I. Introduction. One of the most interesting aspects of aging is that everyone knows what the word means, and yet when you get around to determining a common definition, it becomes clear that there is little agreement on just what 'aging'. Is it simply the passage of time? A usage of finite resources? An accumulation of no more than physical cell debris? A paradigm of agreed upon social perceptions? No one knows for sure, or at least no one has repeated proven one of the above definitions - much less any of the many others not cited - to be valid in the scientific sense (that is, results that are reproduced by detached experimenters).

In current times, with occurrences which would have been simply impossible just a few years ago such as post-menopausal women bearing children, the notions of what is generally accepted to be representational of aging and of those who are aged themselves are undergoing dramatic shifts in meaning, and particularly so in a swing away from the historical negative view of the older years as times of diminishment and / or deterioration, or at best detached wisdom.

Most seniors in the United States do not experience depression, but many do. Of those seniors with depression, many commit suicide - - Lebowitz (1996) reported that more than two-thirds of suicides by seniors in the United States occurs in the presence of depression. Given that the suicide rate among seniors in the United States is twice that of any other age group (Blazer, Bachar, & Manton, 1992), and is generally stated to be under-reported as well (Saxon and Etten, 1994), depression among seniors is an area that warrants attention from clinical psychologists.

This section focuses on depression among seniors in the United States with a concluding emphasis on distinguishing between depression and dementia among seniors. Distinguishing between senior depression and dementia is not generally an easy task given that , as Oxman (1993) pointed out, major depression is usually associated with some cognitive impairment, and dementia is often associated with depressive symptoms.

The aged population
The numbers and percentages of older individuals in the United States has increased dramatically in this century. Four percent of the population was age sixty-five / + in 1900, 7% (9 million) in 1940, and 12.3% (29.8 million) in 1990. Projections are that both the numbers and percentages of older adults will more than double during the first quarter of the new century. Life expectancy has also increased: 47.3 years in 1900 to 75.0 years in 1987 (Cockerham, 1991). Population aging is not unique to the United States, and indeed is a world-wide phenomena, both in terms of numbers and percentages of older adults with respect to their total populations. Unique to the United States among Western countries, however, is that the suicide rate among the older ages has increased (Cockerham, 1991) in the United States at the same time it is decreasing within other Western countries.

Depression in the Older Ages
Although there is some evidence that faster metabolizing of amine neurotransmitters from age-related increases in monoamine oxidase (MAO) levels produces a relative neurotransmitter depletion, and thus creates a greater risk for depression in the older ages (Robinson et al, 1971), depression itself is not a normative component of chronological aging. It is, however, a dysfunction that occurs often in late life that is commonly under-diagnosed and under-treated. Blazer and Hughes (1987) suggested that 15% of non-institutionalized seniors experience significant depressive symptoms, while Samuels & Katz (1995) indicated that 25% of those in nursing homes have depressive symptoms. The majority of patients with major depression suffer from repeat episodes that increase in severity and decrease in responsiveness to medication ( Greden, 1993; Piccinelli & Wilkinson, 1994).

Causal Factors of depression in the older ages
Genetic predisposition. Older adults who have had only vague histories of mild depression are 1.5 to 3 times more vulnerable to depression if there is diagnosed clinical depression among their first-degree relations (Andreasen, Rice, & Endicott, 1987; Gershon et al., 1987).

Stress plays a major role in the patient's first two episodes of major depression (Kendler, Kesssler, Neale, Heath, & Eaves, 1993). Traumatic experiences, genetic factors, temperament, and interpersonal relations are potential impacts on stress and the development of depression (Ezquiaga, Aquso Gutierrrez, & Garcia Lopez, 1987 .

Organic causes of depression in older adults include: post stroke, head trauma, and medication side-affects, among others (Greenberg & Brown 1985). Given that seniors often have a high level of pharmacological intake, attention is warranted to the potential for depression attributable to medication side-effects.

Substance abuse that results from failure to adjust alcohol intake to match the age-related decreases in metabolizing the depressive affects of alcohol on the Central Nervous System (Miller, 1991) is a casual agent in depression among seniors that is often overlooked.

Unresolved grief - whether for the loss of a loved one, or for more symbolic losses such as health, appearance, financial stability, job prestige, and / or cognitive function - is often a precursor to depression (Zisook & Schucter, 1991). Unresolved grief can result in social isolation, diminished physical status, increased substance abuse, and may lead to increased suicidal ideation.

