Nursing Management for Depression in Older Adults
Depression in Older Adults
Depression is the most common mental disorder among older adults in the United States and one of the most disabling conditions among elderly persons worldwide (Sable, Dunn, & Zisook , 2002). More than 6 million Americans age 65 and older representing approximately 15% of US older adults suffer from depression (Sable et al., 2002).
The prevalence of clinical depression ranges from about 5% in community samples to 20% in nursing home residents and nearly 30% of older adults seen in primary care settings (Alexopoulos, 2001).
About 50% of older adults who are hospitalized for medical illnesses or receiving long-term care experience clinically significant depression ( Alexopoulos ). Older adults are vulnerable to depression for a number of reasons. Approximately 80% have at least one chronic medical condition that can trigger depression (Sable et al.).
In addition, about 6 million older adults need assistance with their daily
activities (Sable et al.), and inability to meet one's own personal needs has
been associated with increased vulnerability to late-life depression.
Depression As Clinical Syndrome
While depression is often viewed as a clinical syndrome with specific diagnostic criteria, depression has also been conceptualized as a mood state or as a collection of symptoms (Beck, 1997).
Because older adults may not meet the diagnostic criteria for the clinical syndrome, studies of older adults commonly use the term depression to mean depressive symptoms (Futterman, Thompson, Gallagher-Thompson, & Ferris, 1995).
Clinical depression is usually qualified by an adjective to specify a particular type or form, including reactive, agitated, and psychotic. In addition, based on etiology, depression is classified as endogenous (due to internal processes) or exogenous (due to external factors).
Depression is termed primary when it is not preceded by any physical or psychiatric condition and secondary when preceded by another physical or psychiatric disorder. Finally, depression is classified as acute (less than 2 years: duration) or chronic (more than 2 years).
Depression Under DSM IV
Clinical depression consists of characteristic signs and symptoms, as well as type of onset, course, duration, and outcome. The Diagnostic and Statistical Manual of Mental Disorders (DSM IV) (American Psychiatric Association, 1994) classifies clinical depression into major, minor, and dysthymic subtypes.
Major depression refers to a depression that meets specific diagnostic criteria for duration, impairment of functioning, and the presence of a cluster of physiological and psychological symptoms (American Psychiatric Association).
Minor depression
includes fewer depressive symptoms than major depression. Dysthymia consists of
fewer symptoms than are expressed in major depression but more than in minor
depression, and it is more chronic (American Psychiatric Association).
Depression In Older Adults
Diagnosing depression in older adults is fraught with challenges. Depressed mood is one of the depressive symptoms that older adults may experience, but others may also experience a range of affective responses (Futterman et al., 1995).
Indeed, many studies have reported that in older adults, a predominant depressed mood may not be as prominent as symptoms of irritability, anxiety, or physical or somatic symptoms and changes in functioning (Alexopoulos, 2001; Futterman et al.; Sable et al. al., 2002).
In addition, symptoms of cognitive impairment that may occur in elders with depression may be mistaken for dementia (Sable et al.).
It is estimated that about 15% of older adults have depressive symptoms that do not meet diagnostic criteria specified by the Diagnostic and Statistical Manual of Mental Disorders (DSM IV) (American Psychiatric Association, 1994) for diagnosis of major depression (Alexopoulos), Regardless These older adults can experience functional deficits in activities of daily living (ADL) and instrumental activities of daily living (ADL) that compromise their independence and quality of life.
Indeed, the symptoms of depression can
lead to total inability of the older individual to care for themselves and to
relate to others. There is also a potential for people with depression to
negatively affect family members and others around them.
Community Seeking Mental Health Services
Not surprisingly, few elders in the community seek mental health services. Most depressed elders are seen by general practitioners for psychosomatic complaints. Part of the symptomatology of depression is a focus on physical problems, and this requires practitioners to carefully assess for depressive symptoms.
Suicide is a risk factor for depressed older adults. The suicide rate
for individuals aged 80 and over is twice that of the general population and is
particularly high in older White males. Interestingly, most suicidal elders
recently visited a general practitioner prior to their suicidal act.
Risk Factors Related To Depression
Studies of risk factors for late-life depression have examined the effects of gender, age, and race/ethnicity. Like earlier depression, late-life depression more commonly strikes women than men, at approximately a 2:1 ratio ( Kockler & Heun , 2002).
Recent population based studies have estimated the prevalence of geriatric depression at 4.4% for women and 2.7% for men, while the estimated lifetime prevalence for clinical depression is about 20% in women and 10% in men ( Kockler & Heun ; Sable et al . ., 2002).
Although female gender is a
risk factor for depression throughout the life span, gender differences
decrease with increasing age (Sable et al.), and white men ages 80 to 84 years
are at greatest risk for suicide ( Kockler & Heun ).
Cohort Studies on Mental Disorders
Cohort studies have shown that the oldest old, those over age 85 years, are more likely than the youngerld, those between 65 and 74, to experience depressive symptoms (Blazer, 2003).
Depression is thought to afflict older adults of all
racial and ethnic backgrounds similarly (Alexopoulos, 2001; Bruce, 2002);
however, its symptoms may not be consistent across racial/ethnic groups, making
early diagnosis and challenging treatment.
Elder Adult Depression And Nursing Research
Research on depression among older adults was ignored in the past and is still a neglected area. Clearly, much more nursing research is needed. It is critical that nurses assume leadership in disseminating information about the outcomes of a variety of treatments that can be used for depression in later life.
There
is a particular need to examine suicide in late life and to develop better
assessment instruments for detecting suicidal ideation in elders.
Give your opinion if have any.