Recognizing and Treating Depression: A Guide for the Elderly and Their Caregivers
by Rich OBoyle, Publisher
Depression greatly diminishes a persons quality of life, personal joy and productivity. Too often elderly persons who reside in assisted living facilities, nursing homes, or live alone suffer from depression. Their declining health and functioning, multiple life changes, and diminished personal resources are factors predisposing them to depression. Unfortunately, those family members who care for them also suffer disproportionately from depression and other adverse health conditions.
Depression is a medical condition, which affects the whole person; body, mind and spirit. Societal stigma and misunderstandings continually affect detection, treatment and prevention of depression. Depression can be managed and treated so that the persons quality of life, personal joy, and productivity can return. Because depression is a common and personally devastating condition for elderly people, it is essential that family members and caregivers watch for warning signs and help their elders to seek treatment.
Major depressive disorder, often referred to as depression, is a common illness that can affect anyone. About 1 in 20 Americans (over 11 million people) get depressed every year. Depression affects twice as many women as men. Late-life depression is quite different from depression in the non-elderly population. In the United States, about 15% of elderly people living in the community (e.g., living at home or with family members) are depressed, while 30-40% of those residing in nursing homes are depressed. Major depression occurs in approximately 1-4% of the community-based elderly; this rate increases to 10-12% in medical care settings and 20-25% in nursing homes.
Family caregivers experience high rates of depression and illness while caring for loved ones. According to a 1998 study by the National Family Caregivers Association, 61% of "intense" family caregivers (those providing at least 21 hours of care a week) have suffered from depression. Some studies have shown that caregiver stress inhibits healing. A 1999 study published in the prestigious Journal of the American Medical Association found that elderly caregivers with a history of chronic illness themselves who are experiencing caregiving related stress have a 63% higher mortality rate than their non-caregiving peers.
Caregivers need to be aware of the warning signs of depression in both the individuals who they care for, and themselves.
Depression is more than sadness and low mood. It is more than the "low feeling" we all experience now and then but goes away when we take a walk or have coffee with a friend. Depression is more than the grieving that occurs after the death of a loved one.
Depression is the darkest of moods. It is an empty feeling. Many things and people are no longer interesting. Aches and pains keep coming back and go on and on for weeks, months, or years. Depression is a whole body disorder that affects the way you think, and the way you feel, both physically and emotionally. It isnt normal to feel depressed all the time when you get older. On the contrary, most older people feel satisfied with their lives.
Depression is difficult to recognize in the elderly because other changes are also occurring and these can mask real depression. Physical conditions, grieving, and dementia may commonly mask depression. The way depression is expressed is also different in the elderly than in other populations. Instead of looking sad, elderly with depression will more often have physical ailments, headaches, and stomach pain, with no medical cause and be tired or irritable.
Depressive disorders come in different forms, just as is the case with other illnesses such as heart disease.
Major depression is manifested by a combination of symptoms (see symptom list) that interfere with the ability to work, study, sleep, eat, and enjoy once pleasurable activities. Such a disabling episode of depression may occur only once but more commonly occurs several times in a lifetime.
A less severe type of depression, dysthymia, involves long-term, chronic symptoms that do not disable, but keep one from functioning well or from feeling good. Many people with dysthymia also experience major depressive episodes at some time in their lives.
Another type of depression is bipolar disorder, also called manic-depressive illness. Not nearly as prevalent as other forms of depressive disorders, bipolar disorder is characterized by cycling mood changes: severe highs (mania) and lows (depression). Sometimes the mood switches are dramatic and rapid, but most often they are gradual. When in the depressed cycle, an individual can have any or all of the symptoms of a depressive disorder. When in the manic cycle, the individual may be overactive, over-talkative, and have a great deal of energy. Mania often affects thinking, judgment, and social behavior in ways that cause serious problems and embarrassment. For example, the individual in a manic phase may feel elated, full of grand schemes that might range from unwise business decisions to romantic sprees. Mania, left untreated, may worsen to a psychotic state.
