Depression In Older Adults and Nursing Management

Afza.Malik GDA

Nursing Interventions for Depression in Older Adults

Depression In Older Adults and Nursing Management

Aging and depression types and level.Criteria of depression, health risk psychological symptoms,causes, screening and Nursing management...

Aging and Depression 

    Contrary to popular belief, depression is not a normal part of aging. Rather, depression is a medical disorder that causes suffering for patients and their families, interferes with a person's ability to function, exacerbates coexisting medical illnesses, and increases use of health services (Lebowitz, 1996 ) . 

    Despite the effective treatments available for late life depression, many older adults lack access to adequate resources; Barriers in the health care reimbursement system are particular challenges for low income and ethnic minority older adults (Charney et al., 2003). 

    In a comprehensive review of research on the prevalence of depression in later life, Hybels and Blazer (2003) found that although major depressive disorders are not prevalent in late life (1%-5%), the prevalence of clinically significant depressive symptoms is high. (3%-30%). 

    What is more, these depressive symptoms are associated with higher morbidity and mortality rates in older adults than in younger adults ( Bagulho , 2002; Lyness et al., 2007).

Level or Severity of Depression 

    The rates of depressive symptoms vary, depending on the population of older adults: community dwelling older adults (3% -26%), primary care (10%), hospitalized older adults (23%), and nursing home residents (16% -30%; Hybels & Blazer, 2003). 

    Certain subgroups have higher levels of depressive symptoms, particularly those with more severe or chronic disabling conditions, such as those older people in acute and long-term care settings. 

    Depression also frequently coexists with dementia, specifically Alzheimer's disease, with prevalence rates ranging from 22% to 54% ( Zubenko et al., 2003). 

    Cognitive impairment may be a secondary symptom of depression, or depression may be the result of dementia (Blazer, 2002, 2003). 

    It should also be noted that the prevalence of major depression has been increasing in those born more recently. so that it can be expected that the prevalence of depression in older adults will go up in the years to come.

Depression and Medical Illness

    Late life depression often occurs within a context of medical illnesses, disability, cognitive dysfunction, and psycho social adversity, frequently impeding timely recognition and treatment of depression, with subsequent unnecessary morbidity and death ( Bagulho , 2002: Lyness et al., 2007). 

    A substantial number of older patients encountered by nurses will have clinically relevant depressive symptoms. 

Nurses remain at the frontline in the early recognition of depression and the facilitation of older patients access to mental health care. 

    This chapter presents an overview of depression in older patients, with emphasis on age-related assessment considerations, clinical decision making, and nursing intervention strategies for older adults with depression. 

    A standard of practice protocol for use by nurses in practice settings is also presented.

What is Depression? and Depression along with Anxiety

    In the broadest sense, depression is defined as a syndrome comprised of a constellation of effective, cognitive, and somatic or physiological manifestation (National Institutes of Health (NIH) Consensus Development Panel, 1992). 

    Depression may range in severity from mild symptoms to more severe forms, both of which can persist over longer time with negative consequences for the older patient. 

    Suicidal idealization, psychotic features (especially delusional thinking), and excessive somatic concerns frequently accompany more severe depression (NIH Consensus Development Panel, 1992). 

    Symptoms of anxiety may also coexist with depression in many older adults (Cassidy, Lauderdale, & Sheikh, 2005; DeLuca et al., 2005). In fact, comorbid anxiety and depression have been associated with more severe symptoms, decreases in memory, poorer treatment outcomes (DeLuca et al., 2005; Lenze , et al., 2001), and increased rates of suicidal ideation (Sareen et al. , 2005).

Criteria of Major Depression

    The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV-TR) lists criteria for the diagnosis of major depressive disorder, the most severe form of depression. 

    These criteria are frequently used as the standard by which older patients' depressive symptoms are assessed in clinical settings (American Psychiatric Association [APA), 2000). 

    Five criteria from a list of nine must be present nearly every day during the same 2-week period and must represent a change from previous functioning: 

(a) depressed, sad, or irritable mood

(b) anhedonia or diminished pleasure in usually pleasant people or activities

(c) feelings of worthlessness, self-reproach, or excessive guilt

(d) difficulty with thinking or diminished concentration

(e) suicidal thinking or attempts

(I) fatigue and loss of energy

(g) changes in appetite and weight

(h) disturbed. sleep

(i) psycho motor agitation or retardation. 

    For this diagnosis, at least one of the five symptoms must include either depressed mood, by the patient's subjective account or observation of others, or markedly diminished pleasure in almost all people or activities. 

    Concurrent medical conditions are frequently present in older patients and should not preclude a diagnosis of depression; indeed, there is a high incidence of medical comorbidity,

    Major depression, as defined by the DSM-IV-TR, seems to be as common among older as younger cohorts. 

    A recent review found diagnostic thresholds (number and type of symptoms) to be consistent between older adults (age 60 and older) and middle-aged adults (age 40 and older; Anderson, Slade, Andrews, & Sachdev, 2009). 

    However, older adults may more readily report somatic or physical symptoms than depressed mood (Pfaff & Almeida, 2005). 

