SINGAPORE: Linda Loh remembers a time when her 85-year-old mother used to be a “very nice person”.
As the tantrums began, at first the family put this down to Mdm Lee Sui Yee’s old age – but then, nothing seemed acceptable to her. “I’d talk to her, but she’d say that I never listen to her,” said her daughter.
“I’d try to cool myself down … just walk into the kitchen and stay away from her. But she’d also scold me for not staying and talking to her.”
An irritable Mdm Lee would especially be worked up about noise, such as a child crying or anybody talking loudly.
When she had a fall and was admitted to hospital in July 2016, the family found out the truth.
After she shouted at the nurses, struggled with them and, at one stage, talked about committing suicide – which she nearly did by trying to strangle herself – she was diagnosed with an episode of Major Depressive Disorder.
And her recovery has been slow. She would rather lie around at home, quietly and listlessly, than move about to improve her mood and blood circulation.
“Last time, she liked to listen to music – her operas. Now she never even asks me to turn on the TV for her,” sighed her daughter.
One in five elderly persons in Singapore aged 75 and above show signs of depression, according to the Singapore Longitudinal Ageing Study in 2012 by the National University of Singapore’s Yong Loo Lin School of Medicine.
And depression among the elderly has its own set of challenges, as seen in the documentary Facing Depression.
WATCH: One family's struggle (5:23)
In cases like Mdm Lee’s, depressive mood swings are related to other health issues, like limited mobility and senile dementia, as well as loneliness and financial anxiety.
FROM PSYCHOLOGICAL TO PHYSICAL
Among the elderly with dementia, it is “very common” for depressive features to be present, said Dr Chris Tsoi, a consultant at the National University Hospital’s Department of Psychological Medicine. “The other way round is also true,” he added.
“All the brain functions are somewhat linked … Emotion will affect memory; memory itself will affect emotion. So when the memory function isn’t that good or tends to remember sad things, (the elderly) tend to be sadder.”
Mdm Lee was diagnosed with dementia in 2016, before her depressive episode. Previously she was “quite independent”, but that changed after she had a stroke and subsequent loss of mobility, said her daughter.
After she was discharged from hospital following her fall, she stayed with granddaughter Brenda Loh. But she got more confused, and even wanted to chase Ms Loh out of her own home.
With a change in environment, a patient like Mdm Lee would not have the “usual cues” needed to keep her brain “functioning normally”, Dr Tsoi explained. “The degeneration would be much faster, and the depression can hardly be treated.”
There can be a physical impact too. Said Dr Tsoi:
We have sufficient data to show that depression also could lead to heart disease and other physical problems, even stroke.
In the case of 70-year-old Stanley Seah, depression was diagnosed after he discovered that he had multiple medical conditions, namely high blood pressure, high cholesterol and diabetes.
But that was only the start: His depression worsened when his wife was diagnosed with a terminal illness.
FROM LOSS TO LONELINESS
The first sign of her failing health was jaundice. It turned out to be a symptom of pancreatic cancer, which eventually spread to her stomach and lungs. Soon after, she required hospice care.
Dover Park Hospice senior medical social worker Sally Gui, who worked with the couple, recalled that Mr Seah looked “quite down most of the time because of the wife’s condition”.
His already vulnerable mind was in a state of confusion. “I couldn’t concentrate on anything,” he shared. “Sometimes it was very hard to fall asleep. I kept rolling in bed until two or three o’clock before I could sleep.”
His wife of 30 years died last July. And he could not stop thinking of her.
I once cried for three days. The pain feels like a knife poking my heart. It hurts a lot.
Dr Tsoi said such a loss is “the most devastating” for elderly patients who had been married for a long time.
He added: “For them, it would be much more stressful than for a younger age group to adapt, both emotionally and socially.”
The NUS’ Singapore Longitudinal Ageing Study in 2004 found that widowed or divorced persons above 65 were more likely to experience depression (22 per cent) than widowed or divorced persons between the ages of 55 and 65 (13 per cent).
