Adelle Gertheimer, age 77, is a is a former teacher who lives alone in downtown Philadelphia. She has osteoarthritis and diabetes mellitus type 2.
When she arrives at the primary-care clinic, she states she hasn’t been taking her prescribed medications because she got “mixed up” about the dosages and forgot some of the numerous daily tablets she takes. Laboratory tests show her diabetes and arthritis are well controlled. After noting the patient’s disheveled appearance, inattentiveness, sad affect, and lethargy, the nurse administers the Geriatric Depression Scale. Ms. Gertheimer scores a 9, indicating moderate depression. She denies thoughts of wanting to harm herself or others.
By 2015, adults age 65 and older will make up about 20% of the U.S. population. While aging brings rewards, it also brings challenges—some of which can seem overwhelming: deaths of family mem-
bers and friends, loss of a sense of purpose, reduced income. And of course, the potential for illness and disability looms large. In light of these losses, many people—even some healthcare professionals—mistakenly assume depression goes hand in hand with aging.
Nonetheless, for many older adults, depression is real and can have deadly consequences. About 5% of adults older than age 55 suffer depression and other mood disorders over the course of a given year. In 2004, persons older than age 65 accounted for 16% of successful suicides in the United States. Alcohol or prescription drug abuse commonly is involved in these suicides.
As the elderly population increases, depression statistics will undoubtedly rise, and nursing practice increasingly will entail identifying and caring for the depressed elderly.
Assessing depression in older persons
According to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (Text Revision; DSM-IV-TR), common forms of depression are major depressive disorder and dysthymic disorder (episodic or chronic).
For a major depressive disorder, DMS-IV-TR criteria are as follows: Five or more of the following findings are present during the same 2-week period and represent a change from the patient’s previous functioning:
- feelings of sadness, hopelessness, or discouragement
- appetite changes with significant weight loss
- sleep disturbances (commonly insomnia)
- psychomotor changes, such as agitation or slowing down
- decreased energy or fatigue
- poor concentration or decision making
- sense of worthlessness or guilt
- recurrent thoughts of death, recurrent suicidal ideation with or without a plan, or a suicide attempt or a specific plan for committing suicide.
At least one of the symptoms is either depressed mood (most of the day, nearly every day) or loss of interest or pleasure in all or almost all activities (most of the day, nearly every day).
For dysthymic disorder, the criteria are as follows: The patient shows a depressed mood for most of the day more days than not (as indicated either by subjective account or by others’ observation) for at least 2 years. While depressed, the patient has two or more of the following:
- poor appetite or overeating
- sleep disturbances
- diminished cognitive and executive function
- feelings of hopelessness
- low self-esteem
- irritability or boredom.
Be aware, though, that subclinical depression increasingly is seen in older adults. This condition commonly manifests as somatic complaints.
Risk of depression increases with the number of prescription and nonprescription medications an older adult takes. Adults age 65 and older currently make up 13% of the U.S population but receive about one-third of all prescriptions. Analgesics and anxiolytics frequently are prescribed for older adults with little regard for their psychological effects and physiologic addictive potential. Adverse effects of drugs that are overused or misused include sedation (common with benzodiazepines), cognitive impairment, and accidents.
Depression screening in older adults
Depression in older adults often goes unreported or undetected, underscoring the need for healthcare givers to become more adept at identifying depression. (See Know the risk factors by clicking the PDF icon above.) Evidence suggests up to 75% of older adults who commit suicide have seen a healthcare professional within 1 month of death.
The Clinical Guidelines for Screening for Depression from the U.S. Preventive Services Task Force give a strong rationale for screening all adults.
Why depression in the elderly is often missed
- In older adults, depression signs and symptoms often differ from those in younger people. Nearly half of depressed older adults don’t report symptoms that match the DSM-IV-TR criteria. Instead, they may report dysthymia, anxiety, or subclinical depression (depression masked by bodily complaints).
- Older adults may think sadness or decreased pleasure is a realistic response to aging.
- Older adults are less likely to self-identify problems, seeking care instead from primary-care physicians, nurse practitioners, or medical specialists when they experience anxiety, depression, or cognitive or physiologic changes. This may stem from the belief that depression and anxiety signify weakness or poor character. With continuing stigmatization of mental health problems, many older persons are reluctant to acknowledge mood or cognitive changes.
- Depression can accompany or stem from serious physical problems, such as heart disease, stroke, diabetes, cancer, endocrine disorders, infections, or Parkinson’s disease. And depression can delay recovery from these illnesses or worsen outcomes.
- Depression may be an early sign of dementia, as the person becomes aware of memory loss. Cognitive changes occur in both conditions. But in depression, they’re more specific to circumstances and come on suddenly, whereas in dementia, they’re global and have an insidious onset.