    The somatic or physical symptoms of depression, however, are often difficult to distinguish from somatic or physical symptoms associated with acute or chronic physical illness, especially in the hospitalized older patient, or the somatic symptoms that are part of common aging processes ( Kurlowicz , 1994). 

    For instance, disturbed sleep may be associated with chronic lung disease or congestive heart failure. Diminished energy or increased lethargy may be caused by an acute metabolic disturbance or drug response. 

    Therefore, a challenge for nurses in acute care hospitals. and other clinical settings is to not overlook or disturb somatic or physical complaints while also “looking beyond” such complaints to assess the full spectrum of depressive symptoms in older patients. 

    In older adults with acute medical illnesses, somatic symptoms that persist may indicate a more serious depression, despite treatment of the underlying medical illness or discontinuance of a depressant genic medication ( Kurlowicz , 1994). 

    Older patients may link their somatic or physical complaints to a depressed mood or anhedonia.

Depression Severity and Major Cognitive Disorders

    In older adults with significant cognitive impairment, symptoms may differ from those who are cognitively intact. 

    Depression may be expressed through repetitive verbalizations (eg, calling out for help) or agitated vocalizations ( eg , screaming, yelling, or shouting), repetitive questions, expressions of unrealistic fears (eg, fear of abandonment, being left alone), repetitive statements that something had will happen, repetitive health-related concerns, and verbal and/or physical aggression (Cohen-Mansfield. Werner, & Marx, 1990). 

    Based on the differences in presentation, Olin, Katz, Meyers, Schneider, and Lebowitz (2002) developed a set of provisional criteria (based on DSM-IV-TR) for the diagnosis of depression in Alzheimer's disease.

Minor Depression

    Depressive symptoms that do not meet standard criteria for a specific depressive disorder are highly prevalent (15%-25%) in older adults. 

    These symptoms are clinically significant and warrant treatment ( Bagulho , 2002; Lyness et al., 2007). 

    Such depressive symptoms have been variously referred to in the literature as “minor depression, “subsyndromal depression,” “dysthymic depression,” “subclinical depression,” “elevated depressive symptoms,” and “mild depression.” The DSM-IV-TR also lists criteria for the diagnosis of “minor depressive disorder” and includes episodes of at least 2 weeks of depressive symptoms but with less than the five criteria required for major depressive disorder. 

    Minor depression is two to four times as common as major depression in older adults and is associated with increased risk of subsequent major depression, greater use of health services, and has a negative impact on physical and social functioning and quality of life ( Bagulho , 2002 ; Gaynes , Burns, Tweed, & Erickson, 2002; Lyness et al., 2007).

Course of Depression

    Depression can occur for the first time in late life, or it can be part of a long standing effective or mood disorder with onset in carrier years. 

    Hospitalized older medical patients with depression are also more likely to have had a previous depression and experience higher rates of mortality than older patients without depression (von Ammon Cavanaugh, Furlanetto , Creech, & Powell, 2001). 

    As in younger people, the course of depression in older adults is characterized by exacerbation, remissions, and chronicity (NIH Consensus Development Panel, 1992); however, older adults appear to be at increased risk for relapse (Mitchell & Subramaniam, 2005). 

    Therefore, a wait-and-see approach with regard to treatment is not recommended.

Serious Depression in Late Life

    Depression is associated with serious negative consequences for older adults, especially for frail older patients, such as those recovering from a severe medical illness or those in nursing homes. 

    Consequences of depression include heightened pain and disability, delayed recovery from medical illness or surgery, worsening of medical symptoms, risk of physical illness, increased health care use, alcoholism, cognitive impairment, worsening social impairment, protein calorie subnutrition, loss of bone mineral density.

    Functional decline, and increased rates of suicide- and non-suicide-related death ( Bagulho , 2002; Hoogerduijn et al., 2007; Smalbrugge et al., 2006; von Ammon Cavanaugh et al., 2001; Wu Q, Magnus, Liu, Bencaz , &Hentz , 2009). 

    The “amplification” hypothesis proposed by Katz, Streim , and Parmelee (1994) stated that depression can “turn up the volume” on several aspects of physical, psychosocial, and behavioral functioning in older patients ultimately accelerating the course of medical illness. 

    For example, Gaynes et al. (2002) found that major depression and comorbid medical conditions interacted to adversely affect health-related quality of life in older adults, and Courtney, O'Reilly, Edwards, and Hassall (2009) identified depression as one of the factors most often associated with poorer quality of life for older adults in nursing homes. 

    For older nursing home residents, depression is also associated with poor adjustment to the nursing home, resistance to daily care, treatment refusal, inability to participate in activities, and further social isolation (Achterberg et al., 2003 ) .

Motility and Suicidal Attempts

    Mortality by suicide is higher among older persons with depression than among their counterparts without depression ( Juurlink , Herrmann, Szalai , Kopp, &Redelmeier . 2004). 

    Rates of suicide among older adults (15-20 per 100,000) are the highest of any age group and even exceed rates among adolescents ( McKeowen , Cuffe, & Schulz, 2006). 

