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Revised by M. Smith (2006) from K.C. Buckwalter & M. Smith (1993), “When You Are More Than ‘Down in the Dumps’: Depression in the Elderly,” The Geriatric Mental Health Training Series, for the Hartford
Center of Geriatric Nursing Excellence, College of Nursing, University of Iowa.
When You Are More Than When You Are More Than ““Down in the DumpsDown in the Dumps””
Depression in Older AdultsDepression in Older Adults
Facts About DepressionFacts About Depression
The most common psychiatric illness for people of all agesUnder- and mis-diagnosed in older adultsMistaken for “problems of aging”
Facts About DepressionFacts About Depression
Risk factors includeFemale genderChronic & disabling illnessLack of social supportRecently bereavedPrior history of depression
7 of 35 million older adults have depression!!!
Diagnosis is DifficultDiagnosis is Difficult
Coexistence of many other problems
medicalphysicalsocialeconomic“normal” aging
May “mask”depression
TRUE FALSE
Suicide in Older AdultsSuicide in Older Adults
Represent 13% of the populationAccount for 1/5 (20%) of all reported suicidesLowest rate of ATTEMPTSHighest rate of COMPLETED SUICIDE
Indirect SuicideIndirect Suicide
Starvation, refusingto eatRefusing neededmedicationsMixing medicationsAlcohol abuseLoss of “will to live”
Poor OutcomesPoor Outcomes
Comorbid ConditionsAnxietyMedical problemsCognitive impairment
Concurrent Problems & IssuesPsychotic depressionImpaired social supportStressful life events Multiple previous episodes
Changes in MOODChanges in MOODSadnessDiscouragementCryingFeeling “down”Having the “blues”Despair
IrritabilityBeing “on edge”AnxietyBroodingPanic attacks
Changes in PERCEPTIONChanges in PERCEPTION
WithdrawalHopelessnessSelf reproach for minor failingsInability to express pleasure
DelusionsHallucinationsWorthlessnessUnreasonable fearsCritical of self, others
Changes in BEHAVIORChanges in BEHAVIORAppetite changeWeight loss/gainSleep disturbanceFatigue, loss of energySlowed speechHealth concerns
Can’t think, concentrateThoughts of deathTachycardiaConstipationPacing, wringing hands
Depression or ???Depression or ???
Stop! Think about CHAIN OF EVENTS!Tempting to think personis “putting us on” or“manipulating”Behaviors are part of depressionAdjust expectations & approaches: Person cannot “just cheer up” or “look at bright side”!
Major DepressionMajor Depression
Depressed mood most of the day, everyday
ORLoss of interest or pleasure nearly every day
and at least 4 additional symptoms . . .
Major Depression, cont.Major Depression, cont.
Significant weight loss or gainInsomnia orhypersomniaPsychomotor agitation orretardationFatigue or loss of energy
Feelings of worthlessness, inappropriate guilt Loss of ability to think, concentrate, make decisionsRecurrent thoughts of death, suicidal ideation
FOUR ADDITIONAL SYMPTOMS
MINOR DepressionMINOR DepressionAlso known as
subsyndromal depressionsubclinical depressionmild depression
2 - 4 times more common than major depression
Associated with:subsequent major depressiongreater use of health servicesreduced physical, social functioningloss of quality of life
Responds to same treatments!
Common Causes of DepressionCommon Causes of Depression
CHAIN OF EVENTSStress & lossBiological depressionPhysical illness and its treatment interact with depression in older adults
Stress and Loss in Late LifeStress and Loss in Late LifeDecreased sensory capacity
visionhearing
Changes in social status, responsibility to othersLoss of family, friends
Relocation due to changing abilitiesDeclining social contacts due to health limitationsReduced functional statusDwindling financial resources
Stress and Loss in Late LifeStress and Loss in Late LifeLoss of meaningful roles
productivitypurpose in living
Loss of self-esteemhelplessnesspowerlessness
Decreased coping options
Biological DepressionBiological Depression
Genetic cause vs. “reaction” to stressseems to come out of “nowhere”family, personal history more commonincreased risk of severity, reoccurrence
Effects of environment and physical illness are still important to address!!
Physical Illness & DepressionPhysical Illness & Depression
Physical illness directly cause symptoms of depression
metabolicendocrineneurologicpulmonarycardiovascularmusculoskeletalothers: cancer, anemia
Physical Illness & DepressionPhysical Illness & DepressionPhysical illness can cause a reaction of depression by causing
chronic pain,fear of paindisability, loss of functionloss of self esteemincreased dependencefear of death
Physical Illness & DepressionPhysical Illness & Depression
Depressed elderly may present with somatic (physical) complaints
aches, painsappetite, weightfatigue, loss of energyconstipationtachycardiainsomnia
Physical Illness & DepressionPhysical Illness & Depression
Medications can cause symptoms of depression
antihypertensivespsychotropicsanalgesicscardiovacscularantimicrobialssteroidsothers
Physical Illness & DepressionPhysical Illness & Depression
Environment in which physical illnesses are treated may contribute to depression . . .
