Overview: This Fast Fact Sheet was developed to assist gerontological nurses in any clinical or non-clinical situation to (1) recognize signs and symptoms of depression, (2) recognize and understand contributing factors, (3) become award of assessment tools, and (4) direct the individual and/or family to skilled health care professionals.
Target Audience: RN’s and LPN’s involved in the care of older adults.
- Depression and the older adult is the most frequent problem that psychiatrists treat in the older adult.
- “Minor depression increases in incident with age.” (Eliopoulos, C., 2005, pg 449)
- “Identified in 15-25% of community-based elders.” (Eliopoulos, C., 2005, pg 449)
- Identified in 25-40% of Long Term Care facility residents.
- 20-30% of older adults institutionalized exhibit symptoms of depression but lack a diagnosis.
- Elderly white men have the highest rate of suicide of the entire adult population.
- Depression in 25% of acutely ill, hospitalized older adults has been found to be even more common.
- “Evidence suggests that depressive disorders are frequently underdetected in the Primary Care setting, particularly among some groups including ethnic minorities and the elderly” (USDHHS, 1999)
Definition of Depression
Depression is defined as a syndrome comprised of a constellation of affective, cognitive, and somatic or physiological manifestation (National Institutes of Health Consensus Development Panel, 1992). Depression may range in severity from very severe to mild forms and can exist for a variable amount of time.
Depressive symptoms that do not meet the standard criteria for a specific depressive disorder are very prevalent in older adults and should be identified and treated. Minor depression is 2-4 times more common than major depression in older adults with increase risk of a future major depression and greater use of health care services.
Guidelines to identify a MAJOR depression disorder during assessment
The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR, Text Revision, Fourth Edition, American Psychiatric Association, 2000) list the criteria for the diagnosis of major depressive disorder, the most severe form of depression.
- Represents a change in previous functions.
- Symptoms cause clinically significant distress or impair social, occupational, or other important areas of functioning.
- Five or more of the following occur nearly every day for most waking hours over the same 2-week period.
- Depressed mood most of the day, nearly every day.
- Significant weight loss or gain (more than 5% of body weight in 1 month)
- Insomnia or hypersomnia
- Increase or decrease in motor activity
- Anergia (fatigue or loss of energy)
- Feelings of worthlessness or inappropriate guilt (may be delusional)
- Decrease concentration or indecisiveness
- Recurrent thoughts of death or suicidal ideation (with or without plan) APA, 2000, Figure 18-1 from Varcarolis, AM, 2002. FOUNDATIONS OF PSYCHIATRIC MENTAL HEALTH NURSING. A Clinical Approach, Fourth Edition., Pg. 456.
Depression – A complex syndrome
Depression is never an aspect of normal aging. Order Adults exhibit depression in several ways:
- Most common are vegetative symptoms such as insomnia, weight loss, fatigue, constipation, anorexia. Agitation, anxiety and delusional symptoms may also be present.
- Expression of guild, apathy, remorse, hopelessness, helplessness, belief one is a burden may be present.
- Problems with personal relationships, social interactions and loss of interest in people.
- Hygiene may be neglected.
- Somatic manifestations of depression might include back pain, abdominal pain, headache.
- Alteration of cognitive status may become apparent.
- Melancholic Features are more common in older depressed people. APA; 2000., Pg. 372.
Illnesses that can trigger depression –
- Chronic Obstructive Pulmonary Disease
- Coronary Artery Disease
- Pancreatic Cancer
- Uncontrolled hypothyroidism
- Metabolic disturbances
- Endocrine disorders
- Gastrointestinal disorders
- Genitourinary disorders
- Musculoskeletal disorders and related pain
- Neurologic disorders
- Vitamin deficiencies
- Chronic non malignant pain syndromes
- Age related vision changes
Some medications that can cause symptoms of depression –
- Narcotics: Morphine, Codeine, Meperidine, Propoxyphene
- Non-narcotic: Indomethocin
- Antiparkinson Drugs
- Hypoglycemic agents
- Psychotrophic Agents
- Cancer chemotherapeutic Agents
Assessment tools –
- Geriatric Depression Scale (Short Form)
Sheikh, JL, Yesavage, JA: ClinGerontol 5:165, 1986
- Scale For Detecting Major Depression in Hospitalized Patients
Koenig, HG, Blazer DG: Clin Geriatr Med 8(2); 235, 1992
- Assessing the Potential for Suicide
Ham RJ, Meyers BS: Late Life Depression and Suicide Potential, Washington, DC, 1993 American Association of Retired Persons
- PEARL – “Depression should be considered in all order persons who report somatic Symptoms, particularly those having chronic symptoms that appear to have no definitive organic basis.”