Medical illness is common with depression in the older ages to the extent that an increase in medical problems is a risk factor for depression (Miller, Paradis, et al., 1996; Lyness et al., 1993). Chronic pain can contribute to depression, and depression can make chronic pain more intense (Williamson & Schulz, 1992; Parmelee, Katz, & Lawton, 1991). Several studies have indicated, however, that seniors function better overall when their depressive symptoms are attended to even in the presence of continued medical dysfunctions (Borson et al, 1992; Miller, Schutz, et al., 1996).

Pseudodementia ('reverse" dementia) in the older ages is almost always comorbid with depression, and may be an indication that dementia will onset several years after depression has been resolved, and attendant cognitive deficits have vanished (Alexopoulos et al, 1993). Thus seniors who present with diagnosable dementia that has no corresponding neurological basis, is comorbid with depression, and whose cognitive impairments reverse themselves subsequent to lifting of depression should be carefully evaluated for risk of dementia.

Sometimes depression appears for the first time in older ages for those in the early stages of dementia, perhaps as a psychological reaction to impending cognitive decline (Jenike, 1994), or perhaps as the result of a disruption of the neuronal system that maintains moods. Zubenko and Moosey (1988) reported that depressed Alzheimer's Disease patients had more plaques and tangles in the locus ceruleus region of the brain at autopsy than non-depressed AD patients. People with Parkinson's Disease and Huntington's Disease, also seen to have increased risk for depression as a result of subcortical degenerative processes (Cassem, 1987).

Clinical presentation
Depression in the older ages is not the same as with other age groups. Seniors are less likely to report that they are depressed, and more likely to convey cognition and somatic concerns. According to the DSM-IV(APA, 1994), the most notable difference between depression in the older ages contrasted to the younger ages is the high prevalence of somatic complaints, particularly with regard to increased arthritic, abdominal, and / headaches. Older adults are often alexithymic (not in tune with their feelings), and thus are less likely to report 'being depressed'; they generally do, however, show complete remission of symptoms when their depression is attended to (Nemiah & Sifneos, 1970).

Anxiety symptoms and irritability are also common with older adults who are depressed, and often present themselves through pacing and / or hand-wringing, as well as obsessing on various issues such as finances, perceived potential health statuses, and / or fears of dying (Alexopoulos et al., 1995). Fear of cognitive decline is a particular source of anxiety in seniors who are bombarded with media attention to the commonality of Alzheimer's Disease among seniors to the extent that many seniors think that serious cognitive decline is inevitable with chronological aging - but it is not.

Treatments
Medication, psychotherapy, and electroconvulsive shock treatment are the primary modes of treating depression in the older years - perhaps alone, or in varying combinations with each other. The severity of depression symptoms, expertise of practitioner, specifics of current medication intake, and degree of suicidal ideation are the major determinants of a course of treatment for depression among seniors.

Medication. SSRIs (selective serotonin reuptake inhibitors) and MAOIs (monoamine oxidase inhibitors) are commonly prescribed for older adults (DeVane, 1994; Pollock, 1994; Schneider, 1996), however these medications lose their efficacy relatively quickly, with 25% to 44% reoccurrence of depressive symptoms within six months of initial remission . McGrath, Quitkin, & Klein (1995) suggested that the relapse during SSRI maintenance may arise from the SSRI-induced depletion of dopamine in the striatum and limbic forebrain, which indicates that the down -regulation of CNS serotonin receptors results from serotonin saturation (Goldberg, Kocis, & Sacks, 1995), and thus potentially increases the level of depression. When SSRI's are not warranted, tricycle antidepressants (TCA's) are commonly prescribed for seniors (Schneider, 1996).

With regard to psychotherapy, interpersonal therapy (ITP) have been shown to be of benefit by itself when dealing with the less severe forms of depression in seniors (Weissman & Markowitz, 1994); others forms of psychotherapy, specifically psychoanalysis and / or cognitive therapy, have not yet been tested in a scientific manner with respect to their benefits in treating depression among seniors (Svartberg & Stiles, 1991; Hollon, Shelton, & Davis, 1993). The 1989 National Institute of Mental Health (NIHM) study compared the success rates of psychotherapy vs. antidepressant drug therapy in the treatment of major depression, and indicated that neither medications nor psychotherapy alone was sufficient to prevent relapses for severely depressed individuals (Elkin et al., 1989).