This series of studies also found that seniors living alone were twice as likely as their peers to develop depressive symptoms.
And their numbers are rising: The Department of Statistics estimates that 83,000 elderly persons will be living alone by 2030, compared with the 47,000 seniors aged 65 and above in 2016.
Mr Seah, who has no children, is now one of them. Mdm Lee, too, was living alone before she fell ill, since her husband died 14 years ago. Initially, however, she could count on her large family.
“At that time, I had another aunty, also about the same age as her,” said Mdm Loh, one of six children. “They’d go to find good food and go shopping together. After my aunty passed away, she felt lonelier.”
With the rest of the family having their own commitments, “they didn’t have much time for her”, admitted Mdm Loh. “She’d feel sad, but she never spoke out.”
TIP OF THE ICEBERG
As loneliness and physical illness gnawed away at Mdm Lee, her depression was compounded by worry that her hospital and medical bills would be a burden on her children.
Her daughter thinks this became the main issue. "She was full of fears. She felt that she was so helpless and hopeless."
Concern for a family member is weighing on Mr Seah too, even as he tries to get over his wife’s death. His sister is mentally unstable and also lives alone. He calls her daily to check on her.
Whenever I call her, she’d say the words ‘I want to commit suicide’. That makes me worried.
The warning signs of suicide in the depressed elderly include unrelenting low mood; anxiety and psychic pain; loss of interest; and sleep problems, among others.
Mr Seah himself was referred to community counsellors when Dover Park Hospice predicted that there might be “some difficult bereavement issues”, said Ms Gui. It hoped to prevent a difficult situation from arising after his wife’s death.
As the widower put it – and others could see – the couple were “very close”. It still shows, from the way he dusts their photo frames lovingly and from the tears that flow when he looks at their photo albums.
“When she was sick, I looked after her. When I was sick, she looked after me. But I did the cooking because her legs were weak,” said Mr Seah, who spent the final two months with her in the hospice.
Recalling her last days, he said forlornly:
I stayed (by her side) four days and four nights. She didn’t pass away. I went out for two hours. She passed away. I was heartbroken.
While he has been getting the help he needs, that may not be so for the majority of depressed seniors.
In the Yong Loo Lin School of Medicine’s Community-based Early Psychiatric Intervention Strategy (2008), about 12 per cent of seniors who had depressive symptoms sought professional help, while 75 per cent did not see themselves as having a mental disorder.
Dr Tsoi is now seeing more cases of depressed seniors, roughly an increase of 5 per cent a year. But he believes this is still an underestimation.
“The reason is depression is such a taboo (subject) in the population,” he said. “Despite the increase, what we’re seeing now is just the tip of the iceberg.”
(Read the commentary: Let's talk about depression)
ALL HAVE VITAL ROLES TO PLAY
The consequences of depression are felt not only by the elderly but also their loved ones – for example 61-year-old Mdm Loh, who quit her job as a kitchen assistant in 2016 to be her mother’s main carer.
She felt “so helpless” in the beginning. “I didn’t even know how to comfort her,” she said. “My heart was aching.”
And then there is her mother’s full schedule of check-ups. “She doesn’t like to wait in the clinic for too long. It’s quite stressful for me, but I don’t really show it,” Mdm Loh said. “I just take it easy.”
When she could not cope, however, the family had to engage a domestic helper. But things did not get easier, as her mother was unhappy with the help.
“Everything the maid did … wasn’t up to her standard,” Mdm Loh explained, citing her mother’s expectations for cooking in particular. “I had to juggle my mum and the maid. It was so tiring for me.”
But she knows she must be positive and try her best. As Dr Tsoi noted, her role is vital to her mother getting back to her usual self.
“If the caregiver can’t tolerate the stress of going through difficulty, most likely the patient will end up in an old folks’ home,” he said.