Depression is dangerous in and of itself. However, researchers are finding that depression is often an unwanted co-traveler with other diseases and disorders, and can create its own health problems. Depression frequently co-occurs with stroke, osteoporosis, urinary incontinence, diabetes, cancer, anxiety disorder, and substance abuse. It appears now that depression is an important risk factor for heart disease along with high blood cholesterol and high blood pressure. Depression may make it harder to take the medications needed and to carry out the treatment for heart disease. It also may result in chronically elevated levels of stress hormones that can harm the heart.
According to the National Institutes of Health, older Americans are disproportionately likely to commit suicide. Individuals ages 65 and older accounted for 19% of all suicide deaths in 1997, even though they comprised only 13% of the general population.
Signs and Symptoms of Depression
If a person has five or more of these symptoms for more than two weeks, it is important that these symptoms be brought to the attention of the individual's health care provider.
1. Behavioral Changes
2. Thinking Changes
3. Mood changes
4. Physical Changes
Is it Depression or Dementia?
Several of the symptoms related to changes in thinking or cognition. Knowing whether the main problem is depression or dementia is often difficult. Depression can imitate dementia and both depression and dementia can have depressive symptoms. Depression can also be superimposed on dementia. In the early stages of dementia, the person may know that his/her memory is declining and this loss can lead to depression. Only a qualified medical professional can conclusively make the distinction between the two. It is helpful to keep notes on suspected dementia-like problems.
Sources: RSI, Inc. and Geriatric Nursing & Healthy Aging
Depression Is a Medical Condition
Modern brain imaging technologies developed over the last few decades are revealing that in depression, neural circuits responsible for the regulation of moods, thinking, sleep, appetite, and behavior fail to function properly, and that critical neurotransmitters chemicals used by nerve cells to communicate are out of balance. Genetics research indicates that vulnerability to depression results from the influence of multiple genes acting together with environmental factors. Studies of brain chemistry and of mechanisms of action of antidepressant medications continue to inform the development of new and better treatments.
What Tips the Balance?
Depression is Not a Normal Part of Aging
As a person ages, the signs of depression are much more likely to be dismissed as crankiness or grumpiness. There is a widespread belief that depression is a natural consequence of aging rather than a treatable source of disability and suffering. This is not true. Depression is not a part of the aging process. Furthermore, there is a widespread belief that depression is a personal weakness in which the depressed person should "snap out of it." The depressed person is personally ashamed and tries to hide his/her feelings by pretending nothing is wrong but inside they feel miserable.
There is widespread ignorance and inadequate recognition of the symptoms of depression because, especially in the elderly, a physical condition, grieving or dementia can mask them. Those who are depressed dont even recognize their own symptoms of depression.
One of the most effective and important mechanisms to combat depression is to emphasize providing elderly people with rehabilitation for illness and injury. This is a concept that in some settings has been lost. Often older people become depressed as a result of injury or illness and therefore need to undergo rehabilitation. Depression has been shown to be a barrier to rehabilitation, so it is critical to address both illness and injury as well as depression simultaneously in order to prevent debilitation in the elderly.
Management of Depression
Reaping the benefits of treatment begins by recognizing the signs of depression. The next step is to be evaluated by a qualified professional. Although depression can be diagnosed and treated by primary care physicians, often the physician will refer the patient to a psychiatrist, psychologist, clinical social worker, or other mental health professional. An informed consumer knows her treatment options and discusses concerns with her provider to form a partnership.
Even severe depression can be highly responsive to treatment. Indeed, believing one's condition is "incurable" is often part of the hopelessness that accompanies serious depression. Such individuals should be provided with the information about the effectiveness of modern treatments for depression in a way that acknowledges their likely skepticism about whether treatment will work for them. As with many illnesses, the earlier treatment begins, the more effective and the greater the likelihood of preventing serious recurrences. Of course, treatment will not eliminate life's inevitable stresses and ups and downs. But it can greatly enhance the ability to manage such challenges and lead to greater enjoyment of life.
