new when you are more than “down in the dumps” depression in … · 2020. 8. 27. · revised by...

Revised by M. Smith (2006) from K.C. Buckwalter & M. Smith (1993), “When You Are More Than ‘Down in the Dumps’: Depression in the Elderly,” The Geriatric Mental Health Training Series, for the Hartford

Center of Geriatric Nursing Excellence, College of Nursing, University of Iowa.

When You Are More Than When You Are More Than ““Down in the DumpsDown in the Dumps””

Depression in Older AdultsDepression in Older Adults

Facts About DepressionFacts About Depression

The most common psychiatric illness for people of all agesUnder- and mis-diagnosed in older adultsMistaken for “problems of aging”

Facts About DepressionFacts About Depression

Risk factors includeFemale genderChronic & disabling illnessLack of social supportRecently bereavedPrior history of depression

7 of 35 million older adults have depression!!!

Diagnosis is DifficultDiagnosis is Difficult

Coexistence of many other problems

medicalphysicalsocialeconomic“normal” aging

May “mask”depression

TRUE FALSE

Suicide in Older AdultsSuicide in Older Adults

Represent 13% of the populationAccount for 1/5 (20%) of all reported suicidesLowest rate of ATTEMPTSHighest rate of COMPLETED SUICIDE

Indirect SuicideIndirect Suicide

Starvation, refusingto eatRefusing neededmedicationsMixing medicationsAlcohol abuseLoss of “will to live”

Poor OutcomesPoor Outcomes

Comorbid ConditionsAnxietyMedical problemsCognitive impairment

Concurrent Problems & IssuesPsychotic depressionImpaired social supportStressful life events Multiple previous episodes

Changes in MOODChanges in MOODSadnessDiscouragementCryingFeeling “down”Having the “blues”Despair

IrritabilityBeing “on edge”AnxietyBroodingPanic attacks

Changes in PERCEPTIONChanges in PERCEPTION

WithdrawalHopelessnessSelf reproach for minor failingsInability to express pleasure

DelusionsHallucinationsWorthlessnessUnreasonable fearsCritical of self, others

Changes in BEHAVIORChanges in BEHAVIORAppetite changeWeight loss/gainSleep disturbanceFatigue, loss of energySlowed speechHealth concerns

Can’t think, concentrateThoughts of deathTachycardiaConstipationPacing, wringing hands

Depression or ???Depression or ???

Stop! Think about CHAIN OF EVENTS!Tempting to think personis “putting us on” or“manipulating”Behaviors are part of depressionAdjust expectations & approaches: Person cannot “just cheer up” or “look at bright side”!

Major DepressionMajor Depression

Depressed mood most of the day, everyday

ORLoss of interest or pleasure nearly every day

and at least 4 additional symptoms . . .

Major Depression, cont.Major Depression, cont.

Significant weight loss or gainInsomnia orhypersomniaPsychomotor agitation orretardationFatigue or loss of energy

Feelings of worthlessness, inappropriate guilt Loss of ability to think, concentrate, make decisionsRecurrent thoughts of death, suicidal ideation

FOUR ADDITIONAL SYMPTOMS

MINOR DepressionMINOR DepressionAlso known as

subsyndromal depressionsubclinical depressionmild depression

2 - 4 times more common than major depression

Associated with:subsequent major depressiongreater use of health servicesreduced physical, social functioningloss of quality of life

Responds to same treatments!

Common Causes of DepressionCommon Causes of Depression

CHAIN OF EVENTSStress & lossBiological depressionPhysical illness and its treatment interact with depression in older adults

Stress and Loss in Late LifeStress and Loss in Late LifeDecreased sensory capacity

visionhearing

Changes in social status, responsibility to othersLoss of family, friends

Relocation due to changing abilitiesDeclining social contacts due to health limitationsReduced functional statusDwindling financial resources

Stress and Loss in Late LifeStress and Loss in Late LifeLoss of meaningful roles

productivitypurpose in living

Loss of self-esteemhelplessnesspowerlessness

Decreased coping options

Biological DepressionBiological Depression

Genetic cause vs. “reaction” to stressseems to come out of “nowhere”family, personal history more commonincreased risk of severity, reoccurrence

Effects of environment and physical illness are still important to address!!

Physical Illness & DepressionPhysical Illness & Depression

Physical illness directly cause symptoms of depression

metabolicendocrineneurologicpulmonarycardiovascularmusculoskeletalothers: cancer, anemia

Physical Illness & DepressionPhysical Illness & DepressionPhysical illness can cause a reaction of depression by causing

chronic pain,fear of paindisability, loss of functionloss of self esteemincreased dependencefear of death

Physical Illness & DepressionPhysical Illness & Depression

Depressed elderly may present with somatic (physical) complaints

aches, painsappetite, weightfatigue, loss of energyconstipationtachycardiainsomnia

Physical Illness & DepressionPhysical Illness & Depression

Medications can cause symptoms of depression

antihypertensivespsychotropicsanalgesicscardiovacscularantimicrobialssteroidsothers

Physical Illness & DepressionPhysical Illness & Depression

Environment in which physical illnesses are treated may contribute to depression . . .

