Psychiatry -mental disorders
Depression
Depression is not a normal part of aging, and studies show that most older people are satisfied with their lives, despite physical problems (National Institute of Mental Health [NIMH], 2014b). To understand depression, the nurse must understand the influence of late-life stressors and changes and the beliefs older people, society, and health professionals may have about depression and its treatment.
Prevalence
Depression remains underdiagnosed and undertreated in the older population and is considered a significant public health issue (Abbasi & Burke, 2014).
Depression is the fourth leading cause of disease burden globally and is projected to increase to the second leading cause by 2030 (World Health Organization, 2014).
Approximately 1% to 2% of adults 65 years and older are diagnosed with major depressive disorder. An additional 25% have significant depressive symptoms that do not meet the criteria for major depressive disorder (Avari et al., 2014).
Symptoms that do not meet the criteria for major depressive disorder have been referred to as minor depression, subsyndromal depression, dysthymic depression, and mild depression.
The DSM-5 replaced the term dysthymia with the term persistent depressive disorder to describe symptoms that are long standing (lasting 2 years or longer) but do not meet the criteria for major depressive disorder.
Recognition and treatment are important because persistent depressive disorder has a negative impact on physical and social functioning and quality of life for many older people and is associated with an increased risk of a subsequent major depression (Harvath & McKenzie, 2012; Uher et al., 2014).
Rates of depression are higher in older adults who experience physical illness, who have cognitive impairment, or who reside in institutional settings. Fourteen percent (14%) of patients receiving home care meet the criteria for depression, and nearly half of all nursing home residents receive antidepressants for depression (Abbasi & Burke, 2014; Smith et al., 2015).
Depression is a major reason why older people are admitted to nursing homes.
Prevalence rates of depression in older adults likely underestimate the extent of the problem. The stigma associated with depression may be more prevalent in older people, and they may not acknowledge depressive symptoms or seek treatment. Many elders, particularly those who have survived the Great Depression, both world wars, the Holocaust, and other tragedies, may see depression as shameful, evidence of flawed character, self-centered, a spiritual weakness, and sin or retribution. Perceived stigma may be less of a concern for the future older population who are more aware of mental health concerns and more likely to seek treatment.
Health professionals often expect older people to be depressed and may not take appropriate action to assess for and treat depression. The differing presentation of depression in older people, as well as the increased prevalence of medical problems that may cause depressive symptoms, also contributes to inadequate recognition and treatment. Primary care providers accurately recognize depression in less than half of individuals with depression (Mental Health America, 2014a). Even if depression is identified, only about 25% of patients receive treatment consistent with current guidelines (Unutzer et al., 2013). The U.S. Preventive Services Task Force recommends screening for depression in the general adult population (USPSTF, 2016). It is important that all health care professionals receive adequate education about depression in older adults.
Racial, Ethnic, and Cultural Considerations
Studies have consistently found that older racial and ethnic minorities are less likely to be diagnosed with depression than their white counterparts but are also less likely to get treated (Akincigil et al., 2012; Woodward et al., 2013). Hispanic adults aged 50 and older are reported to experience more depression than white, non-Hispanic adults; black, non-Hispanic adults; or other, non-Hispanic adults. Gender differences are also present in depression prevalence, and older women suffer depression at twice the rate of older men (Hall & Reynolds, 2014). Differences in the prevalence of major depressive disorder and other mental disorders may be due to differences in the presentation of self-reported symptoms or other aspects of cultural context (Box 24.3). The new criteria in the DSM-5 addressing culturally based explanatory models will assist in better understanding differences in presentation, help-seeking behavior, and provision of more culturally appropriate treatment for all individuals. Racial, ethnic, and gender differences in mental illness, as well as differences within racial groups, have not received adequate attention in the United States (see Chapter 2).
Consequences
Depression is a common and serious medical condition second only to heart disease in causing disability and harm to an individual's health and quality of life. Depression and depressive symptomatology are associated with negative consequences, such as delayed recovery from illness and surgery, excess use of health services, cognitive impairment, exacerbation of coexisting medical illnesses, malnutrition, decreased quality of life, and increased suicide and non–suicide-related deaths (Abbasi & Burke, 2014; Alexopoulos, 2014; Sacuiu et al., 2016). It is highly likely that nurses will encounter a large number of older people with depressive symptoms in all settings. Recognizing depression and enhancing access to appropriate mental health care are important nursing roles to improve outcomes for older people.