Ham RJ, Sloane, PD, Warshaw GA., Primary Care Geriatrics – A Case-Based
Approach, 4th. Ed: 311, 2002
Coordination of Care –
Members of the Health care team skilled to assess, diagnose, plan care and follow-up with re-assessment include the physician, nurse and social worker. The patient and family members should be encouraged to be part of the team. Their involvement can help identify the illness, assist in patient compliance with medications and report to the health care team effectiveness of therapy.
Referrals to experts may be appropriate and these might include:
- Geriatric psychiatrist
- Geriatric neuro-psychologist
- Psych-mental health, advanced practice nurse
- Geropsychiatric in-patient care
- Geropstchiatric out-patient care
Untreated Depression Can….
- Increase a patient’s risk of disability.
- Increase mortality
- Decrease psychosocial functioning.
- Increase use of health care systems.
- Increase the known 15% or more that commit suicide.
“The severity of depression is also higher in older adults. Although depressive episodes may have been a life long problem individuals, it is not uncommon for depression to be a new problem in old age. This is not surprising when one considers the adjustments and losses the elderly face, such as the independence of one’s children; the reality of retirement; significant changers or losses of roles; reduced income restricting the pursuit of satisfying leisure activities and limiting the ability to meet basic needs; decreasing efficiency of the body; a changing of self-image; the death of family members and friends, reinforcing the reality of one’s own shrinking life span; and overt and covert messages from society that one’s worth is inversely proportional to one’s age.” Eliopoulos, C., Gerontological Nursing, Edition 5, 2001, 332.
American Psychiatric Association: Diagnostic and Statistical Manuel of Mental Disorders, Fourth Edition, Text Revision, Washington, DC, American Psychiatric Association, 2000.
Eliopoulos, C., (2001). Gerontological Nursing. Ed. 5, Maryland: Lippincott Williams & Wilkins.
Eliopoulos, C., (2005). Gerontological Nursing. Ed. 6, Maryland: Lippincott Williams & Wilkins.
Ham, R.J., Sloane, P.D.; Warshaw, G.A. (2002). Primary Care Geriatrics-A Case-Based Approach, Ed.4: St. Louis: Mosby.
Salemo, El, Willens, J.S., (1996). Pain Management Handbook-An Interdisciplinary Approach. St. Louis: Mosby.
Salzman, Carl., (1998). Clinical Geriatric Psychopharmacology, Ed. 3, Philadelphia: Williams & Wilkins.
American Psychiatric Association (2000) Diagnostic and statistical manual of mental disorders, (4th edition).
National Institutes of Health Consensus Development Panel (1992).
Diagnosis and treatment of depression in late life, Journal of the American Medical Association, 268, 1018-1024.
Kulowicz, L Chapter 11: Depression in older adults.
Mesney, M. Fulmer, T., Abraham, I and DeAnne Swicker (editors)(2003) Geriatric Nursing Protocols for Best Practice (2nd edition), Springer Series on Geriatric Nursing, Springer Publishing New York.
US Dept of Health and Human Services. Mental Health: A Report of the Surgeon General. Rockville, Md: Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institute of Mental Health, National institutes of Health, US Dept of Health and Human Services, 1999., from: Mental Health CME.com-www.depressionclinic.com.
Joanne L. Alderman, APRN, BC
Gerontological Clinical Nurse Specialist – Private Practice
Allied Health Provider
Tulsa Regional Medical Center
Physician’s Office Building Suite #315
802 S. Jackson
Tulsa, Oklahoma 74127
Allied Health Provider
Meadowbrook Rehabilitation hospital
3219 S. 79th E. Avenue
Tulsa, OK 74145
Cynthia M. Koller, MSN.RN
Executive Director of Behavioral
Health Services/Director of
Psychiatric Nursing (dual role)
Tulsa Regional Medical Center
709 S. Jackson
Tulsa, OK. 74127