To help these families, the NUH has the Geriatric Psychiatry Out-Reach Assessment, Consultation and Enablement (G-Race) programme, which provides home visit services for elderly patients with mobility issues.
An occupational therapist checks on Mdm Lee once every quarter – her mood, cognition and functional abilities – and engages her in various activities, such as flipping through a pack of cards showing various pictures.
“We’d like an activity that lets someone like Mdm Lee use her hands and coordination, but at the same time be happy that she has done something. And the mood will improve,” said principal occupational therapist Eng Jia Yen.
Mr Seah’s counsellor Berlinda Tan from Sage Counselling Centre also visits him in his three-room flat, once every three weeks.
“We believe that everyone has strengths, and so does Stanley,” she said. “When we affirm the strengths he has, it’ll change the way he perceives himself.”
Dr Tsoi noted that depression in old age is not inevitable, precisely because “it’s very much down to how a person perceives things – how their own experience can help them”.
Besides professional intervention, what he recommends to his elderly patients is to “engage with friends, go out more and talk to people more”.
All these help them to develop a lifestyle that’s against depression and memory loss.
At senior care centres, for example, with people available to help the elderly, there is “social pressure” to follow the activities, which they would not otherwise do at home.
NOT GIVING UP
But the first step is always the hardest. It took much persuading by Mr Seah’s counsellor before he agreed to join in the activities at one centre. Other agencies also proposed some activities, but he was not keen.
Even when his wife was alive, he saw himself as “somewhat like a lone ranger”. But Ms Tan would remind him that “there are always people around him who care for him, and community resources if he needs any help”.
Her efforts have paid off: After grieving alone for five months, he became more active, taking a liking especially to Carrom.
“It relieves some tension. I have to concentrate to shoot and all that,” said Mr Seah, who feels more happiness and “freedom” when he goes out nowadays.
He must stay on antidepressants, which help him to sleep. And he still does one other thing: Visit Dover Park Hospice. When he sees room 112, it reminds him of his wife. “It somewhat keeps her memory alive,” he said.
Knowing that grief manifests itself differently over time, Ms Gui said hopefully: “When he can cope with his grief and is feeling better, I suppose he won’t come back to this place so often.”
Mdm Lee, too, has made progress in the course of treatment. Ms Loh, one of her 16 grandchildren, observed: “She’s now calmer, and her mood is slightly better. She doesn’t throw her tantrums or scold people anyhow.”
She has also got used to the maid, recognising the value of her help in moving around. Mdm Lee herself may not speak much, but what she does say is indicative of her improvement.
“I’m too old to think too much. I don’t have to worry about money, so long as there’s a meal for another day,” she said in Cantonese to Dr Tsoi during one of her check-ups.
With her family’s constant encouragement, she is willing to be brought in her wheelchair to the neighbourhood park more often. And she can laugh at photos of her younger self.
Back in the day, she was a kitchen helper in a restaurant, and her daughter recalls how she worked hard for the family, “from morning till night”.
Etched in Mdm Loh’s memory is the difficult period in 1992 when her eldest daughter had leukaemia, and her mother took care of her family.
“She was so worried about me then. She helped to do the cooking, everything, for me, especially as my kids were quite young at that time,” Mdm Loh said gratefully.
“I never think of giving up on her, because I don’t want her to put up in an old folks’ home or nursing home. It’s my duty as a daughter, and also a way to repay her kindness.”
And she remembers the promise the family made to their father before he died: That they would “always take good care of mother”. She said: “I hope that my mum will stay healthy, to live a bit longer and happier.”
Watch this episode of Facing Depression here. The four-part series addresses misconceptions about how depression affects working adults, women, children and the elderly. Read about the demons and stigma working adults must battle.
Where to find help:
Institute of Mental Health’s Helpline: 6389 2222
Samaritans of Singapore Hotline: 1800 221 4444
Singapore Association of Mental Health Helpline: 1800 283 7019