Etiology
The causes of depression in older adults are complex and must be examined in a biopsychosocial framework. Factors of health, gender, developmental needs, socioeconomics, environment, personality, losses, and functional decline are all significant to the development of depression in later life. Depression can occur for the first time in late life or can be part of a long-standing mood disorder with onset in earlier years (Harvath & McKenzie, 2012). Compared with patients 323with early-life depression, older patients with late-onset major depression have less frequent family history of mood disorders. Biologic causes, such as neurotransmitter imbalances, have a strong association with many depressive disorders in late life. This may be a factor in the high incidence of depression in individuals with neurological conditions such as stroke, Parkinson's disease, and Alzheimer's disease (Abbasi & Burke, 2014; Alexopoulos, 2014). High rates of depression are seen in individuals with dementia, and depression is also a risk factor for dementia, particularly early-onset, recurrent, severe depression (Morimoto et al., 2014). Serious symptoms of depression occur in up to 50% of older adults with Alzheimer's disease, and major depression occurs in about 25% of cases. Depression in individuals with Alzheimer's disease may be due to an awareness of progressive decline, but research suggests that there may be a biological connection between depression and Alzheimer's disease as well (Harvath & McKenzie, 2012). Among patients who have suffered a cerebral vascular accident, the incidence of major depressive disorder is approximately 25%, with rates being close to 40% in patients with Parkinson's disease. Medical disorders and medications can also result in depressive symptoms (Boxes 24.11 and 24.12). Other important factors influencing the development of depression are alcohol abuse, loss of a spouse or partner, loss of social supports, lower income level, caregiver stress (particularly caring for a person with dementia), and gender. Some common risk factors for depression are presented in Box 24.13.
Medical Conditions and Depression
• Cancers
• Cardiovascular disorders
• Endocrine disorders, such as thyroid problems and diabetes
• Metabolic and nutritional disorders, such as vitamin B12 deficiency, malnutrition, diabetes Neurological disorders, such as Alzheimer's disease, stroke, and Parkinson's disease
• Viral infections, such as herpes zoster and hepatitis
• Vision and hearing impairment
Medications and Depression
• Antihypertensives Angiotensin-converting enzyme (ACE) inhibitors
• Methyldopa
• Reserpine
• Guanethidine
• Antiarrhythmics
• Anticholesteremics
• Antibiotics
• Analgesics
• Corticosteroids
• Digoxin
• L-Dopa
Risk Factors for Depression
• Chronic medical illnesses, disability, functional decline
• Alzheimer's disease and other dementias
• Bereavement
• Caregiving
• Female (2 : 1 risk)
• Socioeconomic deprivation
• Family history of depression
• Previous episode of depression
• Admission to long-term care or other change in environment
• Medications
• Alcohol or substance abuse
• Living alone
• Widowhood
Implications for Gerontological Nursing and Healthy Aging
Assessment
Making the diagnosis of depression in older people can be challenging, and symptoms of depression present differently in older people. Older people who are depressed report more somatic complaints such as insomnia, loss of appetite, weight loss, memory loss, and chronic pain. It is often difficult to distinguish somatic complaints from the physical symptoms associated with chronic illness. In medically ill individuals, assessment should focus on nonsomatic complaints such as sadness, helplessness, hopelessness, difficulty making decisions, and irritability (Avari et al., 2014).
Hypochondriasis is also common, as are constant complaining and criticism, which may actually be expressions of depression. Older depressed individuals also have a higher rate of psychotic and severe depression with more weight loss and decreased appetite (Abbasi & Burke, 2014).
Decreased energy and motivation, lack of ability to experience pleasure, increased dependency, poor grooming and difficulty completing activities of daily living (ADLs), withdrawal from people or activities enjoyed in the past, decreased sexual interest, and a preoccupation with death or “giving up” are also signs of depression in older people.
Feelings of guilt and worthlessness, seen in younger depressed individuals, are less frequently seen in older people.
Individuals often present with complaints of memory problems and a cognitive impairment of recent onset that mimics dementia but subsides upon remission of depression (previously called pseudodementia).
It is important to note that a large percentage of these patients progress into irreversible dementia within 2 to 3 years, so recognition and treatment of depression are important. It is essential to differentiate between dementia and depression, and older people with memory impairment should be evaluated for depression.
Symptoms such as agitated behavior and repetitive verbalizations in persons with dementia may be an indicator of depression (see Chapter 25).
Comprehensive assessment involves a systematic and thorough evaluation using a depression screening instrument, interview, psychiatric and medical history, physical (with focused neurological exam), functional assessment, cognitive assessment, laboratory tests, medication review, determination of iatrogenic or medical causes, and family interview as indicated (Avari et al., 2014).
Assessment for depressogenic medications, for alcohol and substance abuse, and for related comorbid physical conditions that may contribute to or complicate treatment of depression must also be included (Box 24.14).
Assessment of Depression
• Utilize a depression screening tool (GDS or Cornell if cognitive impairment).
• Assess for suicidal thoughts.
• Investigate somatic complaints and look for underlying acute or chronic stressful events.
• Investigate sleep patterns, changes in appetite or weight, socialization pattern, level of physical activity, and substance abuse (past and present).
