Depressed

Introduction

Depression in the later decades of life is a growing public health problem. Currently, nearly 20% of Americans over age 65 suffer from depressive symptoms.^1,2,3 Over 40% of residents in long-term care facilities and 15% of community-dwelling older adults have been diagnosed with depression.^1,3 Half of older adults receiving treatment for depression experienced first onset of symptoms later in life.^1,2 Depression has significant adverse effects on quality of life for both patients and caregivers. Late life depression is associated with increased risk of morbidity, increased risk of suicide, disability, decreased physical, cognitive and social functioning, greater self-neglect, and consequently, increased mortality in older adults.^1,2

Interprofessional Assessment and Collaborative Interventions

Depression may present differently in old age. Depressed older adults are less likely to endorse affective symptoms such as low mood, sense of worthlessness, and guilt than are younger adults. Instead, they are more likely to display cognitive changes, complaints of poor memory and concentration, somatic symptoms, sleep disturbances, fatigue, and a loss of interest in their normal activities with depression.^1,2 While there are many risk factors to developing late life depression, including genetics, age-related neurobiological changes, and psychosocial vulnerabilities, depressive symptoms frequently present in the context of chronic medical illness.^1,2,3 Diseases most strongly associated with comorbid depression in older adults include cardiac disease, cerebrovascular disease, neurological conditions, and diabetes mellitus.¹ Older adults with late onset depression are also twice as likely to develop cognitive impairment and dementia due to vascular changes in the brain.^1,2 Commonly prescribed medications can also cause depression in older adults, including beta blockers, calcium channel blockers, digitalis, corticosteroids, hormones, anti-Parkinson agents, and benzodiazepines.¹

There are also many psychological and social risk factors for late life depression, including loss of a spouse, changes in role, inadequate social support and lack of social contacts, previous history of depression, and low socioeconomic status.^1,2,3 Older adults who have attained higher levels of education and socioeconomic status and have stayed engaged in social, spiritual, and religious activities are less vulnerable to developing depression later in life.¹ It is essential that nurses and providers screen all patients over age 65 for symptoms of depression regardless of presenting complaints, as older adults are significantly less likely than their younger counterparts to identify depressive symptoms.^2,3 Many older patients attribute changes in mood, cognition, and function to normal aging or physical illness. These attitudes make older patients less likely to seek appropriate treatment for common depressive symptoms.² Providers across all settings, especially primary care, are encouraged to use screening tools such as the Geriatric Depression Scale (GDS) in their practice and refer patients to additional support services for late life depression.^2,3Family members and caregivers who accompany patients on medical visits can be instrumental in identification of depressive symptoms by sharing observations about the patient’s recent cognitive, psychosocial, and functional status.³

Depression in patients of any age can be treated with psychosocial interventions, psychotherapy, psychopharmacology, or a combination of all three.³ Current evidence supports a multifaceted approach to treatment as most effective for older adults with depression.^1,2,3 Cognitive behavioral therapy, life review/reminiscence therapy, and development of problem-solving skills are effective but too infrequently used as treatment for older adults with depression.^1,2,3 Selective serotonin reuptake inhibitors (SSRIs) are most often used as first-line pharmacological treatment for depression in older adults, although some providers may choose to prescribe tricyclic antidepressants and monoamine oxidase inhibitors.^1,2 Acute and primary care providers should seek consultation from geriatric psychiatrists and pharmacists when selecting appropriate medications and adjusting dosage for this vulnerable population. Prescribers and nurses will need to educate patients and caregivers on expected side effects of antidepressants, including sedation, postural hypotension, and other effects seen with anticholinergic medications.^1,2,3 Nurses can also provide education on the importance of adhering to medications and inform that it may take several weeks for the drug to take effect and for patients to feel relief from symptoms.³

Once older adults begin treatment for depression, they must be regularly monitored across health care settings to evaluate response to therapy and need for ongoing or additional treatment.^1,2 This follow-up may be best completed in the primary care setting, as older adults are more likely to seek care from primary care providers for depression than from mental health specialists.¹Primary care providers should regularly screen patients over age 65 for symptoms of depression, side effects of psychotropic medications, disease comorbidities, and current psychosocial stressors and seek to involve patients in decision-making surrounding treatment.² Providers can also refer patients to other resources in the community with the help of psychologists and social workers to encourage patients’ participation in social activities, clubs and interest groups, physical exercise, and talk therapy as means to address late life depression.^2,3

Interprofessional contacts for this topic:

Acute care providers

Geriatric psychiatrists

Primary care providers

Pharmacists

Registered nurses

Social workers

Psychologists

Link to the following evidence-based protocols:

Age-related changes

Assessing cognition

Atypical presentation