    This is, in large part, caused by the fact that White men older than the age of 85 are at greatest risk for suicide, where rates of suicide are estimated to be 80-113 per 100,000 ( Erlangsen , Vach , &Jeune , 2005 ) . 

    In the oldest old (80 years and older), men and women had higher suicide rates than non-hospitalized older adults in the same age range, this age group had significantly higher rates of hospitalization than younger cohorts; three or more medical diagnoses were associated with increased suicide risk ( Erlangsen et al., 2005). 

    Among older psychiatric inpatients, increased risk for suicide was associated with affective disorders and first versus later admission ( Erlangsen , Zarit , Tu, & Conwell, 2006).

    Depressive symptoms, perception of lower health status, poor sleep quality, and absence of a confidant predicted late-life suicide (Turvey et al., 2002). 

    Whereas physical illness and functional impairment increase risk for suicide in older adults, it appears that this relationship is strengthened by comorbid depression (Conwell, Duberstein, & Caine, 2002). 

    Disruption of social support (Conwell et al., 2002), family conflict, and loneliness ( Waern , Rubenowitz . &Wilhelmson , 2003) are also significantly associated with suicide in late life. 

    Treatment of depression rapidly decreased suicidal ideation in older adults (Bruce et al., 2004; Szanto , Mulsant , Houck, Dew, & Reynolds, 2003). However, older adults in higher risk groups (male, older) needed a significantly longer response time to demonstrate a decrease in suicidal ideation ( Szanto et al., 2003).

    Studies have also shown that contact between suicidal older adults and their primary care provider is common ( Luoma , Martin, & Pearson, 2002). 

    Almost half of older suicide victims had seen their primary care provider within 1 month of committing suicide ( Luoma et al., 2002), whereas 20% had seen a mental health provider. 

    Most of the suicidal patients experienced their first episode of major depression, which was only moderately severe, yet the depressive symptoms went unrecognized and untreated. 

    Older adults with clinically significant depressive symptomatology presented with physical rather than psychological symptoms, including patients who, when asked, admitted having suicidal ideation (Pfaff & Almeida, 2005).

Risk for suicidal Attempts 

   Although the risk for suicide increases with advancing age (Hybels & Blazer, 2003), a growing body of evidence suggests that depression is also associated with higher rates of non-suicide mortality in older adults ( Kronish , Rieckmann , Schwartz, Schwartz , &Davidson , 2009; Schulz, Drayer , &Rollman , 2002); however, evidence is inclusive regarding depression as predictive of mortality in hospitalized older adults (Cole, 2007). 

    Depression can also influence decision-making capacity and may be the cause of indirect life-threatening behavior such as refusal of food, medications, or other treatments in older patients (McDade-Montez, Christensen, Cvengros, & Lawton, 2006; Stapleton , Nielsen , Engelberg , Patrick, & Curtis, 2005). 

    Furthermore, depressive symptoms in older adults have been associated with cognitive impairment and, in some cases, progression to dementia (Walker & Steffens, 2010). 

    These observations suggest that accurate diagnosis and treatment of depression in older patients may reduce the mortality rate in this population. It is in the clinical setting, therefore, that screening procedures and assessment protocols have the most direct impact.

Depression in Late Life Is Conflicted with Other Psychological Symptoms 

    Despite its prevalence, associated negative outcomes, and good treatment response. depression in older adults is highly under recognized, misdiagnosed, and subsequently under treated. 

    According to a report by the Administration on Aging (2001), less than 3% of older adults receive treatment from mental health professionals. Use of mental health services is lower for older adults than any other age group (Administration on Aging, 2001). 

    Barriers to care for older adults with depression exist at many levels. In particular, some older adults refuse to seek help because of perceived stigma of mental illness. Others may simply accept their feelings of profound sadness without realizing they are clinically depressed. 

    Lack of care provider training in the identification and diagnosis of depression in older adults is also a barrier to timely recognition and treatment (Ayalon, Fialová , Areán , &Onder , 2010). 

    Recognition of depression is also frequently obscured by anxiety and/or the various somatic or dementia-like symptoms manifest in older patients with depression, or because patient or providers believe that it is a “normal” response to medical illness, hospitalization, relocation to a nursing home, or other stressful life events. 

    However, depression-major or minor-is not a necessary or normative consequence of life adversity ( Snowdon , 2001). When depression occurs after an adverse life event, it represents pathology that should be treated. 

    Treatment for Late-Life Depression Works The goals of treating depression in older patients are to decrease depressive symptoms, reduce relapse and recurrence, improve functioning and quality of life, improve medical health, and reduce mortality and health care costs. 

    Depression in older patients can be effectively treated using either pharmacotherapy or psychosocial therapies, or both (Blazer, 2002, 2003; Mackin &Areán , 2005). 

    If recognized, the treatment response for depression is good: 60%-80% of older adults remain relapse-free with medication maintenance for 6-18 months (NIH Consensus Development Panel, 1992). 