The first step in treatment for depression should be a thorough examination to rule out any physical illnesses that may cause depressive symptoms. Since certain medications can cause the same symptoms as depression, the examining physician should be made aware of any medications being used. If a physical cause for the depression is not found, a psychological evaluation should be conducted by the physician or a referral made to a mental health professional.
Antidepressant medications are widely used effective treatments for depression. Existing antidepressant drugs are known to influence the functioning of certain neurotransmitters in the brain, primarily serotonin and norepinephrine, known as monoamines. Older medications tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) affect the activity of both of these neurotransmitters simultaneously. Their disadvantage is that they can be difficult to tolerate due to side effects or, in the case of MAOIs, dietary and medication restrictions.
Newer medications, such as the selective serotonin reuptake inhibitors (SSRIs), have fewer side effects than the older drugs, making it easier for patients including older adults to adhere to treatment. Both generations of medications are effective in relieving depression, although some people will respond to one type of drug, but not another.
Certain types of psychotherapy also are effective treatments for depression. Cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT) are particularly useful. Approximately 80 percent of older adults with depression improve when they receive appropriate treatment with medication, psychotherapy, or the combination.
In fact, recent research has shown that a combination of psychotherapy and antidepressant medication is extremely effective for reducing recurrence of depression among older adults. Those who received both interpersonal therapy and the antidepressant drug nortriptyline (a TCA) were much less likely to experience recurrence over a three-year period than those who received medication only or therapy only.
Studies are in progress on the efficacy of SSRIs and short-term specific psychotherapies for depression in older persons. Findings from these studies will provide important data regarding the clinical course and treatment of late-life depression. Further research will be needed to determine the role of hormonal factors in the development of depression, and to find out whether hormone replacement therapy with estrogens or androgens is of benefit in the treatment of depression in the elderly.
Although some individuals notice improvement in the first couple of weeks, usually antidepressant medications must be taken regularly for at least 4 weeks and, in some cases, as many as 8 weeks, before the full therapeutic effect occurs. To be effective and to prevent a relapse of the depression, medications must be taken for about 6 to 12 months, carefully following the doctor's instructions. Medications must be monitored to ensure the most effective dosage and to minimize side effects. For those who have had several bouts of depression, long-term treatment with medication is the most effective means of preventing recurring episodes.
The most common side effects of tricyclic antidepressants, and ways to deal with them, are:
The newer antidepressants have different types of side effects:
There are a few rules for managing depression medication well:
Be careful when taking any antidepressant medications. While it is true that these drugs are capable of treating a number of mental illnesses, there is also a risk for addiction. It goes without saying that you should try to make sure this doesn’t happen, but don’t feel as though all hope is lost if you find yourself becoming dependent on these substances. Remember that you can always look into local rehabs in your area, and that the decision to go (or to suggest that a friend or loved one go) may end up saving a life.
Many forms of psychotherapy, including some short-term (10-20 week) therapies, can help depressed individuals. "Talking" therapies help patients gain insight into and resolve their problems through verbal exchange with the therapist, sometimes combined with "homework" assignments between sessions. "Behavioral" therapists help patients learn how to obtain more satisfaction and rewards through their own actions and how to unlearn the behavioral patterns that contribute to or result from their depression.
Two of the short-term psychotherapies that research has shown helpful for some forms of depression are interpersonal and cognitive/behavioral therapies. Interpersonal therapists focus on the patient's disturbed personal relationships that both cause and exacerbate (or increase) the depression. Cognitive/behavioral therapists help patients change the negative styles of thinking and behaving often associated with depression.
Psychodynamic therapies, which are sometimes used to treat depressed persons, focus on resolving the patient's conflicted feelings. These therapies are often reserved until the depressive symptoms are significantly improved. In general, severe depressive illnesses, particularly those that are recurrent, will require medication along with, or preceding, psychotherapy for the best outcome.
