Depression Kurlowit Harvath
Lenore H. Kurlowicz, Theresa A. Harvath
On completion of this chapter, the reader will be able to:
Discuss the consequences of late life depression.
Discuss the major risk factors for late-life depression.
Identify the core competencies of a systematic nursing assessment for depression with older adults.
Identify nursing strategies for older adults with depression.
(for description of Evidence Levels cited in this chapter, see Chapter, Evaluating Clinical Practice Guidelines, page ??) [PUBLISHER PLEASE INSERT PAGE]
DEPRESSION IN OLDER ADULTS
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 utilization of health services (Lebowitz, 1996). Despite the efficacious 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 elders (Charney et al., 2003). In a comprehensive review of research on the prevalence of depression in later life, Hybels & 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. What is more, these depressive symptoms are associated with higher morbidity and mortality rates in older adults (Bagulho, 2002 [Level V]; Lyness et al., 2007).
The rates of depressive symptoms vary, depending on the population of older adults: community-dwelling older adults (3 to 26%), primary care (10%), hospitalized elders (23%), and nursing home residents (16 to 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 adults 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; Blazer, 2003 [both Level VI]). It also should 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.
Late life depression occurs within a context of medical illnesses, disability, cognitive dysfunction, and psychosocial adversity frequently impeding timely recognition and treatment of depression, with subsequent unnecessary morbidity and death (Bagulho, 2002 [Level V]; 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 also is presented.
What is Depression?
In the broadest sense, depression is defined as a syndrome comprised of a constellation of affective, cognitive, and somatic or physiological manifestations (National Institute of Health [NIH] Consensus Development Panel, 1992 [Level I]). Depression may range in severity from mild symptoms to more severe forms, both of which can persist over longer periods of time with negative consequences for the older patient. Suicidal ideation, psychotic features (especially delusional thinking), and excessive somatic concerns frequently accompany more severe depression (NIH Consensus Development Panel, 1992 [Level I]). Symptoms of anxiety may also coexist with depression in many older adults (Cassidy, Lauderdale & Sheikh, 2005; DeLuca et al., 2005). In fact, co-morbid anxiety and depression have been associated with more severe symptoms, decreases in memory, poorer treatment outcomes (Lenze et al., 2001; Deluca et al., 2005), and increased rates of suicidal ideation (Sareen et al., 2005).
The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) (American Psychiatric Association, 2000 [Level VI]) 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, 2000 [Level VI]). 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: (1) depressed, sad, or irritable mood, (2) anhedonia or diminished pleasure in usually pleasurable people or activities, (3) feelings of worthlessness, self-reproach, or excessive guilt, (4) difficulty with thinking or diminished concentration, (5) suicidal thinking or attempts, (6) fatigue and loss of energy, (7) changes in appetite and weight, (8) disturbed sleep, and (9) psychomotor 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. However, older adults may more readily report somatic or physical symptoms than depressed mood (Pfaff & Almeida, 2005 [Level IV]). 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 disregard 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, in spite of treatment of the underlying medical illness or discontinuance of a depressogenic medication (Kurlowicz, 1994). Older patients may link their somatic or physical complaints as the cause of their depressed mood or anhedonia. Depression may also be expressed through repetitive verbalizations (e.g., calling out for help) or agitated vocalizations (e.g., screaming, yelling, or shouting), repetitive questions, expressions of unrealistic fears (e.g., fear of abandonment, being left alone), repetitive statements that something bad will happen, repetitive health-related concerns, and verbal and/or physical aggression (Cohen-Mansfield, Werner, & Marx, 1990).
Depressive symptoms that do not meet standard criteria for a specific depressive disorder are highly prevalent (15% to 25%) in older adults. These symptoms are clinically significant and warrant treatment (Bagulho, 2002 [Level V]; 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 5 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 (Baguhlo, 2002 [Level V]; Gaynes, Burns, Tweed, & Erickson, 2002; [Level III]; 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 affective or mood disorder with onset in earlier 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 [Level III]). As in younger people, the course of depression in older adults is characterized by exacerbations, remissions, and chronicity (NIH Consensus Development Panel, 1992 [Level I]). Therefore, a wait-and-see approach with regard to treatment is not recommended.
