Depression is the most common mental illness in the elderly. Approximately 10% to 15% of people over 65 have clinically significant depression and probably twice that number have mild depression.1 liiere is a great disparity between the number of elderly with a diagnosis of depression (5%)2 and the number of elderly with symptoms of depression (20% to 50%). 3·4 Symptoms of depression are the same as those of several other conditions, thus making diagnosis difficult.
Depression at any age may present with symptoms in four areas: emotional, cognitive, physical, and behavioral. In the elderly, vague physical complaints and preoccupation with bodily function may be the only symptoms.
Eating, sleeping, elimination, and energy changes are the most common physical complaints. Cognitive changes are more common in the elderly than in members of younger age groups and may include changes in memory, attention span, and feelings about the future.
Behavior changes such as withdrawal from activities or increased irritability may be present. Mood or emotional symptoms that are characteristic of depression in younger ages may not be present at all in the elderly; when present, they may not be expressed unless the elderly person is asked. Mood changes, when present, are the same as in younger individuals and include sadness, unhappiness, and feeling blue.
The main feature of clinical depression is change - change from usual patterns, habits, or moods. The second feature of depression is that it persists - changes may last months or even years. Depression can be differentiated from normal blue days in that the symptoms last at least two weeks. A summary of signs and symptoms of depression is found in Table 1 .
Underdiagnosis of depression is indeed a tragedy because once diagnosed properly it is a very treatable disease. The worst thing that can happen if depression goes untreated is, of course, suicide. White elderly males have a higher suicide rate than any other age group.5 Elderly males are more likely to use lethal means and thus suicide attempts are more often successful.
In addition, they have less of a tendency to alert others of their suicidal thoughts. Even when not ending in suicide, untreated depression can cause severe emotional pain and discomfort, social withdrawal from activities, decline in physical health secondary to anorexia and insomnia, or loss of independent living. Though these consequences are not as tragic as suicide, they should not be dismissed lightly. Depression that is undiagnosed is more likely to end in such negative outcomes.
Physicians, needless to say, treat depression once it has been diagnosed. However, those elderly who have not been in contact with a physician, who have mild to moderate depression not responsive to medications, or who have depressive symptomatology without a diagnosis of depression often go untreated. Less than one fourth of people with depression receive any treatment.6
Empirically, treatment of depression should be based on the cause of the depression. The etiology of depression is still under great debate. Biological theories are mainly concerned with genetic predisposition and changes in the chemicals in the brain, specifically neurotransmitters and monoamine activity. Endogenous depression or "depression that arises from within" without any obvious external cause may be explained by the biological theories. This type of depression is often severe and seems to respond well to antidepressant medications or ECT (electroconvulsive therapy).
Some drugs (especially antihypertensives, antiparkinson, anti-inflammatory and CNS depressives) and some diseases (notably Parkinson's disease, brain tumors, thyroid disease, pernicious anemia, cancer of the pancreas and uremia) can cause depression.7·8 Biological theories may also explain the pathophysiological processes involved with this cause of depression. An obvious treatment is eliminating the offending medications and controlling the physical illnesses that may be causing the depression.
SUMMARY OF SIGNS AND SYMPTOMS OF DEPRESSION IN THE ELDERLY
Psychological theories as an etiology of depression may explain the type of depression that results from suffering a loss, called reactive depression. (This type of depression is usually moderate or mild and is less responsive or unresponsive to medications.) It is difficult to define the borders between normal grief and reactive depression. If the focus is symptom relief, accurate distinction between these two conditions becomes a moot point.
Traditionally, treatment of depression in the elderly by physicians other than psychiatrists has depended upon the severity of the condition, rather than the cause. The cause of a depression and the resultant severity are roughly similar. If symptoms are very severe, with suicide a definite risk, the person may be hospitalized. A person who is moderately to severely depressed but not suicidal is given medications as an outpatient.
These two groups of depressed individuals are the most likely ones to be suffering from endogenous depression and thus medication is a logical course of action. If symptoms of depression are mild to moderate or unrecognized as a sign of depression, they are frequently ignored. Reactive depression is the most common depression in the elderly and generally produces less severe symptoms than endogenous depression.
