Depression In 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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