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Acknowledging, Recognizing, and Treating Depression in Elderly Long-Term Care Residents
Depression in individuals with dementia is associated with a decreased quality of life, increased healthcare use, and higher mortality rates. The prevalence of clinical depression in elderly long-term care (LTC) residents who have dementia is estimated to be as high as 63%. While actual suicide attempts may be uncommon in LTC facilities, death wishes and feelings of worthlessness are common, and these feelings should never be considered normal. LTC residents with depression who engage in self-harming behaviors, such as refusing food or medical care, may actually be attempting suicide. Although depression in the elderly often remains undiagnosed, prognosis is good when there is prompt recognition and treatment. This article seeks to raise awareness of depression in the elderly, which often presents atypically in this population, and discusses various treatment strategies. (Annals of Long-Term Care: Clinical Care and Aging. 2010;18[11]:30-32.)
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Depression is the most common mental health disorder in seniors and is particularly common among those living in long-term care (LTC) facilities.1-3 The prevalence of clinical depression in this population has been estimated to range from 9% to 49%,1,4 with one article reporting a rate as high as 63%.5 People living in LTC facilities have a multitude of possible chronic illnesses, and the vast majority suffer from some form of dementia. Gruber-Baldini and colleagues report that depressive symptoms were more than twice as common in seniors with mild-to-moderate dementia.4
Of the many behavioral and psychological symptoms that can occur in dementia, depression is one of the most prevalent and can occur at any stage of the disease.3,6 Depression in dementia is associated with a decreased quality of life, increased use of healthcare, and higher mortality rate; it has been found to increase mortality by 59%.5-7 The Canadian Institute for Health Information reports that the odds of dying are 1.5 to 2 times higher in elderly LTC residents with depression than for those without depression.1 Although little research is available on suicide attempts in elderly individuals with dementia, particularly in the LTC setting, suicidal ideation, death wishes, and feelings of worthlessness have been reported in up to 42% of people with dementia.5
There are claims that suicide attempts are less common in LTC facilities, possibly due to the close supervision of residents; however, LTC residents with depression who engage in self-harming behaviors, such as refusing food or medical care, may be expressing a suicide attempt that is going unnoticed.8 Depression in the elderly often remains undiagnosed, but when screening, recognition, and treatment occur, prognosis is good and quality of life is improved.9,10
Understanding Depression in the Elderly
Depression is often difficult to diagnose in elderly persons, whether or not they have dementia, because it tends to present atypically in this population.11 Seniors with depression are less likely to report a saddened mood and crying spells. Instead, they tend to present with anorexia, disruption in sleep patterns, and fatigue.12 Depression is the most common cause of unintentional weight loss in the elderly in any environment.13
Multiple somatic symptoms are also common, such as pain (headache or abdominal), unexplained gastrointestinal issues, abrupt changes in memory, inability to concentrate, and refusal to eat or accept medical help.11,12 There may be reports of “just not doing well.” Diagnosing depression in patients with dementia, especially when dementia is in its later stages, is a particularly challenging endeavor because of communication difficulties and the overlapping symptomatology of these diseases.7 Two reports found irritability to be one of the most frequently observed symptoms in elderly individuals with depression and dementia.3,7 Apathy is a neuropsychiatric symptom that is also commonly found in dementia,14,15 but it does not always signal depression.
