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    Depression in the elderly

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    RN/Thomson AHC Home Study Program
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    CE credit is no longer available for this article. (Expired June 2008)


     

    Originally posted June 2006

    By Regina A. Spires, RN, BSN

    REGINA SPIRES, a staff nurse at the Palmetto Health Eye Clinic in Colombia, SC, wrote this article while working on the Transitional Care Unit at Providence Northeast Hospital, also in Columbia. The author has no financial relationships to disclose.

    Contrary to what many people think, depression isn't a normal part of aging. Here's what you can do to help older patients get the care they need.

    Everyone feels sad or down at some time. It's a normal reaction to life's losses and disappointments. For the elderly, who are likely to experience declining health, the death of a spouse, and the loss of one relative or friend after another, it's not unusual for that sadness to linger. Nonetheless, staying "down in the dumps" for more than a couple of weeks can be a sign of depression.

    Without treatment, depression can seriously diminish their quality of life. It can also lead to suicide—a risk that's especially high among elderly patients. The suicide rate among older white men with severe depression, for example, is six times higher than that of the general population.1

    Depression also increases the risk of coronary artery disease, stroke, and diabetes. In addition, it's been linked to higher mortality rates following an MI or stroke and to slower rehabilitation after hip surgery.2 What's more, the death rate for depressed nursing home residents is one-and-a-half to three times greater than for their non-depressed counterparts.3

    Detection is a major issue. Many depressed older people go undiagnosed and untreated because their symptoms are seen as a normal response to the many losses and physical changes associated with aging.1,3 That belief, along with the difficulty in distinguishing it from dementia and other cognitive disorders, helps explain why only one out of three primary care physicians routinely screens older patients for depression.4

    In fact, depression is not a normal part of aging. The mental and emotional suffering that continues unabated requires treatment, no matter what the cause.1

    That's where you come in.

    Because nurses spend considerably more time with patients than physicians do, you can play a crucial role in identifying seniors suffering from depression and seeing that they get the treatment they need.

    Is it depression or dementia?

    A diagnosis of depression hinges on a number of criteria from the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) that includes:5

    • depressed mood,
    • loss of interest or pleasure,
    • weight loss or gain,
    • insomnia or hypersomnia,
    • psychomotor agitation or retardation,
    • fatigue or loss of energy,
    • feelings of worthlessness or excessive guilt,
    • decreased concentration or indecisiveness, and
    • thoughts of death or suicide.

    To be diagnosed with major depression, a patient must meet five or more of these criteria, including depressed mood and loss of interest or pleasure, for at least two weeks.2,5 In older adults, however, the disease often manifests in different ways, so relying solely on the DSM-IV criteria can be problematic. Geriatric patients are more likely to report vague physical complaints—somatization—than to describe themselves as depressed or even admit to feeling sad.1,2

    Other indicators of depression in the elderly, including irritability, anxiety, and social withdrawal, are listed in the box on page 41.3 The presence of two or more of these signs or symptoms should alert you to the need for further evaluation.2

    If you suspect that your elderly patient suffers from depression, you may want to screen him using the Geriatric Depression Scale (GDS), shown in the box on page 42.3,6 The tool, which is comprised of a series of Yes or No questions, is a reliable way to detect depression and takes very little time to complete. The downside? Neither the GDS nor other similar screening tools can produce accurate results in patients with moderate to severe cognitive impairment.4

    If your patient has a cognitive impairment, it's important to determine whether it's a byproduct of depression or a sign of something else: dementia.

    Depression can, of course, cause changes in cognitive function. Depressed patients often have trouble with organization, planning, abstract thinking, memory, and social skills— a condition sometimes labeled pseudodementia.7 Unfortunately, when an elderly patient exhibits such cognitive impairment, dementia is often more likely than depression to be blamed. Patients with dementia can also develop depression, of course, making it particularly challenging to distinguish between the two.

    The Mini-Mental Status Exam7—which asks the patient to do things like counting backwards from 100 by 7s, naming the day of the week and the season, and spelling a word backwards—can help. A person with dementia will try to perform the tasks but is likely to fail; a severely depressed individual can usually complete the tasks successfully, but typically requires much encouragement and coaxing.3

    Talking to the patient's family will also provide some much-needed insight into your patient's condition. Find out if the cognitive or mood changes you are observing predate his hospital admission. If so, obtaining a recent history of changes in his mental status from the patient's primary caregivers can provide helpful clues.2,7 Keep in mind, too, that the onset of dementia is usually gradual, while depression often develops more rapidly.

    Look, too, for factors that increase the risk for depression. These include a prior episode—or a family history—of major depression, a recent loss, substance abuse, and a lack of a support network.7 Stroke, cancer, diabetes, coronary artery disease, or Parkinson's disease have also been associated with an elevated risk of depression.2

    Based on what you and the healthcare team learn, the physician will likely perform a thorough physical exam and order a neurologic evaluation to identify any physical abnormalities that could account for his symptoms. He will also order a psychiatric consult, as needed.

    Open the door to help

    If your elderly patient is diagnosed with depression, offer him your support. Encourage your patient to verbalize his feelings. Spend as much time at the patient's bedside as possible. And assess his strengths so that you can help him learn how to draw on them in a time of need.

    Help your patient understand that depression can be successfully treated, and reassure him that he won't always feel this way. It's important, too, to find out whether he's in danger of harming himself.7,8

    Directly asking a patient whether he has ever thought of suicide or self-harm is the most effective way to find out. Although some clinicians hesitate to question patients about suicide for fear of planting the idea in someone's head, research has shown that that's not the case. Instead, patients often answer truthfully, and without hesitation.

