Older adults are more susceptible to depression due to the physiological and psychosocial changes that come along with aging. As we age, we are more likely to experience psychosocial changes such as loss of a partner or close friend, retirement, living alone, lack of social interaction, or change in living environment (Cahoon, 2012). Older adults typically have more than one chronic medical condition (comorbidities), and/or a possible decrease in independence or cognitive function, which is secondary to the physiological changes of aging.
These alterations may cause an older adult to experience feelings of sadness, making them at a higher risk for developing depressed feelings.
Other risk factors for depression include female gender, polypharmacy, and substance abuse or dependence (Cahoon, 2012). According to Cahoon (2012), about 1 in 5 elderly Americans have some sort of depressive symptoms. Prolonged feelings of sadness are not a normal aspect of aging, which is still unacknowledged. Depressed older adults are at a higher risk of suicide and are more likely to complete the act compared to the younger adults.
Unfortunately, in older adults, depression is overlooked or underdiagnosed and is subsequently untreated or inadequately treated (Cahoon, 2012).
The term depression describes numerous symptoms of negative emotional experiences. The most commonly seen presentation of depression is moderate to severe feelings of sadness or loss of interest in doing most activities (apathy). These are classical symptoms of major depression. Common presentations of depression include complaints of unexplained fatigue, lack of concentration, changes in weight, anger, anxiety, sadness, irritability, and thoughts of self-harm (Dunphy, Winland-Brown, Porter, & Thomas, 2015).
In older adults, the diagnosis of depression can present in numerous ways.
Many symptoms may overlap with other associated illnesses, making it difficult to determine if the patient is depressed. Depressed older adults may complain of or present with a poor appetite, weight loss, sleep problems, indistinct pain, memory problems, and slowed movement. However, they may not present with the typical presentation of depression in that they may not report being sad at all but have the aforementioned, unexplained physical symptoms (Cahoon, 2012).
Ideally, this syndrome is diagnosed by clinical interview findings. Major depressive disorder is diagnosed with the diagnostic and statistical manual of mental disorders (DSM-5). DSM-5 criteria state that at least five of the following symptoms have been present during the past two consecutive weeks and signify a change from previous functioning. These symptoms include either a depressed mood or anhedonia (loss of interest or pleasure). The other symptoms are as follows: apathy, change in appetite, insomnia or hypersomnia, behavioral agitation or retardation, loss of energy, feeling of worthlessness or guilt, loss of concentration, or recurrent thoughts of death or suicide (Dunphy et al., 2015).
Common misdiagnoses of depression include dementia, Parkinson’s disease, delirium and thyroid disorders. This mistake of misdiagnosis occurs due to the symptom overlap with all of these conditions. It is crucial to perform a thorough patient history and physical examination in order to make the correct diagnosis. Diagnostic testing would include thyroid stimulating hormone and a complete blood count (CBC) to rule out an underlying thyroid disorder or infectious process causing delirium (Dunphy et al., 2015).
According to Zivin (2013), this syndrome can affect a patient’s ability to function or worsen a disability, which could cause unexpected early retirement. It can initiate and exacerbate medical illnesses and potentially lead to death. Depression will have a negative impact on the patient’s quality of life. Treatment for depression in older adults may be delayed due to the fact their symptoms exhibit those similar to another medical condition or illness (Zivin, 2013). The patient’s family and/or caregivers may experience financial stress secondary to the need of providing care for their loved one, which may result in the loss of income. The added physical and emotional demands increase the family and/or caregiver’s risk of depression themselves. Studies show that caregivers for depressed elderly patients have a long-term risk for health issues and increased mortality (Zivin, 2013).
If suspicious for depression, preliminary questioning during the interview should include if the patient has felt down or hopeless over the past month followed by asking if they have little interest in doing things over the past month. If the patient reports experiencing at least one of these over the last month, this warrants further evaluation (Dunphy et al., 2015). However, older adults may not be aware that they are experiencing depressive symptoms.
