Running head: DEPRESSION IN OLDER ADULTS
Depression in Older Adults
Lacey Hastings
Stenberg College
Psychiatric Care of the Older Adult Practice- Theory
Debbie McCreedy
1
DEPRESSION IN OLDER ADULTS
2
Abstract
Depression is a very common and serious issue among older adults, being the most common
mental health problem, and yet remains underdiagnosed and undertreated. The reason for this
lies in the false beliefs of normal aging, the many contributing complex factors and comorbid
medical conditions. Depression has many negative effects on older adults, including increased
disability, worsening physical conditions, cognitive impairment, decreased quality of life,
increased suicide and non-suicide related death. The reality of suicide among the elderly is a
direct cause of untreated depression; the failure to treat depression increases morbidity and
mortality for older adults (Touhy, Jett & McCleary, 2012). Depression is a major issue, with
notable affects, yet there is treatment, and treatment can improve quality of life for many older
adults suffering from depression. The connection between physical and mental health is even
more prevalent and complex in older adults and therefore physical and mental health issues
should not be taken lightly, and should include a bio psychosocial framework of assessment, and
intervention.
DEPRESSION IN OLDER ADULTS
3
Depression in Older Adults
The reality of depression among today’s geriatric population is a prevalent growing issue
that needs attention. Depression is the most common mental health problem in later life (Touhy,
Jett, & McCleary, 2012), with general estimates being 15%- 20% of the elderly facing
depression, and rising to 30-45% prevalence for depressive symptoms of those elders residing in
the community and those in nursing homes (Stuart, 2009; Das et al. 2009, Touhy, Jett, &
McCleary, 2012). Unfortunately the diagnosis of depression in the elderly population is missed
85 % of the time (Stuart, 2009). This is due to the complexity of this issue, and the complexity of
geriatric patients. Depression is not a normal part of aging, and it has been shown that older
people are satisfied with their lives, despite physical problems (National Institute of Mental
Health [NIMH], 2013). Depression is overlooked and undertreated in the geriatric population for
reasons such as beliefs and acceptance of depression being a normal part of aging, stigma of
depression by the elderly and society, comorbid medical conditions, differing presentation of
symptoms than the younger population, cognitive deterioration, all in which further complicating
the diagnostic process. These complications of depression and complications of diagnoses lead to
severe consequences for older adults, contributing to worsening physical and mental conditions,
and increasing the risk of morbidity and mortality
Defining Depression
Depression is a common but very serious illness; it consists of an array of
affective, cognitive and somatic or physiological symptoms (Touhy, Jett & McCleary, 2012).
DEPRESSION IN OLDER ADULTS
4
Depression can be described as feeling sad, blue, unhappy, and miserable or down in the dumps;
which can be normal for many; in shorter periods of time, lasting only a couple days. Clinical
depression is a mood disorder, in which those feelings of sadness, loss, anger, or frustration
interfere with everyday life for a longer period of time (National Institute of Health, 2013).
Depression ranges in severity and duration and is usually classified as major depression, minor(
subsyndromal) depression or dysthymia (National Institute of Health, 2013). The diagnoses of
mild-to-major depression would be determined by the symptoms, severity and duration. For
instance major depression would include more symptoms of depression ( worthlessness, sadness,
guilt, anger, decreased energy, interest, or motivation etc.), and a longer duration- over two
weeks (National Institute of Health, 2013). Dysthymia is mild but long-term form of depression,
with symptoms lasting for at least two years. This paper will focus on subsyndromal and major
depression; however it will be noted that the intended criteria for these diagnosed depressions are
not sensitive to geriatric symptoms and conditions (Touhy, Jett & McCleary, 2012).
Misdiagnoses of Depression
As mentioned above depression is missed 85% of the time in older adults (Stuart, 2009),
and major depressive disorder (MDD) is undiagnosed in approximately half of all elderly with
this disorder ( Das et al. 2009). Why is this? There are many contributing factors that lead to the
underdiagnoses and under treatment of depression, such as beliefs, comorbid medical conditions,
presentation of symptoms, and cognitive deterioration; which will be discussed further. However
it is important to note that depression can be treated, and often times is reversible; 60- 80% of
older people will improve with appropriate medication, psychotherapy, and psychosocial
DEPRESSION IN OLDER ADULTS
5
interventions, or a combination of these (Kurlowicz & Harvath, 2008; as cited in Touhy, Jett &
McCleary, 2012).
Beliefs. Health care providers and society often mistakenly belief that depression is
normal in aging (Stuart 2009; Touhy, Jett & McCleary, 2012; Varcarolis & Halter 2010;
Thompsell, 2008); thus leading to inappropriate action being taken to assess and treat depression.