    If your patient says Yes when asked about suicide, ask him if he has a plan, and find out if he has a means of killing himself, two indicators that boost lethality. In this case, you'll need to call the physician and arrange for suicide precautions as soon as possible.6

    Successfully overcoming depression will likely hinge on a combination of antidepressants and psychological counseling.7 The physician will need to take into account factors such as medications the patient may already be taking for other conditions, physical and cognitive limitations, and nutritional needs.

    The antidepressants of choice for the treatment of geriatric depression are the selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), and others.7 Which one the doctor selects will depend upon its potential for interactions with the patient's other meds.

    Adjustments may need to be made after an initial course of treatment, depending upon how well the patient tolerates the side effects. SSRIs have been associated with increased agitation, nervousness, insomnia, nausea, diminished sweating, increased body temperature, and sexual dysfunction.9 A patient may have to try several different antidepressants to find one that's suitable.

    You should caution patients taking an SSRI not to skip a dose or stop taking the medication without physician supervision. Abrupt withdrawal can trigger a discontinuation syndrome.9 Although it's not dangerous, withdrawal symptoms—anxiety, insomnia, irritability, nausea, vomiting, vivid dreams, dizziness, tremor, chills, and fatigue—can be quite distressing for the patient. Fortunately, they usually resolve within 24 hours of restarting the drug.9

    If your patient does not have a therapist, see that he gets a referral before discharge. Stress the importance of following through with talk therapy and medication, and encourage him to draw upon the support of his family, friends, hobbies, and exercise as needed.

    As our population continues to age, you can expect to see more cases of geriatric depression. It's likely, too, that you'll often be the first to spot subtle signs and symptoms. Knowing what to look for and when and how to intervene will ensure that these patients don't suffer in silence.


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    REFERENCES

    1. Alexopoulos, G. S., & Katz, I. R. "The expert consensus guideline series: Pharmacotherapy of depressive disorders in older adults. Special report." 2004. www.psychguides.com/Geriatric%20Depression%20contents.pdf (30 Mar. 2006).

    2. Raj, A. "Depression in the elderly. Tailoring medical therapy to their special needs." 2004. www.postgradmed.com/issues/2004/06-04/raj.htm. (22 Mar. 2006).

    3. Sable, J., Dunn, L., & Zisook, S. (2002). Late life depression: How to identify its symptoms and provide effective treatment. Geriatrics, 57(2), 18.

    4. Evers, M., & Marin, D. (2002). Mood disorders: Effective management of major depressive disorder in the geriatric patient. Geriatrics, 57(10), 36.

    5. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

    6. Bruce, M. L., Ten Have, T. R., et al. (2004). Reducing suicidal ideation and depressive symptoms in depressed older primary care adults. JAMA, 291(9), 1081.

    7. Compton, M. T., & Nemeroff, C. B. "Depression." 2004. www.medscape.com/viewarticle/487260 (30 Mar. 2006).

    8. Rabins, P. V., & Black, B. S. (2000). Effectiveness of a nurse-based outreach program for identifying and treating psychiatric illness in the elderly. JAMA, 283(21), 2802.

    9. Ditto, K. "SSRI discontinuation syndrome." 2003. www,postgradmed.com/issues/2003/08-03/ditto.htm (30 Mar. 2006).


    When to take a closer look

    The presence of two or more of the signs and symptoms listed here indicates a need to further evaluate your elderly patient for depression:

    • Agitation/anxiety/worrying
    • Alcohol or other substance abuse
    • Cognitive impairment
    • Diminished ability to complete activities of daily living
    • Excessive guilt
    • Irritability
    • Lack of initiative and diminished problem-solving ability
    • Marital discord
    • Obsessions and compulsions
    • Paranoia
    • Social withdrawal
    • Somatic complaints

    Source: Sable, J., Dunn, L., & Zisook, S. (2002). Late life depression: How to identify its symptoms and provide effective treatment. Geriatrics, 57(2) 18.


    Geriatric Depression Scale

    Ask your patient to choose the answer that best reflects her feelings during the past week:

    1. Are you basically satisfied with your life?
    YES/NO

    2. Have you dropped many of your activities and interests?
    YES/NO

    3. Do you feel that your life is empty?
    YES/NO

    4. Do you often get bored?
    YES/NO

    5. Are you in good spirits most of the time?
    YES/NO

    6. Are you afraid that something bad is going to happen to you?
    YES/NO

    7. Do you feel happy most of the time?
    YES/NO

    8. Do you often feel helpless?
    YES/NO

    9. Do you prefer to stay at home rather than going out and doing new things?
    YES/NO

    10. Do you feel you have more problems with memory than most?
    YES/NO

    11. Do you think it is wonderful to be alive now?
    YES/NO

    12. Do you feel pretty worthless the way you are now?
    YES/NO

    13. Do you feel full of energy?
    YES/NO

    14. Do you feel your situation is hopeless?
    YES/NO

    15. Do you think most people are better off than you are?
    YES/NO

    SCORING KEY

    Answers in bold are indicative of depression. Assign one point to each bold answer. A total score of more than 5 but less than 10 suggests depression and the need for a follow-up interview. Scores of more than 10 almost always indicate depression.

    Source: Yesavage, J. "Geriatric depression scale (GDS)." www.stanford.edu/~yesavage/GDS (27 Mar. 2006).


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