Abstract
Depression is a critical mental health issue that has been becoming widely recognized in public health. Research and clinical treatment of depression in older adults and geriatric populations are often limited and overlooked. Later life depression is diagnosed in 13.3% of the population. Older populations have significantly high rates of depression due to life contexts or underlying medical conditions leading to poor quality of life and other health risks. Cultural and social considerations can play a role in causing the condition. Depression is a clinically diagnosed condition based on DSM-5 of the American Psychiatric Association. There are various nursing interventions such as pharmacological treatment, mental health support, meditation, and physical programs that are effective in managing depression. While the evidence and research surrounding later-life depression are more limited in comparison to studies on depression in young people, it is a growing body of evidence that this paper seeks to explore.
Introduction
Issues of mental health have slowly gotten the recognition that they deserve for some time now. Key among mental health issues is depression which is a serious public health concern throughout an individual’s lifetime. Often, the major focus has been on depression among young people which can be evidenced by the increase in the number of teen suicides. This creates a scenario where the focus of efforts tackling depression is centered on youth while the elderly are neglected. Late-life depression generally occurs between the ages of 60-65 (Glover, 2017).
Several factors may be credited with causing depression later in life one of them being that most people eventually end up retiring and they are conflicted about what to do since their life changes and they have to give up on routines that they had gotten used to for years. An individual’s life at this point experiences several role changes for example having to take part in household tasks which may lead to negative self-evaluation. Even the thought of retiring might be depressing to some people since they worry about the reduction in the income flows since they are going to have to get used to pension funds and some might not have saved enough money to sustain them throughout their retirement.
Moreover, the elderly years of an individual are usually the last stage of development according to Erikson’s developmental psychology theory, and at this period, most individuals want to leave a mark in the world. This may be extremely difficult because an individual at this stage, reflects on their achievements and mistakes in life which might in some instances breed depressive feelings since they might feel like failures. Similarly, elderly persons often are stressed by the fact that they are going to be a burden on their families which makes them feel useless and this is due to the negative stereotype that is attributed to aging. This might be made worse especially in instances where these individuals have to be sent to nursing homes which makes them feel as if their family is giving up on them.
The consequences of untreated late-life depression are severe because it accelerates the effects of any illnesses that such people might be suffering from (Glover, 2017). Several factors increase the risk of depression later in life, for example, being single or divorced, lack of a supportive network, physical conditions like stroke, cancer, and dementia. Further, certain medications that are prescribed to individuals may manifest some of their side effects through depression. Similarly, people who have a history of depression in their family are likely to experience depression later in life.
Depression rates are abnormally elevated in instances where patients have underlying medical conditions and this is one of the factors that impede the detection of depression because it is difficult to distinguish whether the patient’s symptoms are a result of depression or their medical condition (Alexopoulus, 2019).
Signs and symptoms of depression
The American Psychiatric Association classifies depression as a mental disorder affecting a person’s mood (DSM-5 American Psychiatric Association, 2013). It is a feeling of loss, sadness, or anger that disrupts a person’s daily routine. Depression affects people differently. It can affect the daily activities leading to reduced productivity and poor time management, or it can affect the relationships with other people and influence the severity of underlying health conditions. When it affects mood, it causes anger, irritability, restlessness, aggressiveness, and makes one anxious. The other symptom is that it makes one emotionally vulnerable through feelings of sadness, lack of hope, and emptiness (DSM-5 American Psychiatric Association, 2013).
Depression also affects behaviors by causing individuals to become less interested in activities in which they would find pleasure and become tired quickly. A person suffering from depression will develop suicidal thoughts and is highly likely to engage in dangerous activities such as drug abuse and excessive drinking of alcohol. Depression also causes reduced sexual interest and performance. Depression patients have reduced cognitive abilities shown in poor concentration, inability to complete tasks, and delayed responses when interacting with others. Depression affects the quality of sleep as it causes restlessness. It can lead to either insomnia or sleepiness. Physical health is also affected by depression due to problems like headache, pain, digestive issues, and fatigue (DSM-5 American Psychiatric Association, 2013).
Cultural Considerations
Across cultures, some of the factors contributing to depression are alike. They include unemployment, traumatic events, and issues related to gender (Chang et al., 2017). These aspects of depression often revolved around the sufferings of loss. However, people perceive and interpret distress in different ways across cultures. In western culture, depression is attributed to biomedical rather than environmental factors (Chang et al., 2017). As a result, people tend to ignore ecological aspects and concentrate on their biological factors when dealing with depression. Genetic vulnerability is different across cultures. People from East Asia have a high prevalence of genes linked to depression (Bigdeli et al., 2017). When people abandon their cultural contexts, they have a high risk of becoming depressed (Chang et al., 2017).
Scope of the Problem, Statistics, and Cost
With a growing number of older adults in many countries, late-life depression is a major public health concern. The cost of informal care for depressed older adults is four times as high as the non-depressed older adult. There is an emphasis on the need for treatments that are safe and cost-effective. Older adults’ lack of responses to antidepressants, side effects, and risk to drug interactions yields a need for evidence-based non-pharmacological options to treat depression (Jonsson et al., 2016).