A therapist can help an individual to identify and correct errors in thinking, that is, where the person is seeing things as bad, when really they arent so bad. Some of those thinking errors are:
The counseling that works on those problems can be either in individual sessions with a doctor or other professional or in a group. A key factor is restoration of the sense of control and autonomy in every possible aspect of a persons life. Depressed people must be helped to see that they have choices, and that they are in control of their own lives.
Its much better if the person can talk about his/her symptoms and be involved in assessing his/her own problems, rather than having professionals confer and issue orders without the persons involvement.
For the same reasons that counseling helps, increased contact with friends and family may help lift depression, too. Although its very hard when you are depressed to make yourself move and do things, it is important to try or to help your loved one to make the effort. Focus on activities that were once important in your life or your loved ones life, and get them started again.
Spiritual renewal and rediscovery of meaning in ones life are powerful tools for overcoming the fear and the sadness that go along with depression. Some spiritual activities include:
Depression can be overcome, even though it disabling to daily functioning, happiness, and personal growth. People with depression can be helped to manage and stabilize the disabling aspects of the condition and result in lives, which continue to have meaning, personal growth and a sense of hope for the future.
When elderly people are depressed, they need to be helped to exercise as many personal choices and decisions as they are able. Depression affects the whole person, body, mind and spirit. Because of this, any plans of care for addressing depression, must include all of these dimensions. The final responsibility for overcoming depression rests with the individual affected by it, however it is unlikely that some elderly individuals can do this without the help of their caregivers. Depression may so extensively saps the energy and spirit of people that other resources are needed to initiate recovery.
One of the major issues for a depressed person is his/her pervasive feeling of being unable to control the people or events in his/her surroundings. This is sometimes called "learned helplessness." Learned helplessness means that no matter how hard one tries, one is unable to have any influence on others or on the environment. This results in giving up making choices and trying to influence. Planning for, encouraging, and assisting elderly individuals to make as many choices as they are able and applauding their efforts when they do can become a turning point in reducing depressions grip on the frail elderly person.
How To Help Yourself If You Are Depressed
Depressive disorders may make one feel exhausted, worthless, helpless, and hopeless. Such negative thoughts and feelings make some people feel like giving up. It is important to realize that these negative views are part of the depression and typically do not accurately reflect the actual circumstances. Negative thinking fades as treatment begins to take effect. In the meantime:
It is advisable to postpone important decisions until the depression has lifted. Before deciding to make a significant transition, such as changing jobs, getting married, or getting divorced, discuss it with others who know you well and have a more objective view of your situation.
People rarely "snap out of" a depression. But they can feel a little better day-by-day.
Remember, positive thinking will replace the negative thinking that is part of the depression and will disappear as your depression responds to treatment. Let your family and friends help you.
Meeting Your Loved Ones Needs
In the 1940s and 1950s Abraham Maslow developed one of the most popular and well-regarded theories of human motivation. Maslow theorized that people grow towards self-actualization after satisfying basic human needs, such as food, water, shelter, and security. Once basic needs are satisfied, the individual moves onto to greater levels of self-esteem, acceptance, recognition, and wisdom.
Frail elderly, in particular, express depression through physical symptoms such as headaches, backaches, backaches, stomach distress, and constipation. Often medical evaluation has determined there is no organic cause for these symptoms. Physiological needs for balanced, nutritious meals, regular exercise and adequate, usual, uninterrupted sleep are of utmost importance for health and improvement of depression. Depressed people are often sedentary and have no motivation to move. Yet, exercise is known as a positive force for relieving depression. Exercise activates serotonin and norepinephrine and increases socialization, both known to enhance mental health.
Safety and Security Needs
Depression causes preoccupation with self, which may result in ignoring potential environmental hazards. For whatever reason, depressed persons feel a very strong need for a predictable, lawful, orderly world in which unexpected, unmanageable, or other dangerous things do not happen.
Love and Belonging Needs
A depressed person is at risk for not having his/her needs for love and belonging met because of feelings of being a burden to others, of being no fun, and spreading doom and gloom to others.
