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Depression in elderly people

Depression In Elderly People

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.

Bibliography

Ahmed, Iqbal & Junji Takeshita. "Late-life Depression." Generations.

Winter 1996. V20n4. P17-22. Barrett-Connor, Elizabeth & Lawrence A. Palinkas.

"Low Blood Pressure and Depression in Older Men: A Population Based Study.

British Medical Journal. February 12, 1994. V308n6926. P446-450. Butler, Cohen,
et al. "Late-life Depression: Treatment Strategies for Primary Care

Practice." Geriatrics. April 1997. V52. P51-57. Butler, Robert N. & Myrna

Lewis. "Late Life Depression: When and How to Intervene. Geriatrics. August

1995. V50. P44-51. Friedrich, M. J. "Recognizing and Treating Depression in
the Elderly." Journal of the American Medical Association. October 6, 1999.

V282i13. P1215. Jackson, Rupert & Bob Baldwin. "Detecting Depression in

Elderly Mentally Ill Patients: The Use of Geriatric Depression Scale Compared
with Medical and Nursing Observations. Age and Aging. September 1993. V22n5.

P349-354. "Management of Anxiety and Depression in Elderly Persons. American

Family Physician. April 1996. V53n5. P1861-1863. Pinkowish, Mary Desmond.

"Keeping Older Patients Depression Free." Patient Care. March 30, 1999. V3.

P19. Robinson, Gail K. et al. "Managed Care Policy: Meeting the Mental Health

Needs of the Aged?" Generations. Summer 1998. V22n2. P58-63. Wilkinson,

Phillip. "Cognitive Therapy With Elderly People. Age and Aging. January 1997.



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