack of understanding about depression on the part of professionals and the general public. In 1999, to promote awareness of depression in the elderly and to suppress its stigma, he made a gift that established the Fuqua Center for Late-Life Depression and various Emory chairs and programs to improve mental health in the elderly.

If you would like more information about the Fuqua Center or to support its programs, contact Kat Carrico, senior associate vice president of development, at 404-727-2512, kat.carrico@emory.edu.


Adriana Hermida

A computer line away

Teresa experienced her first onset of psychiatric problems in her mid-70s.

Formerly cheerful and outgoing, Teresa (not her real name) lost interest in everything, stopped talking, and withdrew into herself. Puzzled by the sudden onset and remembering what he had learned about late-onset depression in presentations by the Fuqua Center, Teresa’s local doctor sent her to Emory geriatric psychiatrist Adriana Hermida (right).

By the time Teresa’s frantic family arrived at Hermida’s Atlanta clinic, hours away from their rural Georgia home, Teresa was the textbook picture of profound depression that looks like dementia (pseudo-dementia). Hermida had seen this before. After a careful examination, and with permission from the family, she treated the silent, unresponsive woman with electroconvulsive therapy. “It was like turning a switch back on,” says Hermida.

Although Teresa remembers nothing of her descent into severe depression and pseudo-dementia, her mood, personality, and ability to think and remember everything else is back to normal. She now comes to her local doctor’s office every six to eight weeks to talk to Hermida via telemedicine.

If doctors, hospitals, nursing homes, and other individuals and facilities want a consultation on a specific patient, it’s only a computer line away. The Fuqua Center was an early adopter of telemedicine, a service that allows patients in outlying areas to access psychiatric services locally.

In her geriatric clinic at Wesley Woods, Hermida and other providers see about five telemedicine patients a week. She moves easily from an exam room with a patient to another with a video monitor, doing the same things in each: assessing symptoms, history, and medications and sending reports back to each patient’s primary care provider. At the telemedicine sending site, a nurse who has received training from Fuqua staff conducts physical exams and helps with cognitive assessment (for example, having the patient draw a clock face, which the nurse holds up to the video camera).

It’s been two years now since Teresa’s diagnosis, and she is fine. That makes Hermida happy—but it also makes her wonder how many other Teresas are in nursing homes, their sudden late-life depression unrecognized or misdiagnosed as dementia.

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