Depression is often the cause or result of feeling inadequate as a person. Some people with depression have been unsuccessful in handling their emotions alone. Feeling powerless and giving up can result when repeated attempts to help their own depression have failed. Depressed people may have very negative opinions about themselves and feel very negative about their future. They often cant describe one good thing about themselves and one thing they enjoy. They minimize past achievements, concentrate on present failures even minor ones. They feel they have nothing to look forward to. This leads to abandoning previous roles because they cant be perfect and are afraid of failing and withdrawal from activities.
Depression needs to be freed first before energy can be directed toward creative self-expressions and personal achievements.
Talking to Depressed Elderly
Many times caregivers and family members to elderly individuals will avoid conversation because they perceive the elderly person as grumpy or negative. It is important to remember that the negativity is a symptom of the depression and may not always be a personality trait. Of course many of us know of difficult older persons who never seemed to get along with anyone throughout their lives. Taking steps to engage a depressed elderly individual in conversation can help them to open up and begin to cope with their illness.
Here are some suggestions for talking with a person who is depressed and withdrawn:
Listen. Giving your time, full attention, and listening is the most important thing that you can do. Depressed elderly need an opportunity to put their feelings into words, to hear themselves explain the problem, and to know that you are hearing them and attempting to understand.
Acknowledge the sadness, irritability, or withdrawal. You should respond to the feelings as much as to the words spoken. You might say, "Your sadness makes you cry very often." If you name the feeling, your loved one will know that he/she is being heard and understood. If your loved one doesnt agree with the way you phrased it, she/he will explain the true feelings more carefully. Dont observe a feeling and just leave. Distressed feelings need to be addressed when they are identified.
Do not judge your loved ones feelings. Avoid saying "You shouldnt feel that way." Instead, restate the feelings you think you are hearing to see if that is actually what the person meant. Find out what is behind those feelings. For example, you might say, "You are wondering whether your life could ever be as meaningful as when you were in your 30s."
Resist giving advice. The solutions that "take" are the ones that the elderly person "owns" himself. If he thought of it, or believes that he thought of it, he is more likely to follow through and make the change. We all dislike thinking that someone else is running our lives. After letting your loved one express his concerns and feelings turn the ownership for the solution to him. Ask him what he thinks would help him to feel better or improve the situation that is problematic. Discuss alternative solutions to problems with him and adopt an approach that encourages him to generate his own solutions. For example, you might say, "You need to discover what is best for you," or "Tell me what are the solutions and their pros and cons."
Praise even minor accomplishments. Make sure that your praise is an honest acknowledgement of what progress has been made in any activity but particularly those that you know will alleviate depression. Engage your loved one in conversations about previous successes, what he does well and likes about himself.
Be honest and promote realistic expectations. Unrealistic expectations can lead to further failure and feelings of worthlessness. Help your loved one set goals that he/she can meet. For example, you might say, "Two days ago you didnt think you could walk into the dining room alone but today, you went there for breakfast.
Be patient and dont push your loved one to respond. Depression slows many processes and oftentimes the elderly person needs time to formulate a response. Depression can numb feelings and it may take more time to feel and to even put a name on the feeling.
Relieving Mild Depression Special Activities
The vast majority of people with depression are experiencing a milder form of depression. All people with depressive symptoms need medical care and treatment. If depression is mild or when the person will not seek help from mental health providers, these alternative forms of treatment or special activities may be helpful. These special activities impact on some of the underlying reasons for depression in elderly persons such as loneliness, losses of all kinds especially of health and functioning, and lack of pleasurable activities each day.
Unveiling Depression in Women: A Practical Guide to Understanding
and Overcoming Depression by Archibald Hart and Catherine Hart
Transition Issues for the Elderly and Their Families
- Online Depression Screening Test from the
New York University School of Medcine Department of Psychiatry http://www.med.nyu.edu/Psych/screens/depres.html
- Older Adults: Depression and Suicide
Facts (National Institute of Mental Health) http://www.nimh.nih.gov/publicat/elderlydepsuicide.cfm
Available from ElderCare Online www.ec-online.net ©2002 Prism Innovations, Inc.