• Ask direct questions about psychosocial factors that may influence depression: elder abuse, poor environmental conditions, and changes in the patient role after death or disability of a spouse/partner.
• Obtain psychiatric and medical histories.
• Perform a physical exam including a focused neurological exam.
• Complete a functional assessment (pay close attention to changes in ADL function).
• Perform a cognitive assessment; depressed patients may show little effort during examination, answer “I don't know,” and have inconsistent memory loss and performance during exam.
• Conduct a medication review (assessment for medications that may cause depressive symptoms).
• Ask about psychotic symptoms (delusions, hallucinations) and symptoms of bipolar disorder.
• Perform laboratory work as appropriate to rule out other causes of symptoms (e.g., TSH, T4, serum B12, vitamin D, folate, complete blood count, urinalysis).
• Utilize family/significant others in obtaining key information to correlate patient's symptoms with others' observations; always assess and interview patient first.
Screening of all older adults for depression should be incorporated into routine health assessments across the continuum of care in hospitals, primary care, long-term care, home care, and community-based settings.
The Geriatric Depression Scale (GDS), a self-report scale, was developed specifically for screening older adults and has been tested extensively in a number of settings (see Chapter 8, Table 8-3).
It is only appropriate for cognitively intact individuals and those with mild to moderate cognitive impairment.
The Cornell Scale for Depression in Dementia (CSD-D) is recommended for the assessment of depression in individuals with severe cognitive impairment and includes an interview with an informant followed by an attempted interview with the individual with dementia. If he or she is unable to respond to the questions, many can be completed through observation. The instrument takes about 20 minutes to administer.
Additional research is needed to develop and validate a depression screening instrument that will accurately detect depression symptoms across varying levels of dementia (Brown et al., 2015
Interventions
The goals of depression treatment in older adults are to decrease symptoms, reduce relapse and recurrence, improve function and quality of life, and reduce mortality and health care costs (Harvath & McKenzie, 2012).
When compared with younger individuals, older people demonstrate comparable treatment response rates, although they may have higher rates of relapse following treatment. As a result, treatment may need to be longer to prevent recurrences (Abbasi et al., 2014).
If depression is diagnosed, treatment should begin as soon as possible, and appropriate follow-up should be provided.
Depressed people are usually unable to follow through on their own and without appropriate treatment and monitoring may be candidates for deeper depression or suicide. Interventions are individualized and are based on history, severity of symptoms, concomitant illnesses, and level of disability.
Nonpharmacological Approaches
Current evidence shows that both cognitive-behavioral therapy (CBT) and second-generation antidepressants have similar effectiveness, but the medications are more likely to cause harm than the utilization of CBT alone. The American College of Physicians recommends that clinicians choose between either CBT or second-generation antidepressants to treat patients with major depressive disorder after discussing treatment effects, adverse effect profiles, cost, accessibility, and preferences with the patient (Garthlehner et al., 2016).
Other types of nonpharmacological treatment that have been found to be helpful in depression include family and social support, education, grief management, exercise, humor, spirituality, CBT, brief psychodynamic therapy, interpersonal therapy, reminiscence, life review therapy (see Chapter 4), problem-solving therapy, and complementary therapy (e.g., tai chi) (Abbasi & Burke, 2014; Chan et al., 2014; DeKeyser & Jacobs, 2014).
The development of effective, simplified, and accessible psychotherapeutic approaches, including telephone or Internet-based programs, is important. Despite evidence-based guidelines calling for combined pharmacological and psychotherapeutic treatment, and the fact that older adults often prefer psychotherapy to psychiatric medications, psychological interventions are often not offered as an alternative treatment of depression (American Psychological Association, 2014). Reasons for this include time, reimbursement constraints, and a limited well-trained geriatric mental health workforce (McGovern et al., 2014).
Collaborative care.
Few older adults with mental health disorders receive care from mental health specialists and most prefer treatment in primary care settings. More than 70 randomized controlled trials have shown collaborative care, an evidence-based approach for integrating physical and behavioral health services in primary care, is more effective and cost-efficient than usual care across diverse practice settings and patient populations (Hall & Reynolds, 2014; Unutzer et al., 2013). Some research suggests that collaborative care may improve ethnic and economic disparities in the diagnosis and treatment of depression (Hall & Reynolds, 2014). Collaborative care models include a primary care provider (PCP, an MD or NP), care management staff (often nurses), and a psychiatric consultant working in an interprofessional team. Care managers are trained to provide evidence-based care coordination, brief behavioral interventions/psychotherapy, and treatment support initiated by the PCP, such as medications. The psychiatric consultant, either through face-to-face or by telemedicine consult, advises the team and provides guidance on patients who present diagnostic challenges or who are not yet showing improvement (Hall & Reynolds, 2014; Unutzer et al., 2013).