    In addition, treatment of depression improves pain and functional outcomes in older adults (Lin et al., 2003). 

    Recurrence of depression is a serious problem and has been associated with reduced responsiveness to treatment and higher rates of cognitive and functional decline (Driscoll et al., 2005). 

    When compared to younger patients, older adults demonstrate comparable treatment response rates; however, they tend to have higher rates of relapse following treatment (Mitchell & Subramaniam, 2005). 

    Therefore, continuation of treatment to prevent early relapse and longer term maintenance treatment to prevent later occurrences is important. 

    Even in those patients with depression who have a comorbid medical illness or dementia, treatment response can be good ( losifescu , 2007). 

    Older patients who have mild cognitive impairment are at greater risk for developing dementia if their depression goes untreated ( Modrego &Ferrandez , 2004).

Cause And Risk Factors

    Several biological and psychosocial factors have been associated with increased risk for late-life depression. Genetic factors or heredity seem to play more of a role when older adults have had depression throughout their life (Blazer & Hybels, 2005). 

    Additional biological causes associated with late-life depression include neurotransmitter or “chemical messenger” imbalance or dysregulation of endocrine function (Blazer, 2002, 2003). 

    Elevated levels of homocysteine have also been associated with increased risk for depression in older adults (Almeida et al., 2008), Neuroanatomic correlates, cerebrovascular disease, brain metabolism alterations, gross brain disease, and the presence of apolipoprotein E have also been etiologically linked to late-life depression (Butters et al., 2003). 

    Risk for depression in late life has been associated with physical disability, severe stroke, and cognitive impairment (Hackett & Anderson, 2005). Huang, Dong, Lu, Yue, and Liu (2010) found that depression was associated with arthritis, hypertension, diabetes, urologic problems, and severe stroke.

Psychological Factors

    Psycho social risk factors for depression in older adults include cognitive distortions, stressful life events (especially loss), chronic stress, low self-efficacy expectations (Blazer, 2002, 2003; Blazer & Hybels, 2005), poor self perceived health, inadequate coping strategies, previous psychopathology ( Vink , Aartsen , &Schoevers , 2008).

    Narcissistic personality traits ( Heisel , Links, Conn, van Reekum , &Flett , 2007), and a history of alcohol abuse ( Hasin & Grant, 2002). (For more information, see Chapter 26, Substance Misuse and Alcohol Use Disorders.)

Social and Demographics Factors 

     The social and demographic risk factors for depression in older adults include female sex, unmarried status, stressful life events, smaller network size, female gender, and the absence of a supportive social network (NIH Consensus Development Panel, 1992; Vink et al . , 2008). 

    Bereavement is also a risk factor for depression, especially in older women (Cole, 2007; Onrust &Cuijpers , 2006).

    Interestingly, in a meta analysis of the impact of negative life events on depression in older adults. Kraaij , Arensman , and Spinhoven (2002) found that while specific negative life events (eg, death of significant others, illness in self or spouse, or negative relationship events) were moderately associated with increases in depression, the total number of negative life events and daily hassles had the strongest relationships with depression in older adults. 

    The stress associated with family care giving has been. repeatedly associated with higher rates of depression in older caregivers ( Pinquart & Sorensen, 2004). In particular, caring for an older adult with dementia has been associated with higher rates of depression than other caregiving situations and with higher mortality rates ( Pinquart & Sorensen, 2004). 

    This suggests that clinicians should pay close attention to the accumulation of negative life events and daily hassles when developing programs and targeting interventions to mitigate depression in older adults who are at risk for developing depression.

    In older adults, there is additional emphasis on the co-occurrence of specific physical conditions such as stroke, cancer, dementia, arthritis, hip fracture surgery, myocardial infarction, chronic obstructive pulmonary disease, and Parkinson's disease. 

    Medical comorbidity is the hallmark of depression in older patients and this factor represents a major difference from depression in younger populations (Alexopoulos, Schultz, &Leb - owitz , 2005). 

    Several conditions have been associated with higher levels of depression in older adults, including heart failure (Johansson, Dahlström , &Broström , 2006) and other cardiovascular diseases (Van der Kooy et al., 2007), Alzheimer's disease, stroke, and Parkinson's disease (Hackett, Anderson, House, & Xia, 2008; Strober & Arnett, 2009). 

    In an evidence-based review, Cole (2005) found that disability, older age, new medical diagnosis, and poor health status were among the most robust and consistent of all correlates of depression among older medical patients. 

    Those with functional disabilities, especially those with new functional loss, are also at risk. For example, comorbid depression is common in older patients with hip fractures.

Occurrence of Major Depressive Disorders 

    Major depressive disorder has been found to be twice as common in community-dwelling older adults compared to primary care settings (Bruce et al., 2002). 

    In a systematic review and meta-analysis, Cole and Dendukuuri (2003) found that depression in community-dwelling older adults was associated with bereavement, sleep disturbance, disability, prior depression, and female gender. 

    Other significant factors included poor health status, poor self-perceived health, and new medical illness with disability (Cole, 2005; Cole &Dendukuuri , 2003).