- Cultural factors can affect a person’s signs and symptoms of depression and willingness to seek treatment.
After performing a comprehensive physical assessment, review your findings for indicators of a reversible medical condition that might account for depressed mood and signal the need for further medical evaluation. To assess the patient’s mood, consider using a standardized scale for greater accuracy. The best choice is the Geriatric Depression Scale (GDS, short form), a 15-question, forced-choice tool that includes subjectively identified behaviors and feelings. It can be given by the nurse or completed by the patient in about 5 to 7 minutes. The patient gives “yes” or “no” responses depending on how he or she has been feeling in the past week. Tested and used extensively to screen for depression in older adults, GDS is especially effective when the patient’s baseline score is compared to subsequent scores. But it shouldn’t replace a diagnostic interview by a mental health professional.
Other effective tools designed for primary-care settings are the Patient Health Questionnaire 2 (PHQ-2) and the Patient Health Questionnaire 9 (PHQ-9). PHQ-2 asks questions about depression, helplessness, and lack of pleasure. Positive responses on this tool indicate the need to administer the PHQ-9, a nine-item self-report scale measuring the frequency of various physical, emotional, and intellectual states; the items derive from the DSM-IV-TR criteria for major depression. Scores range from 0 to 27, with higher scores indicating more severe depression. A score of 11 or higher on the PHQ-9 should trigger provider intervention. As nurses increasingly encounter depressed older people, use of the GDS or PHQ-9 can give direction for referral and more comprehensive evaluation.
Expert consensus guidelines and nursing resources define the best clinical practices and are available in psychiatric–mental health nursing texts and other resources, as well as from geropsychiatric and geriatric nursing competency statements, and the National Institute of Mental Health and National Institute on Aging.
Because older people of all ethnic groups tend to turn to primary-care practitioners rather than specialists, nurses and general medical physicians are well situated to intervene. Expert consensus best-practice guidelines identify psychotherapeutic and pharmacothera- peutic interventions for mental health specialists, including how to assess for suicidal thoughts or plans. The guidelines recommend either psychotherapy or pharmacotherapy for mild depression, and both types of therapy for major depressive disorder.
Interpersonal interventions by trained nurses have brought symptom relief to some older women. Follow-up is important to assess for diminished symptoms and improved function. Referral to relapse prevention is desirable, as older persons often need more time to recover. With severe depression that resists treatment, brain stimulation in the form of electroconvulsive therapy or transcranial magnet stimulation may be helpful.
For some patients, arranging for environmental intervention may be important. Examples include housing modifications (for instance, advising the patient to move to an assisted living facility), access to appropriate services (such as arranging for Meals on Wheels), and stronger social networks (for instance, referring the patient to a support group for older adults).
After Adelle Gertheimer scores a 9 on the GDS, the nurse continues with a comprehensive assessment, including a tobacco, drug, and alcohol history. Then she and the physician collaborate to develop a treatment plan. Based on her GDS score and additional assessment findings, Ms. Gertheimer is referred for psychotherapeutic and psychosocial interventions and is prescribed an antidepressant. She agrees to short-term cognitive behavioral therapy, which aims to change thinking and behaviors. This therapy can be done by a psychiatric nurse practitioner or other mental health practitioner trained in this model.
The physician prescribes a minimum 6-month course of a selected serotonin reuptake inhibitor (SSRI). For older adults, experts recommend a low starting dosage for SSRIs (with the dosage increased gradually) or a novel antidepressant, such as venlafaxine or bupropion). SSRIs cause a relatively low incidence of CNS, cardiovascular, and anticholinergic adverse effects. Although tricyclic antidepressants remain an option, they’re contraindicated in severe depression with suicidal ideation. Both SSRIs and novel antidepressants should be used cautiously, taking comorbidities into consideration.
When interventions fail
Reasons for intervention failures among older adults include failure to screen for depression and caregiver discomfort in prescribing antidepressants. But even when such drugs are prescribed, patients may discontinue their use due to adverse effects or the time lag between starting the drug and feeling better (generally 8 to 12 weeks). Also, when referred to a psychotherapist, older persons may choose not to follow up out of reluctance to discuss their problems.
Light at the end of the tunnel
Today, depression commonly is assessed and treated in primary-care and general medical settings, and nurses are assuming new roles as generalists and specialist practitioners to increase outreach and make treatment more widely available to older adults. Nurses need to know how to identify signs and symptoms of depression in these patients and should be able to screen for depression.
Visit www.AmericanNurseToday.com for a complete list of references. Click on the PDF icon above for information on the GDS and model programs for treating depressed older adults.
Madeline A. Naegle is a professor, coordinator of the Substance Related Disorders Sequence, and director of the WHO Collaborating Center in Geriatric Nursing Education at New York University College of Nursing in New York City.