Pharmacological Approaches
Choice of medication depends on comorbidities, drug side effects, and the type of effect desired. People with agitated depression and sleep disturbances may benefit from medications with a more sedating effect, whereas those who are not eating may do better taking medications that have an appetite-stimulating effect. There are more than 20 antidepressants approved by the FDA for the treatment of depression in older adults. 326 The most commonly prescribed antidepressants are the selective serotonin reuptake inhibitors (SSRIs). These agents work selectively on neurotransmitters in the brain to alleviate depression. The SSRIs are generally well tolerated in older people. Many are now available in both tablet and oral concentrate forms for easier use. Side effects are manageable and usually resolve over time; most cause initial problems with nausea, vomiting, dizziness, dry mouth, or sedation. Hyponatremia can also occur. If sexual dysfunction occurs, it will resolve only with discontinuation; therefore, if the person is or plans to become sexually active, a different drug may be necessary. For those who do not respond to an adequate trial of SSRIs, there is another group of antidepressants that combines the inhibition of both serotonin and norepinephrine reuptake inhibitors (SNRIs) (e.g., venlafaxine [Effexor]). These also may be preferred by those who are engaged in or who anticipate sexual activity because they are less likely to have sexual side effects. One of the atypical antidepressants, such as bupropion (Wellbutrin) or trazodone, may also be used. In the context of reducing polypharmacy, Wellbutrin also reduces nicotine dependency, and trazodone is sedating—for the person who has difficulty getting to or staying asleep. Since the development of the SSRIs and SNRIs, the older monoamine oxidase (MAO) inhibitors and tricyclic antidepressants are no longer indicated because of their high side effect profile including risk for falls. If depression is immobilizing, psychostimulants may be used but cardiac function must be monitored closely because there are limited data on safe use in the older adult (Abbasi & Burke, 2014). All antidepressant medications must be closely monitored for side effects and therapeutic response. Side effects can be especially problematic for older people with comorbid conditions and complex drug regimens. There is a wide range of antidepressant medications, and several may have to be evaluated. Only about one-third of depressed older adults achieve remission with any single agent (McGovern et al., 2014). Similar to other medications for older people, doses should be lower at first (50% of the target does) and titrated as indicated while adequate treatment effect is ensured. A patient who has responded to antidepressant treatment should continue treatment for approximately 1 year after a first depressive episode because recurrence rates are high after earlier discontinuation. After a second or third episode, treatment should be extended after remission and some may require lifelong treatment. Often, older people may be resistant to take medication for depression, and it is helpful to stress that although there may be circumstances precipitating the depression, the final effect is a biochemical one that medications can correct (Abbasi & Burke, 2014).
Other Treatments
Electroconvulsive therapy (ECT) is considered an excellent, safe therapy for older people with depression that is resistant to other treatments and for patients at risk for serious harm because of psychotic depression, suicidal ideation, or severe malnutrition. ECT results in a more immediate response in symptoms and is also a useful alternative for frail older people with multiple comorbid conditions who are unable to tolerate antidepressant treatment.
Rapid transcranial magnetic stimulation (rTMS) is a treatment approved in 2008 by the FDA to treat major depressive disorder in adults for whom medication was not effective or tolerated. The treatment consists of administering brief magnetic pulses to the brain by passing high currents through an electromagnetic coil adjacent to the patient's scalp. The targeted magnetic pulses stimulate the circuits in the brain that are underactive in patients with depression with the goal of restoring normal function and mood. For most patients, treatment is administered in 30- to 40-minute sessions over a period of 4 to 6 weeks. The effectiveness of the treatment is still being evaluated in older adults (Abbasi & Burke, 2014).
Family and Professional Support for Depression
• Provide relief from discomfort of physical illness.
• Enhance physical function (i.e., regular exercise and/or activity; physical, occupational, recreational therapies).
• Develop a daily activity schedule that includes pleasant activities.
• Increase opportunities for socialization and enhance social support.
• Provide opportunities for decision-making and the exercise of control.
• Focus on spiritual renewal and rediscovery of meanings.
• Reactivate latent interests or develop new ones.
• Validate depressed feelings as aiding recovery; do not try to bolster the person's mood or deny his or her despair.
• Help the person become aware of the presence of depression, the nature of the symptoms, and the availability of effective treatments.
• Emphasize depression as a medical, not mental, illness that must be treated like any other disorder.
• Provide easy-to-use educational materials to older adults and family members, such as those available through NIMH.
• Involve family in patient teaching, particularly younger family members who may have different life experiences related to depression and its treatment.
• Provide an accepting atmosphere and an empathic response.
• Demonstrate faith in the person's strengths.
• Praise any and all efforts at recovery, no matter how small.
• Assist in expressing and dealing with anger.
• Do not stifle the grief process; grief cannot be hurried.
• Create a hopeful environment in which self-esteem is fostered and life is meaningful.