Depression Among  Older Adults

    Rates of depression among minority older adults are not well understood. Beals and colleagues (2005) found that the rates of major depressive episodes among older American Indians were 30% of the national average. 

    In a review, Kales and Mellow (2006) found lower rates of depression and higher rates of psychotic diagnoses among African American older adults. 

    In a systematic review of studies of older Asian immigrants, Kuo , Chong, and Joseph (2008) found that the prevalence of depression among Asian Americans ranged from 18% to 20% with significant variability between different Asian minority groups. 

    For example, studies of Vietnamese older adults estimated depression at 50%, whereas studies of older Japanese Americans was at 3%. Depression was linked to gender, recency of immigration. English proficiency, acculturation, service barriers, and social support. 

    Baker and Whitfield (2006) reported that depressive symptoms were significantly associated with increased physical impairment among older Blacks. 

    Williams and colleagues (2007) found that when African American and Caribbean Blacks experience a major depressive disorder, it is usually untreated, more severe, and more disabling than for non-Hispanic Whites. 

    Furthermore, significant disparities exist in the quality of mental health services received by minority older adults ( Virnig et al., 2004). 

    A study of Medicare + Choice plans enrollees revealed that minority older adults received substantially less follow-up for mental health problems following hospitalization ( Virnig et al., 2004).

 Clinical Miss Handling of Depressive Patients  

    Although misdiagnosis and subsequent inappropriate treatment can lead to poor health outcomes for minority older adults (Kales & Mellow, 2006), it is not clear that “simple” bias alone can explain the disparities in depression management that exist. 

    For example, Beals and colleagues (2005) point out that differences in the social construction of depressive experiences may confound the measurement of depression in ethnic olderadults . 

    Older American Indians may be reluctant to endorse symptoms of depression because cultural norms associate these complaints with weakness ( Beals et al., 2005). 

    In a thoughtful analysis of health disparities, Cooper, Beach. Johnson, and Inui (2006) explore the complex interactions and relationships between patients and providers that frame the context in which disparities can occur. 

    They point out that many historical, cultural, and class related factors can influence the development of therapeutic relationships between providers and patients. 

    Until more research clarifies the symptom pattern of late-life depression in minority populations, it is important that clinicians be open to atypical presentations of depression that warrant closer scrutiny.


    Protocol 9.1 presents a standard of practice protocol for depression in older adults that emphasizes a systematic assessment guide for early recognition of depression by nurses in hospitals and other clinical settings. 

    Early recognition of depression is enhanced by targeting high-risk groups of older adults for assessment methods that are routine, standardized, and systematic by use of both a depression screening tool and individualized depression assessment or interview (Piven, 2001 ) .

    It can be challenging to differentiate depression symptoms from dementia symptoms because cognitive impairment is frequently a symptom of depression and significant cognitive impairment in older depressed adults has been implicated in later development of dementia. 

    Therefore, assessment for presenting symptoms indicative of both depression and dementia requires focused attention on the historical progression of symptoms, getting collateral information from a reliable informant (family or caregiver) and using a screening tool sensitive to change in mood symptoms in cognitively impaired individuals (Steffens, 2008).

Depression Screening Tools

    Because many older adults do not present with obvious depressive symptoms (Pfaff & Almeida, 2005), it is important that screening for depression among older adults is incorporated into routine health assessments. 

    Nursing assessment of depression in older patients can be facilitated by the use of a screening tool designed to detect symptoms of depression. Several depression screening tools have been developed for use with older adults. 

    In a systematic review, Watson and Pignone (2003) evaluated the accuracy of different depression screening tools. 

    They found that the Geriatric Depression Scale-Short Form (GDS-SF: Sheikh &Yesavage , 1986), the Center for Epidemiologic Studies Depression Scale (CES-D; Radloff , 1977), and the Self CARE(D) (Banerjee, Shamash , MacDonald, & Mann, 1998) were the most accurate screening tools to detect major depression as well as subsyndromal depressive symptoms (Watson &Pignone , 2003).

    In a more recent targeted review of evidence-based depression screening tools for older adults, the two most commonly cited were the GDS-SF and the CES-D. 

    In addition, the Brief Patient Health Questionnaire-9 (BPHQ-9) and the Cornell Scale for Depression in Dementia (CSDD) were reviewed in depth because they are also evidence based and are being used with increasing regularity with older adults (Roman & Callen , 2008). 

    The GDS-SF has been a reliable screening tool for depressive symptoms in mild cognitive impairment but not in older adults with Alzheimer's disease ( Debruyne et al., 2009). The CSDD was developed specifically to detect symptoms of depression in older adults with dementia.

Individualized Assessment and Interview

    Central to the individualized depression assessment and interview is a focused assessment ment of the full spectrum of symptoms (nine) for major depression as delineated by the DSM-IV-TR (APA, 2000). 

    Furthermore, patients should be asked directly and specifically if they have been having suicidal ideation-that is, thoughts that life is not worth living or if they have been contemplating or have attempted suicide. 