Electroconvulsive therapy (ECT) may be indicated when depression needs to be rapidly attended to in order to reduce imminent risk of suicide, although it should be noted that ECT in combination with lithium tends to cause delirium (el-Mallakh, 1988) without, however, causing long term memory loss ((Zorumski, Rubin, & Burke, 1988); Hay, 1991).

Distinguishing between depression and dementia in the senior ages.
Although the task of distinguishing between depression and dementia is not always one that is easy to complete, it is vital that the distinction be made for seniors are generally amenable to treatment for depression, and, as has been indicated previously in this paper, seniors generally have a better quality of life without depression - whether or not other medical conditions, including dementia, are comorbid. The following general guidelines are primarily based on material presented by Dr. Michael Dow (1994) in Psychopathology and Aging I, and reprinted with his permission.

Cognitive deficits cased from depression may develop fairly quickly. Dementia usually has a gradual onset unless it is associated with head trauma, some other insult, or a specific change in medical status such as a stroke. While it is true that stoke, head trauma, MI, or other physical conditions can also lead to depression, it seems most likely that cognitive deficits that occur soon after these events are reflective of dementia.

Cognitive deficits cased from depression typically show some improvement when the depression lifts. This is true whether the depression improves from the passage of time or from the effects of medication or therapy.

Depressed persons are almost always aware of cognitive deficits , and many people tend to admit them. Some people with dementia may deny or be unaware of their cognitive deficits.

The presence of depression does not rule out dementia. It is very possible to have both. The lack of depression makes the dementia diagnosis more likely in a person who does have cognitive deficits. However, it is important to remember that depression means different things to different people. It isn't enough just to ask "Are you depressed?"

Cognitive performance has greater variability with depressed persons : performance may range from deficient to adequate on the same task at different time periods.

Cognitive performance is less variable with neurological impairment : usually or always impaired.

If the level of cognitive impairment is greater than the level of depression, this implies a neurological basis for at least some of the impairment. Severe depression can cause severe performance decrements, but mild depression should not cause severe performance decrements.

Focused deficits may be more likely due to neurological conditions. Depression seems to affect the somewhat general processes of attention, concentration, and memory the most. If an individual had a noticeable specific deficiency in word finding (anomia), for example, and this deficiency was more pronounced than deficiencies in concentration, attention, and memory, it would be more likely that this was a neurologically based deficiency. Agnosia and apraxia are two other examples that tend to indicate neurological deficits if these difficulties are greater than apparent difficulty with attention, concentration, and memory. It should be pointed out that while focused deficits may suggest neurological causation, this does not mean that general difficulties imply a psychological condition. Wide-spectrum neuropsychological difficulties could be due to depression or they could be due to dementia.

Depressed persons tend to show decrements on timed tasks, more than on untimed tasks. This may or may not be true for dementia. Thus, this is a soft indicator.

Worry, cognitive rumination, and anxiety may function to bring on many of the cognitive deficits among depressed persons, by interfering with attention and concentration. Thus the level of worry and anxiety that a person experiences may be a (soft) indicator of whether depression or dementia is operative. Said another way: depressed persons without much worry / rumination / anxiety are less likely to show state-dependent cognitive deficits than are depressed persons who do have significant worry / rumination / anxiety. This implies, but does not prove, that a depressed older person without much worry / rumination / anxiety who seems to have cognitive deficits should be evaluated more thoroughly for dementia.

Conclusion
Depression among seniors is not normatively positively correlated with chronological aging, but it does occur all too often. The escalated rate of suicides among seniors in the United States represents a call-to-arms in treating depression among seniors, given the high comorbidity of depression and reported suicides among seniors in the United States. There currently is an extensive among of published research in this area, but significant disagreement exist in almost all statistics cited, with the exception that suicide among seniors is most likely drastically under-reported. Depression, for the most part, is readily treatable at all ages, and seniors are particularly positively receptive to having their depression treated, even when they are not well versed in the terminology and expectations of treatments. Hopefully, as further attention is paid to depression in the older ages, the rate of suicide among seniors will decrease, and quality of life in the older ages for today's seniors - - and tomorrow's seniors, as well - - will increase.

IV. Cognition

V. Family

VI. Social

VII. Work

VIII. Retirement

IX. Summary

X. References.

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