Two significant consequences of this approach to treatment are obvious. Because depression is thought to be a medical problem treated best with medications and hospitalizations, nurses are relatively uninvolved and are relegated to the role of "giver of pills." Second, many elderly people with clinical depression or depressive symptomatology are not receiving treatment.
Treating depression in the elderly only by administering medications is a practice that should be challenged. Other treatment options should be considered, in combination with medications, for the severely depressed and instead of medications for the mild to moderately depressed. Research indicates that mild to moderate depression frequently responds to supportive care, increased activity, counseling or psychotherapy9"" and only requires medication when these other measures do not result in a favorable response. Normal grieving following a loss can also be helped by these same nondrug treatments.
Supportive care includes such measures as: 1) assistance with activities of daily living; 2) good nutrition; 3) promoting comfort; 4) relief of physical and emotional pain; 5) giving information and encouragement; 6) encouraging the person to talk about feelings; 7) encouraging physical and mental activities; 8) advocacy; 9) ongoing interest; 10) encouraging involvement of family and friends; and 11) environmental adjustments. These measures are the forte of nurses. With guidance in choosing the appropriate supportive measure for each individual, many more depressed elderly could be helped.
Most nurses are familiar with both the nursing process and Maslow's hierarchy of needs. The nursing process includes assessment, identifying problems, establishing goals, intervention, and evaluation. This problem-solving process is very helpful in organizing thinking into a logical format that leads to a specific, measurable approach to care planning. An essential part of the nursing process is problem identification or nursing diagnosis. "Once the problem is clearly identified, the solution is evident. The nursing actions to be taken also become evident when the problem is recognized. ",2 (p 25)
Maslow's hierarchy of needs naturally groups data into categories that nurses recognize and remember easily. It also establishes priorities for intervention from more basic needs to higher needs. Nursing process begins with assessment, the gathering of data, and includes history taking and physical assessment. The goal of assessment is to uncover symptoms of depression previously discussed.
Critically important to assessing depression is a careful history. Emphasis should be placed on the psychosocial history and should include both the person's normal characteristics and those the person is now exhibiting. In order to be significant, symptoms must be new to differentiate from life-long characteristics and must persist for at least two weeks to differentiate from normal "blue days."
Once the data are gathered, they must be analyzed to identify problems. This is probably the most critical step, and to be effective must include the elderly person. "The nurse must be careful that problems identified are perceived as problems by the client."12 (p 26) Problems can be arranged in terms of Maslow's hierarchy of needs which are: 1) physiologic needs; 2) safety and security needs; 3) need for love, belonging and affection; 4) need for esteem and self respect; and 5) need for self actualization. Table 2 shows the interaction between the nursing process and Maslow's hierarchy of needs.
Maslow made it clear when developing his theory that people are not likely to be motivated to satisfy higher needs until lower ones are somewhat satisfied.13 (p 98) The elderly with the most severe symptoms must have their most basic needs met first. Elderly persons with only mild symptoms of depression are likely to be able to take care of their most basic needs independently and will require assistance only in fulfilling higher needs. To look at treatment for depression in this kind of framework will focus on symptoms and provide relief for many depressed elderly now being ignored or "lost in the cracks."
The most basic needs, physiologic needs, predominate in motivation of human behavior and must be supplied first. These are needs for food, fluid, air, warmth, shelter, rest, sleep, sex, and avoidance of pain. A person in the grips of severe depression will be in severe emotional pain that is as real and as uncomfortable as physical pain. This is likely to be the main motivator and an area of primary importance. Those who are suicidal are probably motivated by a desire to end the pain. Such patients require immediate assistance. Electroconvulsive therapy (ECT), hospitalization, or medication may be the first step in treatment. Elderly persons with such severe symptoms are in the minority, but must be recognized and referred.