    The number of symptoms, type, duration, frequency, and patterns of depressive symptoms, as well as a change from the patient's normal mood of functioning, should be noted. 

    Additional components of the individualized depression assessment include evidence of psychotic thinking (especially delusional thoughts), anniversary dates of previous losses or nodal/ stressful events, previous coping style (specifically alcohol or other substance abuse). 

    Relationship changes, physical health changes, a history of depression or other psychiatric illness that required some form of treatment, a general loss and crises inventory, and any concurrent life stressors. 

    Subsequent questioning of the family or caregiver is recommended to obtain further information about the older adult's verbal and nonverbal expressions of depression.

Differentiation Of Medical Or Iatrogenic Causes Of Depression

    Once depressive symptoms are recognized, medical and drug-related causes should be explored. 

    As part of the initial assessment of depression in the older patient, it is important to obtain and review the medical history and physical and/or neurological examinations. 

    Key laboratory tests should also be obtained and/or reviewed and include thyroid-stimulating hormone levels, chemistry screen, complete blood count, and medication levels if needed. 

    An electrocardiogram, serum B. a urinalysis, and serum folate should also be considered to assess for coexisting medical conditions. These conditions may contribute to depression or might complicate treatment of depression. 

    In medically older patients, who frequently have multiple medical diagnoses and are prescribed with multiple medications, these “organic” factors in the cause of depression are a major issue in nursing assessment. 

    In collaboration with the patient's physician, efforts should be directed toward treatment, correction, or stabilization of associated metabolic or systemic conditions. When medically feasible, depress genic medications should be eliminated, minimized, or substituted with those that are less depress genic ( Dhondr et al., 1999). 

    Even when an underlying medical condition or medication is contributing to the depression, treatment of that condition or discontinuation or substitution of the offending agent alone is often not sufficient to resolve the depression, and antidepressant medication is often needed.

Interventions And Care Strategies

    Clinical Decision Making and Treatment Regardless of the setting, older patients who exhibit the number of symptoms indicative of a major depression, specifically suicidal thoughts or psychosis, and who score above the established cutoff score for depression on a depression screening tool (eg, 5 on the GDS-SF) should be referred for a comprehensive psychiatric evaluation. 

    Older patients with less severe depressive symptoms without suicidal thoughts or psychosis but who also score above the cutoff score on the depression screening tool (eg, 5 on the GDS-SF) should be referred to available psychosocial services (ie, psychiatric liaison nurses, geropsych atric advanced practice nurses, social workers, psychologists, a clergy member) for psychotherapy or other psychosocial therapies, as well as to determine whether medication for depression is warranted. 

    It is also important to note that older adults at risk for depression may benefit from brief interventions that focus on preventing the development of depression (Cole, 2008; Cole & Dendukuuri, 2003; Forsman, Jane-Llopis, Schierenbeck , &Wahlbeck , 2009 ) . 

Types and Severity of Depressive Symptoms

    The type and severity of depressive symptoms influence the type of treatment approach. 

    In general, more severe depression, especially with suicidal thoughts or psychosis, requires intensive psychiatric treatment, including hospitalization, medication with an antidepressant or antipsychotic drug, electroconvulsive therapy (ECT), and intensive psychosocial support (Blazer, 2002, 2003). 

    Less severe depression without suicidal thoughts or psychosis may require treatment with psychotherapy or medication, often on an outpatient basis. 

    Collectively, these data also suggest that patients who have depression complicated by multiple medical and psychiatric comorbidities may benefit from a referral to an interdisciplinary treatment team with specific expertise in geropsychiatry. 

    The three major categories of treatment for depression in older adults are biologic therapies (eg, pharmacotherapy, ECT, and exercise), psychosocial therapies (eg, cognitive-behavioral, psychodynamic, and reminiscence therapy), and interdisciplinary team interventions. 

    A compelling body of evidence supports the efficacy of these diverse treatment modalities for older adults with depression ( Arcan & Cook, 2002; Cuijpers , van Straten , & Smit. 2006; Hollon et al., 2005).

Biologic Therapies in Treatment of Late Life Depression

    In the past, tricyclic antidepressants (TCAs) were often contraindicated in older adults because of the anticholinergic side-effect profile (Mottram, Wilson, & Strobl, 2006). 

    More recently, however, there has been a dramatic increase in the development and testing of different pharmacological agents used to treat depression in older adults. 

    The most common classes of these newer medications include the selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and TCA-related medications. 

    These agents work selectively on neurotransmitters in the brain to alleviate depression. SSRIs have been effective in treating poststroke depression (Hackett et al., 2008; Chen, Guo, Zhan, & Patel, 2006) and depression in persons with Alzheimer's disease (Thompson, Herrmann, Rapoport, & Lanctôt, 2007 ) .

    When the SSRIs are compared to other classes of antidepressants to treat late-life depression (eg. SNRIs, TCAs, TCA-related medications), they have similar treatment efficacy (Mottram et al., 2006; Mukai & Tampi, 2009 ; Salzman, Wong, & Wright, 2002; Shanmugham , Karp, Drayer , Reynolds, & Alexopoulos, 2005). 

