Diagnosis and Treatment of Depression in the Elderly
Mental disorders are becoming more prevalent in today’s society as people add stress and pressure to their daily lives. The elderly population is not eliminated as a candidate for a disorder just because they may be retired. In fact, mental disorders affect 1 in 5 elderly people. One would think that with disorders being rather prevalent in this age group that there would be an abundance of treatment programs, but this is not the case. Because the diagnosis of an individual’s mental state is subjective in nature, many troubled people go untreated regularly (summer 1998). Depression in the elderly population is a common occurrence, yet the diagnosis and treatment seem to slip through the cracks.
Depression is an example of a metal condition that may slip through the cracks when it comes to detection. The health care industry contributes to the overlooking of depression in the elderly because of the overwhelming desire to keep costs down. The factors of depression are open for interpretation, which results in different doctors looking for different things. In addition to that, elderly people may not exhibit the traditional symptoms of depression either. Aged individuals may have symptoms of depression that go unnoticed due the fact that those symptoms are being attributed to a different ailment. “One half of all depressed patients seen by general physicians are not identified as depressed (August 1995).” Also, some of the things people look for in detecting depression are things that society seems to think are the norm for our elders (October 1999).
In addition, there appear to be a few fundamental differences between depression in the young and old. Elderly people tend to have more ideational symptoms, which are related to thoughts, ideas, and guilt. Elderly depressed individuals are also more likely to have psychotic depressive and melancholic symptoms such as anorexia and weight loss. Finally, older people tend to have more anxiety present in their depression than younger patients do (winter 1996).
In the natural order of things, bodies tend to wear down somewhat and people become higher risk candidates for various health problems. It is the increase in health problems that allows for some symptoms of depression to be overlooked. Doctors begin to attribute all problems and ailments to the primary problem, neglecting the possibility of depression. The prevalence of low blood pressure is one of those items that do increase as an individual ages. The correlation of depression with low blood pressure also increases as time passes, particularly among men. A study by Barrett-Connor and Palinkas indicated “men with low blood pressure scored significantly higher on both the emotional and physical items of a depression test (February 1994).” These same individuals also scored higher on measures of pessimism, sadness, loss of appetite, weight loss, and preoccupation with health than did people with normal blood pressure. Some believe that because low blood pressure can cause fatigue, anyone with these two symptoms could possibly be diagnosed with depression. This is a snowball effect where the low blood pressure causes the fatigue, which in turn causes someone to feel useless, which further develops into other possible depressed symptoms. An interesting side note to this study was that the low blood pressure found in the patients was not directly related to any chronic health condition (February 1994).
Low blood pressure is not the only risk factor for the development of depression. Some other factors include losses dealing with jobs, status, finances, physical ability, or relocation. Family problems dealing with divorce, siblings, children, or a death can also send one on a downward spiral. Changes in the brain such as decreased adaptive capacity, neurotransmitter and receptor changes, cognitive impairment, and dementia increase the risk of depression (winter 1996). As more factors enter the equation and the patient becomes more depressed, the likelihood of a suicide attempts increases.
As previously mentioned, diagnosing depression in the elderly can be a challenging task due to all of the factors involved. When considering if an individual is depressed, one must examine the individual’s background, cognition, medical history, etc. In order to diagnose depression, there are written and oral inventories of a person’s mind that need to be performed. Symptoms of severe depression include: diminished interest in usual activities, significant weight loss or gain, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or guilt, diminished ability to concentrate, and recurrent thoughts of death or suicide. Depression does not always have to be severe. To be diagnosed with mild depression or dysphoria, the mood of the patient would first need to be depressed for two years. In addition to that, two of the following characteristics would need to be present: low self-esteem, poor concentration, difficulty making decisions, overeating or a poor appetite, low energy level, insomnia or hypersomnia, and feelings of hopelessness (August 1995).
Diagnosing depression can be a difficult task due to the human element involved. A recent study by Jackson and Baldwin tested nurses’ skills of observation in detecting depression in hospital patients. They were asked to categorize patients as definitely not depressed, probably not depressed, probably depressed, and definitely depressed. The responses given by the nurses were checked against written inventories that had been filled out and analyzed. The results indicated the nurses were not accurate in their assessment until those labeled as “probably not depressed” were moved into the “definitely depressed” category. This illustrates that the patient may have exhibited symptoms of depression, but those symptoms were attributed to another health problem leading to the diagnosis of depression being overlooked (September 1993).
Another way to diagnose a patient is by having the patient complete the GDS, or Geriatric Depression Scale once he or she had been treated for the primary illness. This is a 30-question survey of things happening to a patient, both physically and mentally. These results are then analyzed using the Geriatric Mental Status Schedule (GMSS) on a computer. The GMSS compares psychiatric symptoms in stage 1 to organic disorders in stage 2. Preferences are given to organic disorders in stage 2 because it is believed that these are the primary causes. In GMSS stage 1 the patient must score a severity level of 3 (out of 5) to be classified as syndromal depression. In the experiment conducted by Jackson and Baldwin 36% of the sample was classified as having syndromal depression. This sample was made up of elderly medically ill hospital inpatients. The selection appears to reflect the general population fairly well, as it is believed that between 9% and 45% of the medically ill elderly experience depression (September 1993).