Late-life depression (LLD) is a mental health disorder that is prevalent in 13.3% of the older population (Axel, Declercq, Lemey, Tandt & Petrovic, 2018). LLD is associated with an excessive cost to society in informal care and health care. The cost to treat an older person with depression is 1.86 times greater than that of an older person that does not suffer from depression (Axel et al., 2018). LLD is a life-threatening condition and the consequences of not treating it can result in diminished quality of life, aggravation of chronic conditions, and suicide. Older patients tend to seek medical advice from their general practitioner for physical complaints and many times it is underdiagnosed. It is important that general practitioners can identify the risks of LLD, diagnose and treat the disorder. LLD when diagnosed and treated in a timely has a good prognosis. Seventy percent of older adults with depression recover well from episodes of depression when treated with a pharmacological agent (Axel et al., 2018).
Nursing Interventions
Depressive symptoms or depression itself are often overlooked in older adults, even by healthcare professionals. Registered nurses (RNs) that work with patients in later stages of life, either through care in hospitals or care centers for the elderly, can intervene. RNs are placed at the frontline of care which can help identify, assess, and intervene according to the nursing process. However, mental health is a challenging aspect, with many RNs having the lack of knowledge or absence of confidence to readily discuss depression with their patients. However, evidence demonstrates the importance of identifying and addressing depression in older individuals to direct them to proper mental health care and potentially prolong life duration (Borglin et al., 2019).
Pharmacological treatments are commonly the first-line approach to treating depression with the use of antidepressants. Some APRNs can prescribe these medications or refer them to a primary care physician. In many cases, patients are encouraged to see a psychiatrist based on a referral. RNs can offer support and follow-ups to treatment, ensuring that older patients are adhering to treatment. The offering of general support such as listening, communicating, and counseling (to a professionally appropriate level) are believed to be effective (Borglin et al., 2019). Nurses can guide or direct patients to techniques such as mindfulness meditation. There is evidence from multiple studies which suggest that mindfulness-based interventions which nurses can learn to implement or lead, can significantly improve depression and are effective to use alongside conventional treatments (Reangsing et al., 2020).
Another potential intervention is introducing a physical activity program as fitness may have positive effects on decreasing anxiety, stress, and other factors which contribute to depression. According to Lok et al. (2017), nurses can develop physical activity regimens aimed at older adults and the elderly, including in nursing homes, that take into account their health and physical mobility. The exercise regiment consisted of a warm-up, rhythmic exercise, and cool-down for a total of 30-40 minutes in addition to 30 minutes of free walking on four days of the week. The intervention aimed at individuals aged 65 and older demonstrated a notable decrease on the Beck Depression Scale and an increase on the SF 36 Quality of Life Questionnaire (Lok et al., 2017).
Research studies
The personality makeup of neuroticism has been associated with an increased risk of depression across all ages. A research study was conducted to examine the relationship between neuroticism and depression in elders. The study methodology used the NEO Personality Inventory (NEO-PI) to assess neuroticism utilizing various cognitive neuroscience-based measures to evaluate emotional control. The NEO-PI includes neuroticism as part of five personality factors. Neuroticism was developed as a construct within the NEO-PI to identify individuals likely to have psychological distress and a component subscale that includes depression. The subjects were enrolled in a study grant named Neurobiology and Adverse Outcomes of Neuroticism in Late-life Depression. The research results showed that 33 older depressed subjects scored higher on measures of anxiety and neuroticism when compared with a group of 27, not depressed older subjects. The neuroscience-based measures showed depressed subjects expressing more negative words when compared with controls on an emotional test. In this preliminary work, a significant difference was found in measures of neuroticism and emotional controls among depressed and non-depressed older adults. The evidence indicates that higher levels of neuroticism in elders with major depression are associated with reduced response to treatment over time (Axel et al., 2018).
Two-thirds of those over the age of 65 have two or more medical conditions and the multimorbidity increases with advanced age. Should the management of depression be essential to the care of older adults with multimorbidity? A research study conducted by John Hopkins, Pennsylvania, and Pittsburgh University evaluated whether depression management programs would improve the mortality risk among increasing levels of comorbidity (Gallo et al., 2016). The study sample included 1204 older patients who completed the Charlson Comorbidity Index (CCI) and baseline interview questions. The study intervention provided primary care physicians with algorithms for the care of depression that offered psychotherapy, antidepressant dose adjustments, and symptom monitoring. The study measured mainly the depression status based on interviews, comorbidity, and mortality at 8 years. The research showed that patients with the highest comorbidity and depression under usual care were at increased risk of mortality when compared to depressed patients with minimal comorbidity. On the other hand, patients under intervention practice with the highest level of comorbidity and depression when compared to depressed patients with minimal comorbidity were not at significantly increased risk. The research concluded that depression care management programs lessen the combined effect of multiple morbidity and depression on mortality. Depression management is necessary for optimum patient care and should be primary in focus when caring for older adults (Gallo et al., 2016).
Conclusion
It is evident that depression in older adults and the elderly is a prevalent and serious condition that can impact their health status and quality of life. Healthcare professionals need to regard this as a vital issue in order to identify, assess, and intervene at early stages. With proper diagnosis under the DSM-5 guidelines and competent interventions, it is realistic to manage depression and mitigate the negative effects on mental and physical health in older populations.
References
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