IsolationSensory deprivationEnforced dependency
AssessmentAssessmentDepression symptomsSuicidal thoughtsPsychiatric history
personalfamily
Physical health/illnessMedicationsRecent loss/stressResources/abilities
Geriatric Depression ScaleGeriatric Depression Scale
Score “0” or “1”Add up points (0-30)Further assessment if > 10Remember! Screening tool; assess symptoms further!!
Suicide AssessmentSuicide AssessmentAlways ASK!!!“Have you thought that life isn’t worth living?”If YES, then . . .
“Have you thought about harming yourself?If YES, then . . .
“Do you have a plan?”If YES, examine lethality. . .
Is the plan viable? Can they execute it?Are means deadly, available?
Look carefully!!
Psychiatric HistoryPsychiatric HistoryPrevious episodes of depression
Check chart/recordUndiagnosedBad nerves; nervous breakdown; went to bed sickAfter childbirth, (post-partum), children leave (empty nest), death of loved one, retirement
Physical Health/IllnessPhysical Health/Illness
Consider factors thatincrease isolation, loneliness, fear, or worthlessness!!
Loss of mobilityLevel of disabilityWorry about declining abilitiesPain resulting from health conditions
Look for factors thatdirectly increase depression symptoms
MedicationsNew?Change in dose?
New onset of physical illness
Influenza?Change in status of chronic diseases
Recent LossRecent Loss___ recent relocation?___ change in relationships?___ change in health?___ change in functional abilities?___ change in sensory status?___ change in financial status?___ death of loved one? (even a pet)___ loss of control over daily routines?___ loss of significant role?
Resources & AbilitiesResources & Abilities___ family support?___ community support?___ social network?___ physical abilities?___ functional abilities?___ cognitive abilities?___ financial resources? ___ personality traits? personal history?___ experiences, beliefs, convictions?
PersonPerson--CenteredCentered
Appreciate the older person’s perspective and experience:
control, power lossunwanted dependencymeaning of functional losses, relationship to activity, meaning and purpose in living
Facility, Staff
InterventionsInterventions
Depression is highly treatableDepression is sometimes called “A reason for hope”Many treatments
Talking therapyMedicationsDaily contacts
InterventionsInterventions
Every interaction has “Therapeutic Potential”Social environmentor “milieu” is powerful
Support, encouragementSafety, securityInteraction, involvementValidate worth by the way we treat them!
InterventionsInterventions
First-Line InterventionsCommunicate caring Help see they are unusually sad or blueProvide accurate information about depressionCreate a healthy physical and social environment.
InterventionsInterventions
Communicate caringRemind: WE VALUE THEMeven if they don't seem to careabout themselves right nowAsk: how they feel or what they thinkEncourage: to talk about issues, fearsUnderstand: their point of viewAccept: sadness, other feelings
InterventionsInterventions
Help to realize they are UNUSUALLY sad, blue
Suggest: more than "down in the dumps"Help: identify the things that are troublingRecall: past positive events things haven't always been this badNote: Positive attributes, characteristics they do still have worth!!
InterventionsInterventions
Provide information about DEPRESSION
An ILLNESS, like physical illnessSymptoms are part of depressionCommon in people of all agesHas a treatment AND treatment works
MedicationsTalking therapiesIncreased involvement in activities
Promote Mental HealthPromote Mental Health
Reduce “depressing effects”of the environmentAdjust factors in the social environment
Promote health & well-beingAlter approaches to careOffer different activities/experiences
Promote positive health outcomes!!
Monitor Physical HealthMonitor Physical Health
NutritionEliminationSleep/rest patternsPhysical comfortPain management
relaxation methodsmedicationalternative therapies
Encourage Physical ActivityEncourage Physical ActivityExercise programReferrals
physical therapyoccupational therapyrecreational therapy
Develop daily activity scheduleInvolve in meaningful activity
Promote AutonomyPromote AutonomyCreate mastery experiences
break tasks into stepsassure successpromote self worth, build confidence
Encourage personal control, power
independent activitydecision-makinginvolvement in care
Focus on PositiveFocus on PositiveCurrent abilities
knowledge, wisdomexperiencesattitudes, beliefsattributes
Reminiscence promotes self worthstrengthens tie to identify, “former self”stimulates interests, conversation
Employ Alternative TherapiesEmploy Alternative TherapiesPet therapy
unconditional positive regardsensory stimulationsense of responsibility, meaningful role
Horticultural therapylifespan simulationaroma therapymaintain mobility
Encourage Group ActivitiesEncourage Group Activities
Psychosocial therapiesReminiscenceRemotivationHealth, stress managementSensory stimulation
Many benefitsSocial interactionMastery experiencesRealization “I am not alone in this!
Promote CreativityPromote Creativity
Lots of alternatives:Singing, playing musicStory-tellingDrawing, paintingPoetry, writingMaking crafts, jewelry
Associated with positive health outcomesDecreased depression, lonelinessIncreased health, morale, satisfaction, activity
Enhance Social SupportEnhance Social Support
Identify a “point person”to help identify, mobilize resources
family memberfriend, neighborchurch membersclergyvolunteer visitorpeer counselor
Professional InterventionsProfessional Interventions
Individual therapyGroup therapyMedication therapy
Antidepressants– most commonOthers may be neededfor anxiety or psychotic symptoms
DepressionDepression
A REASON
FOR HOPE