It‘s Not Just Old Age – Depression in the Elderly

The following scenario is played out with increasing regularity in the nation: An elderly person, let’s call her Edith is living alone because she has lost her husband. Due to one or more chronic conditions she has decreased independence. Maybe she can’t drive any more and needs to use a walker or wheelchair. Her condition requires a regime of prescription medications. The chronic condition causes pain. If Edith has family that can visit her they are likely very busy or may not live close enough to visit regularly. Consequently she spends a lot of time alone, and may possibly feel a loss of significance. In this scenario it would not be easy to maintain a positive outlook of the future and life itself.

Depression in the elderly is often unrecognized and undiagnosed. Yet there is a growing awareness that many life factors that the elderly must cope with in fact contribute to the likelihood of depression. Also age affects the structure of the brain. Mental and physical health affect each other. Many elderly suffer from one or more chronic conditions which can cause or worsen depression. Untreated depression can cause chronic conditions and the condition itself or it’s medical treatment can cause depression. Depression also affects treatment compliance or self management of physical conditions.

Depression and related mental disorders are getting more attention in recent years. In 2005 the White House Conference on Aging included mental health and geriatric provider training in their top 10 list of resolutions. This article will discuss what progress has been made toward the goal of better mental health care for the elderly.

Depression is often not diagnosed in the elderly. This in part may be due to assumptions and attitudes that need changing. It is also due to diagnosis being complicated by other physical ailments. Medication can also cause mental side effects. The first point of entry into the medical system is usually a visit to a primary care provider where the patient has unexplained physical symptoms. Increasing training of primary care providers would allow detection of depression in its early more manageable stage. Primary care providers need to have the time to properly assess, treat, and follow up on patients who are depressed to have any success at improvement..

A partnership of several philanthropic organizations created a trial study called IMPACT, an acronym for Improving Mood Promoting Access to Collaborative Treatment for late life depression. Its title is self explanatory, but the team approach to treatment has proven successful. For five years it conducted a randomized trial in various health care systems. Patients received either regular care or IMPACT care. Patients were active decision makers in partnership with their primary care provider in choosing treatment. Their care was overseen by a care manager who is often a nurse. The care manager educated the patient, and provided treatment, support, and follow up in the stepped care concept. The team also includes a psychiatrist who provides consultation if more care is needed. The systematic tracking of outcomes included assessing the patient’s health and the PQ-9 questionnaire and if needed treatment is adjusted or changed. Care is evidenced-based in consultation with the psychiatrist. Currently the majority of states are using or considering IMPACT and the goal is to make the success of this trial more widespread. The IMPACT website provides all the tools, information, and training that is needed to adopt this successful program.

The John A. Hartford Foundation partnering with the American Academy of Nursing created the geropsychiatric nursing collaborative which is presently in the third of its fourth year grant. Its goals are to increase geropsychiatric core competencies for all nurses by creating and making available resources in nursing programs. Because most nurses will work with older adults at some point in their career, the core competencies were composed in collaboration and consultation with key nursing organizations. They first started with a definition of geropsychiatric nursing and the collaborative is based on four concepts. The collaborative will evaluate quality and suitability of curricula and identify gaps. This will occur within the existing framework, geropsychiatric nursing will not be a new sub specialty. The goal is to enhance existing competencies with the use of competency statements.

Geropsychiatric nurse scientists have been responsible for advances in quality of life in terms of treatments of adults with mental illness. The geropsychiatric nurse scientist’s focus is on the person environment relationship. Two notable achievements of these experts in the past few decades are the marked decrease in the use of restraints for agitated elderly nursing home residents. The second is the use of towel bathing for Alzheimer’s patients who are fearful of water and bathing. It is science translated into care that preserves the dignity of the patient. Geropsychiatric nurses are invaluable additions to interdisciplinary teams in assisted living facilities and long term care facilities.

Home health nurses are in a good position to detect depression. Yet they must be given the tools to confidently make an assessment for referral to another professional. Studies have shown that many home healthcare agencies have no referral or follow up plan to refer elderly who may need mental health services. However, the interdisciplinary team approach can accurately assess depressed elders for suicide risk. In one case study the nurse practitioner led interdisciplinary team consisting of a geropsychologist, RN, social worker, occupational therapist, and registered dietician. In the assisted living facility they were the care team for a recently bereaved spouse who suffered from painful cancer among other chronic conditions. He had access to firearms, and the geropsychiatrist suspected he wanted to harm himself. The team gained his trust and supported him emotionally, involving him in the ALF’s festive celebrations of the season, and visiting him more frequently. They successfully averted his plans to commit suicide.

Society should not accept poor mental health as a natural consequence of aging. Nor should it be swept under the rug or its existence ignored. Society owes its senior citizens the best care possible with the least possibility of adverse events. With health care professionals targeting vulnerable populations for early assessment patients will be able to cope with mental illnesses and have a higher quality of life. Nurses have and will play a large part in helping enhance seniors’ mental health and preventing and coping with depression.

Home Healthcare Nurse Vol 27(8) September 2009 p 482-487