If healthcare providers are simply accepting or believing depression to be just a part of aging,
then depression will continue to be swept under the rug, and the elderly will continue to suffer;
when they can be treated. It is also common for older adults to minimize or ignore symptoms,
assuming they are related to age not to current medical or psychiatric problems. According to
Stuart, (2009) “Often these beliefs are reinforced by myths about aging and false assumption of
many health professionals that the problems of older people are irreversible or untreatable”
(p.691). Along with the belief about depression being normal as we age, comes the stigma of
depression; by the elderly themselves and by society. Many older adults still hold on to the
beliefs about depression being shameful, flawed character, self-centered, weakness, sin, or
retribution (Touhy, Jett & McCleary, 2012), therefore this stigma will prevent them from
acknowledging symptoms of depression; contributing to misdiagnoses and under treatment.
Comorbid Medical conditions. The reality is that the number of physical illnesses and
physical disabilities increase with age; therefor it is common for depression to be misdiagnosed
as symptoms of medical conditions, physical illness or physical disabilities (Stuart, 2009; Proctor
et al, 2003; Hartford Institute of Geriatric Nursing 2012). As symptoms commonly experienced
by the elderly tend to be more somatic and may be explained in physical terms, they get
classified as symptoms of physical illness. Overattributing these symptoms to the physical illness
even when other mood symptoms are present represents underdiagnoses (Fiske, Wetherell &
DEPRESSION IN OLDER ADULTS
6
Gatz, 2010). However it is also important to note it is well established that late-life depression
frequently occurs in the context of medical illness, the conditions believed to be most strongly
associated with depression include cardiac and cerebrovascular disease, neurological conditions,
and infections or malignancies (Fiske, Wetherell & Gatz, 2010). Therefore depression may be
looked at as normal when residing within these conditions. With the increased number of
medical diagnoses, in turn comes increased number of medications, with depressive symptoms
being similar to many medication side effects, major depression can be simply be mistaken for
normal side effects of medication (Stuart, 2009).
Presentation of Symptoms. The presentation of depressive symptoms is often different
in the elderly then the younger population; i.e. more physical complaints, which are then
assumed to be part of normal aging (Fiske, Wetherell & Gatz, 2010; Stuart, 2009). The
symptoms more commonly reported are physical symptoms, insomnia, loss of appetite and
weight loss, memory problems or persistent pain, fatigue, psychomotor retardation, loss of
interest in living, and hopelessness about the future (Touhy, Jett & McCleary, 2012; Fiske,
Wetherell & Gatz, 2010); thus the elderly may not report feelings such as worthlessness, guilt,
shame, that accompany the more common symptoms of depression, which lead to further
diagnoses.
Cognitive deterioration. Due to increased medical complications and diseases that may
affect brain function and cognitive impairment in the older adult population, depressive
symptoms may be mistaken for worsening Alzheimer’s or dementia, as the symptoms present
similarly and these conditions can often coexist (Touhy, Jett & McCleary, 2012). For instance
inability to concentrate, with resulting memory impairment and other cognitive dysfunction are
common in late-life depression; however can be mistaken for ‘normal’ cognitive deterioration of
DEPRESSION IN OLDER ADULTS
7
old age, or as resulting symptoms of other cognitive impairments such as Alzheimer’s disease,
dementia, delirium, strokes, etc. Thus contributing to the confusion of, and under treatment of
depressive symptoms in older adults.
Consequences of Depression
Due to the high rates of depression among older adults ; up to one in every four primary
care patients; and the high rates of underdiagnoses; only one third of those patients being
identified with depression (Touhy, Jett & McCleary, 2012). Depression is a major concern facing
the elderly population, a concern that has devastating consequences if not treated. It is known
that late-life depression increases risk for medical illness and cognitive decline (National
Alliance on Mental Illness [NAMI], 2009). Consequences of depression include amplification of
pain and disability, delayed recovery from illness and surgery, worsening of drug side effects,
excess use of health services, cognitive impairment, sub nutrition, and increased suicide- and
nonsuicide-related death (Hartford Institute for Geriatric Nursing, 2012). The longer depression
goes untreated the higher the increase for the risk of morbidity and mortality (Das, et al. 2009).
Depression is a one of the leading causes of disability worldwide; the disability associated with
depression is believed to emanate from decrements in emotional and cognitive function as well
as decline in physical function (Callahan et al, 2005). Depression is associated with effects on
role function and physical function even when controlling comorbid medical conditions. Older
adults with depression report greater functional impairment than those without depression, and
this impairment persists over time (Callahan et al, 2005). Therefore the likelihood of older adults
becoming disabled from depression increase with misdiagnosis and under treatment, and the
likelihood of recovering from disability decreases (Callahan, 2005).
DEPRESSION IN OLDER ADULTS
8
Major depression has severe ramifications for older adults, including the fact that elderly
patients with depression have a 1.5-3 times increased morbidity and a lifetime suicide risk of
approximately 15%, with almost 10% of these patients dying annually from suicide ( Das et al,
2009). Tragically, many of those people who go on to die by suicide have reached out for help—
20 percent see a doctor the day they die, 40 percent the week they die and 70 percent in the
month they die. (NAMI, 2009). Yet depression is frequently missed; possibly due to the fact of
these patients seeking treatment for other physical ailments than they are seeking treatment for
depression; therefore the symptoms are overlooked.