Depression in Late Life is Serious
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 utilization, alcoholism, cognitive impairment, worsening social impairment, protein-calorie subnutrition, and increased rates of suicide and non-suicide related death (Bagulo, 2002 [Level V]; von Ammon Cavanaugh et al., 2001 [Level III]). 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. Indeed, a recent study by Gaynes et al. (2002 [Level III]) found that major depression and comorbid medical conditions interacted to adversely affect health-related quality of life in older adults. 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).
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 to -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 due to the fact that white men over age 85 are at greatest risk for suicide where rates of suicide are estimated to be 80 to 113 per 100,000 (Erlangsen, Vach, & Jeune, 2005 [Level III]). In the oldest old (>80 years) 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 [Level III]).
Depressive symptoms, perceived health status, sleep quality and absence of confidant predicted late life suicide (Turvey et al., 2002 [Level IV]). While 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 [Level VI). Disruption of social support (Conwell et al., 2002 [Level VI]), family conflict, and loneliness (Waern, Rubenowitz, & Wilhelmson, 2003 [Level V) are also significantly associated with suicide in late life. Treatment of depression rapidly decreased suicidal ideation in older adults (Bruce et al., 2004 [Level II]; Szanto, Mulsant, Houck, Dew, & Reynolds, 2003 [Level V]). However, elders in higher risk groups (male, older) needed a significantly longer response time to demonstrate a decrease in suicidal ideation (Szanto et al., 2003 [Level V]).
Studies have also shown that contact between suicidal older adults and their primary care provider is common (Luoma, Martin & Pearson, 2002 [Level V]). Almost half of older suicide victims had seen their primary care provider within one month of committing suicide (Luoma et al., 2002 [Level V]), while 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 [Level IV]).
And while 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 (Schulz, Drayer, & Rollman, 2002). 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 persons (McDade-Montez, Christensen, Cvengros, & Lawton, 2006; Stapleton et al., 2005). 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 Misunderstood
In spite of its prevalence, associated negative outcomes, and good treatment response,
depression in older adults is highly underrecognized, misdiagnosed, and subsequently undertreated. 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. Recognition of depression also is 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; Blazer, 2003; Mackin & Arean, 2005 [all Level VI]). If recognized, the treatment response for depression is good: 60% to 80% of older adults remain relapse-free with medication maintenance for 6 to 18 months (NIH Consensus Development Panel, 1992 [Level I]). In addition, treatment of depression improves pain and functional outcomes in older adults (Lin et al., 2003 [Level II]). 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 (Iosifescu, 2007). Depressed 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 biologic and psychosocial causes for late-life depression have been proposed. Genetic factors or heredity seem to play more of a role when older adults have had depression throughout their life (Blazer & Hybels, 2005 [Level VI]). Additional biologic causes proposed for late-life depression include neurotransmitter or "chemical messenger" imbalance or dysregulation of endocrine function (Blazer, 2002; Blazer, 2003 [both Level VI]). 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 [Level IV]). Possible psychosocial causes for depression in older adults include cognitive distortions, stressful life events, especially loss, chronic stress, low self-efficacy expectations (Blazer, 2002 ; Blazer, 2003 Blazer & Hybels, 2005 [all Level VI]), and a history of alcohol abuse (Hasin & Grant, 2002 [Level III]) (see Chapter 30, Substance Misuse and Alcohol Use Disorders in Older Adults).