IsolationSensory deprivationEnforced dependency

AssessmentAssessmentDepression symptomsSuicidal thoughtsPsychiatric history

personalfamily

Physical health/illnessMedicationsRecent loss/stressResources/abilities

Geriatric Depression ScaleGeriatric Depression Scale

Score “0” or “1”Add up points (0-30)Further assessment if > 10Remember! Screening tool; assess symptoms further!!

Suicide AssessmentSuicide AssessmentAlways ASK!!!“Have you thought that life isn’t worth living?”If YES, then . . .

“Have you thought about harming yourself?If YES, then . . .

“Do you have a plan?”If YES, examine lethality. . .

Is the plan viable? Can they execute it?Are means deadly, available?

Look carefully!!

Psychiatric HistoryPsychiatric HistoryPrevious episodes of depression

Check chart/recordUndiagnosedBad nerves; nervous breakdown; went to bed sickAfter childbirth, (post-partum), children leave (empty nest), death of loved one, retirement

Physical Health/IllnessPhysical Health/Illness

Consider factors thatincrease isolation, loneliness, fear, or worthlessness!!

Loss of mobilityLevel of disabilityWorry about declining abilitiesPain resulting from health conditions

Look for factors thatdirectly increase depression symptoms

MedicationsNew?Change in dose?

New onset of physical illness

Influenza?Change in status of chronic diseases

Recent LossRecent Loss___ recent relocation?___ change in relationships?___ change in health?___ change in functional abilities?___ change in sensory status?___ change in financial status?___ death of loved one? (even a pet)___ loss of control over daily routines?___ loss of significant role?

Resources & AbilitiesResources & Abilities___ family support?___ community support?___ social network?___ physical abilities?___ functional abilities?___ cognitive abilities?___ financial resources? ___ personality traits? personal history?___ experiences, beliefs, convictions?

PersonPerson--CenteredCentered

Appreciate the older person’s perspective and experience:

control, power lossunwanted dependencymeaning of functional losses, relationship to activity, meaning and purpose in living

Facility, Staff

InterventionsInterventions

Depression is highly treatableDepression is sometimes called “A reason for hope”Many treatments

Talking therapyMedicationsDaily contacts

InterventionsInterventions

Every interaction has “Therapeutic Potential”Social environmentor “milieu” is powerful

Support, encouragementSafety, securityInteraction, involvementValidate worth by the way we treat them!

InterventionsInterventions

First-Line InterventionsCommunicate caring Help see they are unusually sad or blueProvide accurate information about depressionCreate a healthy physical and social environment.

InterventionsInterventions

Communicate caringRemind: WE VALUE THEMeven if they don't seem to careabout themselves right nowAsk: how they feel or what they thinkEncourage: to talk about issues, fearsUnderstand: their point of viewAccept: sadness, other feelings

InterventionsInterventions

Help to realize they are UNUSUALLY sad, blue

Suggest: more than "down in the dumps"Help: identify the things that are troublingRecall: past positive events things haven't always been this badNote: Positive attributes, characteristics they do still have worth!!

InterventionsInterventions

Provide information about DEPRESSION

An ILLNESS, like physical illnessSymptoms are part of depressionCommon in people of all agesHas a treatment AND treatment works

MedicationsTalking therapiesIncreased involvement in activities

Promote Mental HealthPromote Mental Health

Reduce “depressing effects”of the environmentAdjust factors in the social environment

Promote health & well-beingAlter approaches to careOffer different activities/experiences

Promote positive health outcomes!!

Monitor Physical HealthMonitor Physical Health

NutritionEliminationSleep/rest patternsPhysical comfortPain management

relaxation methodsmedicationalternative therapies

Encourage Physical ActivityEncourage Physical ActivityExercise programReferrals

physical therapyoccupational therapyrecreational therapy

Develop daily activity scheduleInvolve in meaningful activity

Promote AutonomyPromote AutonomyCreate mastery experiences

break tasks into stepsassure successpromote self worth, build confidence

Encourage personal control, power

independent activitydecision-makinginvolvement in care

Focus on PositiveFocus on PositiveCurrent abilities

knowledge, wisdomexperiencesattitudes, beliefsattributes

Reminiscence promotes self worthstrengthens tie to identify, “former self”stimulates interests, conversation

Employ Alternative TherapiesEmploy Alternative TherapiesPet therapy

unconditional positive regardsensory stimulationsense of responsibility, meaningful role

Horticultural therapylifespan simulationaroma therapymaintain mobility

Encourage Group ActivitiesEncourage Group Activities

Psychosocial therapiesReminiscenceRemotivationHealth, stress managementSensory stimulation

Many benefitsSocial interactionMastery experiencesRealization “I am not alone in this!

Promote CreativityPromote Creativity

Lots of alternatives:Singing, playing musicStory-tellingDrawing, paintingPoetry, writingMaking crafts, jewelry

Associated with positive health outcomesDecreased depression, lonelinessIncreased health, morale, satisfaction, activity

Enhance Social SupportEnhance Social Support

Identify a “point person”to help identify, mobilize resources

family memberfriend, neighborchurch membersclergyvolunteer visitorpeer counselor

Professional InterventionsProfessional Interventions

Individual therapyGroup therapyMedication therapy

Antidepressants– most commonOthers may be neededfor anxiety or psychotic symptoms

DepressionDepression

A REASON

FOR HOPE