    However, SSRIs and SNRIs generally pose a lower treatment risk for older adults with depression ( Chemali , Chahine, &Fricchione , 2009; Mottram et al., 2006; Mukai &Tampi , 2009; Shanmugham et al., 2005). 

    Still, in a systematic review of the literature, Wilson, Mottram, and Vassilas (2008) found that although SSRIs are generally well tolerated in older adults, a significant minority experience serious side effects, including nausea, vomiting, dizziness, and drowsiness. 

    In addition, serious hyponatremia has been associated with the use of SSRIs in older adults (Jacob &Spinler , 2006). Judicious use of TCA-related drugs may be an effective alternative for older adults who cannot tolerate SSRIs (Wilson et al., 2008).

    Older patients should be closely monitored for therapeutic response to and potential side effects of antidepressant medication to assess whether dose adjustment of antidepressant medication may be warranted. 

    Although, in general, it is necessary to start antidepressant medication at low doses in older patients, it is also necessary to ensure that older adults with persistent depressive symptoms receive adequate treatment (American Association of Geriatric Psychiatry. 1992; M. Buffum & J. Buffum, 2005).

     Recent research that has suggested that the use of SSRIs in adolescents can increase suicidality has raised concerns about a similar dynamic with older adults. 

    Several studies, however, have found that the use of SSRI antidepressants to treat late-life depression is not associated with increases in suicidal ideation ( Barbui , Esposito, & Cipriani, 2009, Nelson, Delucchi , &Schneider, 2008; Stone et al. , 2009). 

    In fact, treatment of late-life depression with SSRIs has been shown to significantly reduce suicidal ideation and behavior in older adults ( Barbui et al., 2009; Nelson et al., 2008: Stone et al., 2009).

Electro-Convulsive Therapy

    When older adults are not able to take antidepressants for treatment of late-life depression, clinicians are increasingly looking to the use of ECT to reduce symptoms of depression and improve function. 

    For many individuals, the use of ECT conjures up images of barbaric treatments that leave patients severely cognitively impaired. 

    Although the debate on the efficacy and appropriate use of ECT to treat late-life depression continues ( Dombrovski &Mulsant , 2007), some research suggests that ECT can be an effective option for older adults with depression that is not responsive to other treatments (Navarro et al., 2008). 

    Several studies have found that ECT does not cause increased cognitive impairment in older adults (Gardner & O'Connor, 2008).

Exercise Interventions

    Physical exercise has been established as an effective treatment for depression in the general population, and evidence to support the use in older adults is building. 

    In two recent systematic reviews of physical exercise, interventions concluded that exercise programs decrease depressive symptoms in older adults with major and minor depression ( Sjosten &Kivela , 2006). 

    Tai Chi and Qigong are specific meditative exercise methods that also may decrease depressive symptoms (Rogers, Larkey , & Keller, 2009).

Psycho Social Approaches

    The term psychosocial encompasses a wide array of approaches. This section provides an overview of the three major psychosocial approaches used in the studies reviewed here: 

(a) cognitive behavioral

(b) psychodynamic

(c) reminiscence or life review

Cognitive and Behavioral Therapy

    Cognitive behavioral therapies (CBT) seek to change the cognitive and/or behavioral context in which depression occurs through the use of various specific techniques such as providing new information, teaching problem-solving strategies, correcting skills deficits, modifying ineffective communication patterns, or changing the physical environment. 

    Although specific treatment protocols vary, CBT approaches tend to be active and focused on solving specific, current day-to-day problems, rather than seeking global personality change in the client. 

    Based on a large and growing evidence base, CBT has been shown effective in decreasing depression in clinically depressed older adults (Hill &Brettle . 2005; Laidlaw et al., 2008; Pinquart , Duberstein, &Lyness , 2007: Steinman et al., 2007; Wilson et al., 2008). 

    Training caregivers (family or paid caregivers) to use CBT approaches (improved communication, increasing pleasant events, problem-solving behaviors) has also been shown to decrease depression and related behaviors in older adults with dementia (Teri, Mckenzie, &LaFazia , 2005 ) . 

    Gallagher-Thompson and Coon (2007) also identified CBT interventions as effective in decreasing depression in the older adults who are caregivers for family members with dementia.

Approach to Focus on Therapeutic Relationship

    Psychodynamic approaches focus on establishing a therapeutic relationship as a mechanism of change, as well as the historical causes of current client mood and behavior. The clients' psychological insight and ongoing emotional experience are considered critical for psychological progress. 

    The evidence for effectiveness of psychodynamic approaches with older adults is limited. However, Pinquart and colleagues (2007) reported significant changes in depression with psychodynamic therapies based on three studies and nonsignificant changes in three studies of interpersonal therapy. 

    Additionally, Bharucha, Dew, Miller, Borson , and Reynolds (2006) reviewed 18 studies of psychodynamic approaches (“talk therapy”) with residents of long-term care settings and reported significant positive outcomes on measures of depression. hopelessness, and self-esteem. 