The social and demographic risk factors for depression in older adults include female sex, unmarried status (particularly widowed), stressful life events, and the absence of a supportive social network (NIH Consensus Development Panel, 1992 [Level I]). Interestingly, in a meta-analysis of the impact of negative life events on depression in older adults, Kraaij, Arensman and Spinhoven (2002 [Level I]) found that while specific negative life events (e.g., 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 caregiving has been repeatedly associated with higher rates of depression in older caregivers (Pinquart & Sorensen, 2004 [Level I]). In particular, caring for an older adult with dementia has been associated with higher rates of depression than other caregiving situations (Pinquart & Sorensen, 2004 [Level I]). 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 the older adult who is 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, Schulz, & Lebowitz, 2005 [Level VI]). In an evidence-based review, Cole (2005 [Level I]) 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 (Holmes & House, 2000 [Level I]).
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 [Level VI]). In a systematic review and meta-analysis, Cole and Dendukuuri (2003 [Level I]) 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 [both Level I]).
Depression Among Minority Older Adults
Rates of depression among minority older adults are not well understood. Beals and colleagues (2005 [Level IV]) 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 [Level VI]) found lower rates of depression and higher rates of psychotic diagnoses among African American older adults. Williams and colleagues (2007 [Level IV]) 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 [Level IV]). A study of Medicare plus enrollees revealed that minority older adults received substantially less follow-up for mental health problems following hospitalization (Virnig et al., 2004 [Level IV]).
Although misdiagnosis and subsequent inappropriate treatment can lead to poor health outcomes for minority older adults (Kales & Mellow, 2006 [Level VI]), it is not clear that “simple” bias alone can explain the disparities in depression management that exist. For example, Beals and colleagues (2005 [Level IV]) point out that differences in the social construction of depressive experiences may confound the measurement of depression in ethnic older adults. Older American Indians may be reluctant to endorse symptoms of depression because cultural norms associate these complaints with weakness (Beals et al., 2005 [Level IV]). In a thoughtful analysis of health disparities, Cooper and colleagues (2006 [Level VI]) explored 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.
Assessment of Depression in Older Adults
Box 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 [Level VI]).
Depression Screening Tool
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 & Pignone (2003 [Level I]) 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 Epidemiological Studies Depression Scale (CES-D) (Radloff, 1977) and the SelfCARE(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 [Level I]).
The GDS-SF is a 15-item self-report depression screening tool that is frequently used in a variety of clinical settings. This scale has been validated and used extensively with older adults, including those who are mentally ill, mild to moderately cognitively impaired, or institutionalized. It has a brief yes/no response format and takes approximately 5 minutes to complete. The GDS contains few somatic items that may be potentially confounded with symptoms caused by a medical illness. A GDS-SF score of 11 or greater is almost always indicative of depression and a score of 6 to 9 indicates possible depression warranting further evaluation (Sheikh & Yesavage, 1986). The GDS-SF is not a substitute for an individualized assessment or a diagnostic interview by a mental health professional but is a useful screening tool to identify an elderly patient's depression. Because many older adults do not present with obvious depressive symptoms (Pfaff & Almeida, 2005 [Level IV]), it is important that screening for depression among older adults is incorporated into routine health assessments.
Individualized Assessment and Interview
Central to the individualized depression assessment and interview is a focused assessment of the full spectrum of symptoms (nine) for major depression as delineated by the DSM-IV (American Psychiatric Association, 2000 [Level VI]). 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 elder'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 also should be obtained and/or reviewed and include thyroid stimulating hormone levels, chemistry screen, complete blood count, and medication levels if needed. An electrocardiogram, serum B12, a urinalysis, and serum folate also should be considered to assess for coexisting medical conditions. These conditions may contribute to depression or might complicate treatment of the depression (Alexopoulos, Katz, Reynolds, Carpenter, & Docherty, 2001 [Level VI]). In medically ill older patients, who frequently have multiple medical diagnoses and are prescribed multiple medications, these "organic" factors in the cause of depression area 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, depressogenic medications should be eliminated, minimized, or substituted with those that are less depressogenic (Dhondt et al, 1999 [Level IV]). 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.