There are many ways to go about treating depression in the elderly. According to American Family Physician (April 1996), “there are 7 guidelines to follow: 1) correct any underlying illness; 2) avoid, if possible, prescribing medications that may cause or exacerbate depression; 3) decrease isolation due to sensory deprivation; 4) increase stimulation; 5) consider psychotherapy; 6) consider psychiatric referral for severe depression, and 7) consider the use of antidepressants.”
Cognitive therapy has been used successfully to treat depression in young and middle aged individuals. It is this success that has brought on the growing interest in the results of cognitive therapy on elderly depressed patients. In addition to the success, “the US National Institute of Health consensus conference highlighted the need for continued development in this area (January 1997).” The types of psychological treatments used on the elderly are specifically designed for aged persons. The central idea in cognitive therapy is to take the negative self-opinion and teach ways to reverse this opinion. Validation and reminiscence are examples of techniques used to get the patient to reflect on the accomplishments of his or her lifetime. Hopefully, this will bring back some pleasant memories of family or other accomplishments. It also allows the patient to look at the impact he or she has made in the lives of others and provides feelings of usefulness. These memories and feelings aid in the individual viewing himself as he once did, with a positive outlook.
People often develop negative opinions, called cognitive distortions based on difficulties adapting to change. Normal changes in physical ability, memory, living arrangements, etc. that occur naturally with time can cause an individual to view his life as worthless. The tendency to blame oneself becomes popular because the person likely has an unrealistic view of the aging process. Thus, the goal of cognitive therapy becomes equipping the patient with the ability to alter their internal biased view of life events (January 1997).
Medication, specifically antidepressants are among the other treatment options for depression in the elderly. Antidepressants are drugs the patient takes to improve his or her overall mood. These pills must be taken regularly and require several weeks of ingestion before any results will be noticeable. According to Dr. Sunderland, “every primary care physician should have at least two or three medicines they feel comfortable using (April 1997).” To feel comfortable using a medicine, one must be informed about side effects, how to begin dosing, when to switch dosage, and what to look for in blood tests. Many senior citizens take prescriptions regularly for various ailments. Due to the fact that many senior citizens take multiple prescriptions daily, the physician must also be familiar with how the various drugs interact with prescriptions the patient is currently taking (April 1997).
The most commonly used and most successful antidepressants are tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRI’s’). Tricyclic antidepressants include nortriptyline and desipramine and are frequently used for depressed patients with insomnia. Their side effects include hypotension and constipation, which may be too much for the patient to bear. SSRI’s include fluoxetine (Prozac) and paroxetine (Paxil) and are generally classified as safer, with fewer side effects. The known side effects are insomnia, nausea, and mild headache, which may be more bearable to the individual (April 1996). MAO inhibitors are another type of antidepressant, but not prescribed as frequently due to the alterations a patient must make to his or her diet (August 1995).
Electroconvulsive therapy (ECT) is the treatment for depression used when results are needed immediately and is nearly 80% effective. Only 25% of depressed patients receive this treatment, but it has proved effective when it has been utilized. ECT sends electric pulses (shock waves) into the brain, which enhance the patient’s mood as an antidepressant would. Patients with suicidal tendencies or severe weight problems would be justifiable in using ECT. ECT is a great solution to short term depression because the patient feels better quickly and avoids having to take expensive drugs for an extended period of time. Recent technological advancements allow for treatment of just one side of the brain if so desired whereas in the past it was the entire brain or not at all (April 1997).
Most experts will agree that the most effective way to treat depression is a combination of any or all methods. Each treatment has merits by itself, but those multiply when combined. The most popular combination of treatments includes using antidepressants in conjunction with regularly scheduled visits to a professional. This allows for the drugs to aid in improving the mood between visits, while the visits teach the person how to cope with any cognitive distortions that may arise. The biggest challenge when treating depression is convincing the patient to stick with any type of therapy. Patients become stubborn and quit taking their medication or visiting the doctor as soon as they begin to feel better. This is a huge mistake because it will only cause the individual to fall back into the old patterns and problems.
Depression is one of those conditions that can return if proper preventative measures are not taken. Patients need to understand that depression can return at any time and certain precautions must be taken. The individual needs to continue drug treatments in conjunction with doctor visits to have the highest rate of recovery. A study done by Dr. Reynolds showed that 3 years after being treated for depression, patients who used drug treatments and continued regular visits to the doctor only had a 20% relapse rate. Those who did not continue their medication or doctor visits had a 90% rate of relapse. Dr. Reynolds states, “Our results demonstrate the importance of adding just one counseling secession a month to a medication regimen (March 1999).” It is important to treat depression as early as possible because once the patient passes the age of 70 it becomes difficult for any long-term results. Depression is no different from most other medical problems in that the earlier the problem is detected the better the chances of a successful recovery.
Elderly individuals have many potential reasons to be depressed ranging from society’s perception of them to their own self-opinion. The health of a person also begins to decline as they age which reinforces the depressed state of mind. The elderly deserve our respect and support through their physical and emotional difficulties because we would not be around if not for them. The diagnosis and treatment of depression in the elderly may not be a simple task, but it is one that deserves more attention and further advancement.
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