    Marital and family therapy may also be beneficial in treating older adults with depression, especially older spouses engaged in caregiving (Buckwalter et al., 1999).


    In reminiscence therapy, older adults are encouraged to remember the past and to share their memories, either with a therapist or with peers, as a way of increasing self-esteem and social intimacy. 

    It is often highly directive and structured, with the therapist picking each session's reminiscence topic. In systematic reviews of the literature, reminiscence therapy was found to significantly reduce depression in older adults ( Bohlmeijer , Smit, &Cuijpers , 2003; Hsieh & Wang, 2003; Mackin &Areán , 2005; Pinquart et al., 2007). 

    Nursing interventions to encourage reminiscence include asking patients directly about their past or by linking events in history with the patient's life experience. The use of photographs, old magazines, scrapbooks, and other objects can also stimulate discussion.

    In summary, psychosocial treatment has been found effective in decreasing depression in cognitively intact older adults. 

    There is also empirical evidence for the efficacy of cognitive behavioral based therapies in decreasing depression in individuals with dementia and for the older adults who are caregivers for individuals with dementia. 

    Current studies also demonstrate the utility of working closely with caregivers whether family or staff to reduce depression in persons with dementia. 

    There is also a small but growing body of evidence related to the use of psychodynamic approaches aimed at decreasing depression in older adults associated with comorbid illnesses such as heart disease (Kang-Yi & Gellis, 2010; Lane, Chong Aun Yeong , &Gregory , 2005).

Interdisciplinary Team Models of Care

    Several studies support the use of an interdisciplinary geriatric assessment team for late-life depression (Bao, Post, Ten, Schackman , & Bruce, 2009; Katon et al., 2005; Skultery & Zeiss, 2006).

     Interdisciplinary treatment teams improved physical functioning in older adults with major depressive disorder (Bao et al., 2009; Callahan et al., 2005; Katon et al., 2005: Skultety &Zeiss , 2006) and effectively reduced the depressive symptoms in community- dwelling older adults (age 70 years and older) who were at risk for hospitalization (Boult et al., 2001). 

    Ethnic minority older adults experienced improved treatment of depression when treated by an interdisciplinary treatment team ( Areán et al., 2005) as did low income older adults ( Areán , Gum, Tang, &Unützer , 2007). 

    Similarly , patients with multiple comorbid medical conditions responded positively to an interdisciplinary approach to depression management ( Harpole et al., 2005; Unützer et al., 2002). 

    Although older adults with comorbid anxiety disorders took longer to respond to treatment, they experienced greater reductions in depression when treated by an interdisciplinary team than similar patients receiving usual primary care (Hegel et al., 2005).

Individualized Nursing Interventions for Depression

    Psychosocial and behavioral nursing interventions can be incorporated into the plan of care, based on the patient's individualized need. Provision of safety precautions for patients with suicidal thinking is a priority. 

    In acute medical settings, patients may require transfer to the psychiatric service when suicidal risk is high and staffing is not adequate to provide continuous observation of the patient. 

    In outpatient settings, continuous surveillance of the patient should be provided while an emergency psychiatric evaluation and disposition is obtained.

    Promotion of nutrition, elimination, sleep/rest patterns, physical comfort, and pain control has been recommended specifically for medically depressed ill older adults ( Voyer & Martin, 2003). 

    Relaxation strategies should be offered to relieve anxiety as an adjunct to pain management. Nursing interventions should also focus on enhancement of the older adult's physical function through structured and regular activity and exercise; referral to physical, occupational, and recreational therapies; and the development of a daily activity schedule (Barbour & Blumenthal, 2005). 

    Enhancement of social support is also an important function of the nurse. This may be done by identifying, mobilizing, or designating a support person such as family, a confidant, friends, volunteers or other hospital resources, church member, support groups, patient or peer visitors, and particularly by accessing appropriate clergy for spiritual support.

    Nurses should maximize the older adult's autonomy, personal control, self-efficacy, and decision making about clinical care, daily schedules, and personal routines (Lawton, Moss, Winter, & Hoffman, 2002). 

    The use of a graded task assignment where a larger goal or task is subdivided into several small steps can be helpful in enhancing function, assuring successful experiences, and building older patients' confidence in their performance of various activities ( Areán &, Cook, 2002 ).

    Participation in regular, predictable, and pleasant activities can result in more positive mood changes for older adults with depression (Koenig, 1991). 

    A pleasant events inventory, elicited from the patient, can be used to incorporate pleasant activities into the older patient's daily schedule (Koenig, 1991). 

    Music therapy customized to the patient's preference is also recommended to reduce depressive symptoms ( Siedliecki & Good, 2006).

    Nurses should provide emotional support for depressed older patients by providing empathetic, supportive listening; encouraging patients to express their feelings in a focused manner on issues such as grief or role transition, supportive adaptive coping strategies; identifying and reinforcing strengths and capabilities; maintaining privacy and respect; and instilling hope. 

    In particular, it is important to increase the patient's and family's awareness of the symptoms as part of a depression that is treatable and not the person's fault as a result of personal inadequacies.

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