In working with depressed elderly who are receiving medical treatment, basic needs still must be attended to. Antidepressant medications take two weeks before showing an effect and many have side effects. Common anticholinergic side effects such as constipation, urinary retention, and dry mouth need active intervention. For some antidepressants these side effects can and should be expected. There is a great tendency to be noncompliant with medications that cause unpleasant side effects and do not seem to be "working." Education about antidepressant medications is imperative.
Other physiologic needs are frequently evident in depression and can be remedied by nursing interventions. Nurses are well equipped and feel comfortable handling such common medical problems as malnutrition, dehydration, constipation, and insomnia. Physical exercise may be a useful treatment for several of the physiologic needs. It is well known that exercise stimulates appetite and promotes sleep. When combined with increased fluid intake, it is helpful to relieve or prevent constipation. In addition, several studies1416 have shown that exercise reduces depression and relieves tension. The depressed elderly may need strong encouragement to start on a physical activity regime since depression often includes lethargy as a symptom.
THE NURSING PROCESS AND MASLOWS HIERARCHY OF NEED
For all depressed elderly, physical comfort and emotional well being are enhanced by attention to skin care, dressing, and grooming. Self-care abilities need to be supported, and assistance with activities of daily living should be provided when necessary.
After the physiologic needs are basically satisfied, the safety and security needs require attention. These needs involve the desire to protect oneself and feel free from danger. Humans have a need not only for physical safety but for psychological safety as well. Psychological safety stems from a sense of being in control of one's emotions, life, and future. Part of this is a need for a predictable, lawful, orderly world in which unexpected, unmanageable or other dangerous things do not happen. Again, if these needs are totally unsatisfied, the person becomes preoccupied with them.
Several problems can interfere with fulfillment of safety and security needs. Limited mobility or alterations in sensory perception increase the chance of accidents in the home and contribute to a sense of insecurity. Manipulating the environment to compensate for these impairments is necessary.
Hazards such as loose rugs and clutter must be eliminated. Night lights, bright reading lamps, and telephones with volume control may be helpful. Adaptive equipment such as wheelchairs, walkers, and canes prevent falls and increase a person's sense of security.
Confusion may be associated with depression, increasing the person's sense of insecurity and leading to unsafe behavior. Sometimes what appears to be confusion is really apathy - the person simply does not care enough to make an effort to go to the bathroom or to know the day's date. Sometimes confusion is the result of changes in brain physiology that caused the depression.
In either case, confusion may be as frustrating and frightening to caregivers as it is to the patient. Having it explained that the confusion will lessen or completely disappear with improvement in the depression often is comforting. For the confused person, a structured routine that is understood and does not change from day to day, in stable surroundings and among familiar people, will minimize difficulties. Relocation should be avoided when possible and take place slowly when unavoidable.
People who are depressed often are fearful of not being in control. Depression may feel like an unexpected, uncontrollable force that overwhelms the individual. Patient education about the usual progression of the disease and the prognosis is often very helpful in relieving such fears and problems. Patients need to know that mild to moderate depression and normal grieving are treatable and eventually self limiting even when not treated. People do not stay depressed forever. Treatment is successful in eliminating or reducing most symptoms of depression.
Once both physiologic and safety needs are fairly well satisfied, the love and affection and belonging needs will emerge. These are needs for contact, for intimacy, for friends, for a feeling of having a place where one belongs. A depressed person is at risk for having these needs unsatisfied for two reasons. First, it is not uncommon for a depressed person to become isolated from friends, family, and society. He may feel that he is no fun and will only be a burden on others around him. In order to spare loved ones, the individual in essence tries to protect them from himself and his gloomy moods. A depressed person who is most in need of support from others alienates himself from that same support.
Another reason why the elderly depressed person is likely to have unfulfilled needs for affection is that the depression may have been caused by the loss of a significant other. To replace a recent loss may be especially difficult when enormous energy is being devoted to the grieving process.
Nurses, aides, and other health caregivers can assist the depressed elderly with these needs in a variety of ways. Probably the most important intervention is to communicate to the patient a sense of being unconditionally accepted as a fellow human being. In order to foster a trusting, nonjudgmental relationship, it is important to allow the person to ventilate feelings and give the feedback that all those feelings are all right, not bad. Depressed patients need attention and nurses need to realize that emotional pain is just as real and just as worthy of treatment as physical pain.