Therefore, additional questioning should be related to any recent or previous losses they have experienced (Cahoon, 2012). Examples of these may include a loss of a family member, partner, friend, health, job, independence, home, etc. Sadness is a normal emotional response after a loss but demands further evaluation if it persists to feelings of hopelessness. Additional history should include a review of current medication regimen, family history of depression, and personal history of substance abuse (Cahoon, 2012).
According to Dunphy et al. (2015), physical exam findings may mark a flat affect, withdrawn appearance, tearfulness, or irritability during the encounter. There is no hallmark examination finding that directly points to depression. Further evaluation during the examination should include screening tools to rule in or out depression. Screening tools that are validated for older adults should be performed and include Patient Health Questionnaire-9 (PHQ-9), Beck Depression Inventory (BDI), Center for Epidemiologic Studies Depression Screen (CES-D), and/or Geriatric Depression Scale (GDS-15) (Dunphy et al., 2015). All questionnaires can be self-administered and result in a numeric value depending on selected answers. Although BDI has the highest specificity and sensitivity, it is only obtainable by licensing along with a fee, limiting its use. It is followed by GDS, which is more commonly used (Williams & Nieuwsma, 2018).
There is no specific blood work that confirms the diagnosis of depression. However, diagnostic testing is helpful to completely rule out another underlying illness, conditions or disorder (Dunphy et al., 2015). Rodda, Walker, & Carter (2011), emphasizes that the provider should consider ordering a urinalysis, thyroid stimulating hormone, CBC, electrolytes, liver functions tests, and vitamin B12 level. Additional blood work or testing may be needed depending on the information gathered during the interview (Dunphy et al., 2015).
An advanced practice nurse can intervene to prevent depression by promoting and explaining the importance of healthy eating and staying physically and socially active. For older adults, staying connected with other people is critical, whether it be joining a book club, inviting family or friends to come visit, being a part of a senior club, or simply talking on the phone. Direct face to face interaction is preferred (Robinson, Smith, & Segal, 2018). Studies have shown that older adults who socialize are more likely to have an improvement in their mood (Cahoon, 2012). Physical activity such as walking, taking the stairs, or doing light house work. Even if the patient is disabled, it is still possible to do safe exercises. Physical activities release certain chemicals in the body that improve mood. Conversely, Forsman, Schierenbeck, & Wahlbeck (2011) showed that psychosocial interventions as a primary prevention for depression in older adults is questionable. Providers should educate the older adults to minimize their sugar and carbohydrate intake. This type of diet choice leads to a spiked sugar level that quickly crashes, affecting your mood and energy level (Robinson et al., 2018).
In older adults, the first line pharmacological treatment for depression is selective serotonin reuptake inhibitors (SSRIs). Although side effects are common with antidepressants, this class of antidepressant medication is considered the safest option for this population due to its lower risk of side effects and withdrawal symptoms. The risk of side effects is even lower when started on a low dose and slowly titrated up (Rodda et al., 2011). The most concerning side effects include hypotension, sedation, anticholinergic activity, and cardiotoxicity. Antidepressants are abruptly discontinued due to nausea and vomiting. Clinical practice guidelines recommend that treatment for a single depression episode be treated for at least six to 12 months (Cahoon, 2012).
Forsman, et al. (2011) conducted a systematic review and meta-analysis of prospective controlled trials to assess how effective psychosocial interventions were in preventing depression in older adults (aged 65 years and older) compared to the control group. Overall, the results were statistically significant, but not necessarily always applicable since this is based only on two trials, suggesting more research is needed for further evaluation. It also states that there is a need for more research regarding cost effective psychosocial interventions (Forsman et al., 2011). This review recommends that in clinical practice providers need to offer social activities that are meaningful and tailored to the patient’s needs, disabilities, and preferences. Providers should not make the assumption that a social activity works for all depressed older adults (Forsman et al., 2011).