Conclusion
The high rates for depression among the elderly are undeniable, and the risks are clear
throughout the literature, however it still goes misdiagnosed and undertreated. One could say this
is due to the complexity of geriatric patients, with many contributing factors and coinciding
illnesses, however this is all the more reason for the assessment and treatment of depression in
older adults to be a priority. It is clear that this is not a black and white issue, that diagnosing
depression in older adults if difficult. With taking into consideration all contributing factors,
depression in older adults should be examined through a biopsychosocial framework. Older
adults can live a quality life and deserve to be cared for in a way that promotes this; health care
professionals should “Respect the unique, inherent worth and dignity of all persons and strive to
ensure the rights of individuals are upheld” (RPNC, 2010). That means taking into consideration
their complex care needs, having respect and patience, and completing thorough assessments and
evaluation to ensure their given the care needed and they are treated efficiently.
DEPRESSION IN OLDER ADULTS
9
It is prevalent that medical conditions or physical illness and mental health and
depression are interdependent. Depression can be known as the ‘unwanted co-traveler’
accompanying medical illnesses, worsening physical conditions; and medical conditions can lead
to depression, contributing to mental health conditions. The two are a viscous circle if untreated,
therefore although they are interdependent; they needed to be treated independently, as they are
unique conditions with unique treatment. One needs to know that “physical health and mental
health are interconnected and are a dynamic process that fluctuates across the lifespan” ( RPNC,
2010 ); and take this into special consideration with the geriatric population, as both physical and
mental health can be more prevalent, and thus need more attention.
DEPRESSION IN OLDER ADULTS
10
References
Callahan, C. M., Kroenke, K., Counsell, S. R., Hendrie, H. C., Perkins, A. J., Katon, W., ... &
Unützer, J. (2005). Treatment of depression improves physical functioning in older
adults. Journal of the American Geriatrics Society, 53(3), 367-373. Retrieved from:
http://www.iumsp.ch/Enseignement/postgradue/medecine/doc/jags05_53_367.pdf
Das, B., Greenspan, M., Muralee, S., Choe, C. J., Tampi, R. R., is from Harvard, D., ... & is from
Rush, C. (2007). Late-life depression: A review. Clinical Geriatrics, 15(10), 35. Retrieved
from: http://www.clinicalgeriatrics.com/articles/Late-Life-Depression-A-Review
Fiske, A., Wetherell, J. L., & Gatz, M. (2009). Depression in older adults. Annual review of
clinical psychology, 5, 363. Retrieved from:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2852580/
Hartford Institute of Geriatric Nursing. (2012). Want to know more. Depression. Nursing
Standard of Practice Protocol: Depression in Older Adults. Retrieved from:
http://consultgerirn.org/topics/depression/want_to_know_more
National Institute of Mental Health (NIMH). (2013). Depression in Older Adults. Retrieved
from: http://nihseniorhealth.gov/depression/aboutdepression/01.html
National Alliance of Mental Illness (NAMI). (2009). Depression in Older Persons Fact Sheet.
DEPRESSION IN OLDER ADULTS
11
Retrieved from:
http://www.nami.org/Template.cfm?Section=By_Illness&template=/ContentManagement
/ContentDisplay.cfm&ContentID=7515
National Institute of Health. (2013). Medline Plus. Depression. Retrieved from:
http://www.nlm.nih.gov/medlineplus/ency/article/003213.htm
Proctor, E. K., Morrow-Howell, N. L., Doré, P., Wentz, J., Rubin, E. H., Thompson, S., & Li, H.
(2003). Comorbid medical conditions among depressed elderly patients discharged home
after acute psychiatric care. The American journal of geriatric psychiatry, 11(3), 329-338.
Retrieved from:
http://cmhsr.wustl.edu/Resources/Documents/Comorbid%20Medical%20Conditions%20
Among%20Depressed%20Elderly%20Patients.pdf
Registered Psychiatric Nurses of Canada. (2010). CODE of ETHICS & STANDARDS of
PSYCHIATRIC NURSING PRACTICE. Retrieved from: http://www.crpnbc.ca/wpcontent/uploads/2011/02/2010_Code_Standards.pdf
Stuart, G.W. (2009). Principles and practice of psychiatric nursing. (9th ed.). St. Louis, Missouri:
Mosby-Elsevier
Thompsell, A. (2008). Recognizing depression in older adults in care homes. Nursing &
DEPRESSION IN OLDER ADULTS
12
Residential Care, 10(2), 95-97. Retrieved from:
http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=2009808670&site=eho
st-live
Touhy, T., Jett, K., Boscart, V., & McCleary, L. (2012). Ebersole and Hess’ gerontological
nursing & healthy aging (1st Canadian ed.). Toronto, ON: Elsevier Canada.
Varcarolis, E.M., Halter, J.M. (2010). Foundations of psychiatric mental health nursing.(6th ed.).
St. Louis, Missouri: Saunders –Elsevier