Unfortunately, this attitude is the exception rather than the rule. There is a fear that to relieve emotional pain will require a great deal of time. It is far better to tell a patient that one has five or ten minutes and then give undivided attention for those minutes than to ignore the patient's need for interaction. Nurses need to instruct allied health professionals to talk to the patient during activities of daily living. This is an excellent time for sharing and listening. Many aides are in tune with the elderly 's needs for love and caring and will spend extra time during the day with them. Intuitively such aides realize this unspoken need and will offer it warmly without being told. This is to be encouraged and praised.
The depressed elderly need to be encouraged to attend social activities. Some people have a long history of formal social activities such as volunteering, clubs, and religious organizations. Other elderly have never enjoyed such activities and are unlikely to enjoy them in old age. They may instead have enjoyed private activities such as handwork, TV, time with family and friends. Continuing whatever activities the elderly person has enjoyed in his or her past adult years should be encouraged.
Family and friends often are eager to help and do not know what to do. Regardless of whether the depressed elderly person is in a hospital, a nursing home, or at home, family members should be encouraged to spend time with that person. People feel a sense of belonging to their family and friends. Love and affection may be more readily accepted from those to whom the elderly feel close.
Humans also have a need to give love, and this may be easier for the elderly to do with family members, especially grandchildren. Depression can put a strain on the entire family. Nurses may need to support and listen to family members and provide information to them about how depression may alter behavior. Family members who are supported by nurses, may in turn be more effective in supporting the depressed individual.
The need for esteem and self respect is one of the higher needs and overlaps somewhat with the previous one. Someone who feels that others care about and love him is more likely to feel worthy of being loved. In addition, the need for self esteem and self respect includes the desire for strength, for achievement, for mastery and competence, for reputation or prestige, for status, for recognition, for appreciation, for dignity. It is love of self as well as recognition that one is a unique individual.13 (p 45)
People whose depression stems from personal inadequacy and who feel hopeless that the situation will improve may be depressed about their depression.17 They may have attempted to handle their emotions alone and have been unable to do so. After repeated unsuccessful attempts, a person may begin to feel powerless and give up trying. Such a person may feel incompetent and out of control.
Depressed people may have very negative opinions of themselves and unwarranted pessimism about the future.18 Usually this is not a life-long view but a symptom of depression. When asked to describe one good thing about themselves or one thing they enjoy doing, they will be unable to do so. They will minimize past achievements and concentrate on present, often minor, failures. They may feel they have nothing to look forward to other than continuation of the depression. Their expectations of self may be totally irrational such as: "I must be a perfect wife, mother and grandmother."
Such beliefs about themselves may result in anxiety, guilt, and abandonment of usual roles for fear of failing. In the extreme case it may result in withdrawal from all activities, even personal hobbies and activities of daily living. Eventually they may become completely dependent on others, no longer participating in cooking, home maintenance, or self care. Because this is one of the higher needs, help from a professional with special skills is necessary.
Nurses' basic education equips them to assist patients to meet these needs with counseling, problem-solving skills, and patient education. Nurses do a considerable amount of counseling in their usual practice. Because their observation skills are fine-tuned, nurses are able to understand nonverbal behavior and recognize themes in conversations.
Based on their observations of such clues, nurses can provide a patient with feedback that can be very helpful in assisting that patient to define his own problems. This is often a very difficult thing for a patient to do alone. Once a problem is clearly identified and brought to light, the patient may know the solution.
Other problems can be solved by patient education. Information about the disease process, expected outcomes and alternative types of treatment gives the patient control in choosing a preferred treatment modality. Finally, teaching the problem-solving process can help the patient understand that facts and data must be gathered before action can be taken. The nurse and the patient together can assess past coping mechanisms and past strengths in deciding on a plan to overcome depression.
Nurses tend to discount the effectiveness of these interventions and feel insecure counseling elderly even with minor symptoms of clinical depression or with normal grief. Many older people are reluctant to seek assistance from psychologists or psychiatrists, yet trust nurses and feel comfortable talking with them. If nurses do not provide assistance, this group of elderly may refuse to seek help from other sources.
It is likely that the basis for nurses' reservations in engaging in these activities is the complexity of meeting these higher needs. To be effective, treatment must be highly individualized, taking into account past coping styles, coping adequacies, belief systems as well as presenting symptoms. Nurses need to trust the response they see in elderly depressed clients. If the depressed individual seems to be trusting and open with the nurse, appears compliant with suggestions, and in essence appears to be helped by the nurse's efforts of counseling or problem solving, the nurse needs to believe that these responses are true.
If the depressed person does not appear to be helped, he should be referred to different professionals. Likewise, depressed individuals with certain symptoms should be referred to a specialist. Specifically, if the major symptom appears to be negative thinking and an unrealistic belief system, that person may do well with a specialist in cognitive therapy. If anxiety is the major symptom, behavior therapy may be helpful. Nurses err in favor of referring more often, rather than less often than necessary. It's unlikely a nurse would feel comfortable counseling an individual with severe vegetive symptoms. It is much more likely she will feel insecure counseling elderly with minor symptoms of clinical depression or elderly experiencing normal grief. Nurses are competent and helpful, yet do not always give themselves credit for being so.
All three forms of therapy - problem-solving, cognitive therapy, and behavior therapy - deal with a person's sense of achievement, mastery, and control. Once a person has developed a sense of self-confidence, strength, and capability that permit him to feel in control of his disease, the sense of control can be extended into other aspects of his life.
The highest level of Maslow's hierarchy of needs is the need for self actualization. Maslow says that only about 1% of adults reach this level and many do not strive for it, seeking only to meet lower level needs. Self actualization involves creative impulses, self expression, and achieving everything one is capable of becoming.
Depression so seriously interferes with the satisfaction of many lower needs that there is no energy left to devote to self actualization. Helping a person to overcome depression will free that person to go on with life and attempt to reach this higher level need. It is unlikely that this need could be a priority in a depressed individual.
Discussion of Maslow's hierarchy of needs as it relates to treatment of depression may be helpful to nurses by demonstrating that to attempt to do patient education or problem-solving with a person whose basic needs are unmet is probably unrealistic. When an elderly person is institutionalized for depression, there is a tendency to try to solve all problems before the patient leaves the institution. This cannot always be done.
In this era of DRGs, it is conceivable that a person may be discharged from the hospital or nursing home once the threat of suicide has abated. The elderly person may still be suffering from one of the physical symptoms of depression such as insomnia, constipation, and anorexia and may also be suffering emotional symptoms of sadness and discomfort.
To insist that a patient participate in patient education and problem solving is likely to be fruitless and frustrating until lower level needs are satisfied. It may well be that only the first three levels of the needs hierarchy can be addressed while a person is in the hospital; counseling sessions may have to wait for the home situation or an outpatient clinic.
Nurses often feel insecure around depressed persons, see themselves as unable to help, and believe treatment is only in the hands of physicians and psychiatrists, who consider medications the single treatment mode. In fact, most depressed elderly persons need nursing therapeutics as much if not more than medical therapeutics. The first three basic needs of Maslow's hierarchy must, however, be met before the higher needs can be tackled. All nursing personnel are equipped, without further training, to help the elderly depressed person fulfill these basic needs. It is just a matter of thinking logically through each specific case, observing individual needs, and making an appropriate care plan.
The interventions themselves are not difficult or complicated. They simply need to be correctly identified and emphasized. Nurses, and nurse's aides with guidance, can be instrumental in relieving much of the pain and suffering associated with depression. Good nursing therapeutics are not restricted to any environment. Hospitals, nursing homes, nurse-run clinics, home healthcare services, or any environment where nurses care for the elderly can be the right environment in which to assist the 10% to 15% of the elderly who are are clinically depressed.
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SUMMARY OF SIGNS AND SYMPTOMS OF DEPRESSION IN THE ELDERLY
THE NURSING PROCESS AND MASLOWS HIERARCHY OF NEED