Depression versus Apathy
Depression is associated with emotional distress and manifests as sadness, anxiety, insomnia, anorexia, and irritability.16 While apathy can be associated with depression, many people with this symptom may not experience concomitant depression. Apathy is the absence of motivation, feelings, concern, or interest not attributable to a mood disorder, cognitive impairment, or change in level of consciousness.14,16 Although apathy may overlap with actual depression, it alone should not be assumed to be depression. Tagariello and colleagues report that it is important to distinguish between the two because the treatment for depression (the use of selective serotonin reuptake inhibitors [SSRIs]) may actually worsen apathy.15 On a basic level, apathy involves cholinergic deficits, while depression is associated with neurotransmitter (serotonin, dopamine, or norepinephrine) deficits or imbalances. When evaluating an elderly individual for depression versus apathy, assessing for sadness and feelings of worthlessness, helplessness, and hopelessness can assist in differentiating between the two conditions.15,16
Suicide Potential
Depression is a risk factor for suicide, and the elderly, particularly older white men, have the highest suicide rate worldwide.8,12,17,18 Approximately 90% of people of all ages who have committed suicide had a psychiatric disorder, and depression is the most predictive factor for suicide in the elderly.19,20 Data on actual suicide attempts in the LTC setting are sparse; however, new evidence is emerging that suicidal ideation is common in this setting.21 Suicidal ideation and passive suicide attempts, which are indicators of increased suicide risk, can be found in up to 31% of LTC residents.21
When examining the phenomena of death wishes and passive suicide attempts among nursing home residents, Scocco and associates found that cognitive impairment did not interfere with the residents’ ability to disclose suicidal ideation.8 These researchers suggested that suicide ideation may be the precursor for self-harming behaviors, such as refusing food or medical treatment, which are also known as indirect self-destructive behaviors. I
ndirect self-destructive behaviors are actions that endanger the elder’s life, but would not ordinarily be regarded as suicidal.19 It has been surmised that indirect self-destructive behavior, such as refusing to eat, serves as a substitute for overt suicidal behavior.13 Since the LTC facility is often an individual’s last residence before death, this move may represent the ultimate loss of control; thus, control over death may take on a more crucial meaning to residents.19,22 While research is scant on indirect self-destructive behavior, if such behavior is witnessed, it should be brought to the attention of the practitioner.
Anxiety and Depression
The most common form of anxiety is generalized anxiety disorder, which is often found in association with clinical depression.9,23,24 Of those with diagnosed depression, 65% also demonstrate symptoms of anxiety.25 The second-generation antidepressants, such as SSRIs, are officious in many types of anxiety disorders and are now considered first-line treatment.24 Blank and associates conducted a 32-week trial to assess the efficacy of citalopram on anxiety disorder and found that it was reasonably well tolerated and resulted in significant improvement in anxiety symptoms.23
While elderly individuals with anxious depression had a slower response rate and required an extended period of time to experience results, their quality of life did substantially improve.23 Examples of an increased quality of life include better quality of sleep, improvement in social and mental health function, and renewed enthusiasm. Lenze and colleagues report that the elderly are the leading users of benzodiazepines.26
Although some studies indicate that the use of benzodiazepines is decreasing among the elderly, the fact that this class of drugs is still prescribed despite evidence that their use is addictive, contributes to cognitive impairment, may worsen depression, and increases risk of falls raises concern regarding the appropriateness of prescribing these agents to treat anxiety in the elderly.26,27
In a recent study, Tsunoda and associates researched the feasibility of tapering and discontinuing benzodiazepines, assessing the impact of discontinuation on postural sway and cognitive function in elderly individuals.28 They found that discontinuation of benzodiazepines was feasible and led to a significant improvement in body stability. Since an increase in postural sway correlates with falling in the elderly, discontinuation of benzodiazepines would result in a decrease in falls and their resultant complications. The study also found that some elderly individuals experienced improved cognition following the discontinuation of these drugs, which led to improved quality of life.
Treatment
Depression in the elderly can and should be treated. Any number of treatments or treatment combinations can be considered, including antidepressant drug therapy, electroconvulsive therapy, and psychotherapy. The goal of therapy is complete remission of the depressive episode.9,29 SSRIs, considered the first-line therapy for the elderly,27 have similar efficacy to first-generation antidepressants (tricyclic antidepressants), but have less toxicity in the event of an overdose.30
Tricyclic antidepressants are not the drugs of choice for the elderly because of their anticholinergic properties and risk of cardiovascular side effects.29 The duration of an antidepressant trial is important, especially in the elderly. Mulsant and associates studied the length of time required in an antidepressant trial before declaring a treatment failure.31 The investigators classified people with depression as full responders, partial responders, and nonresponders, and of the 472 elderly participants, most became full responders after an extended trial period.31
In many elderly persons, an extended trial of 12 weeks is required to observe a full response to an antidepressant before declaring a treatment failure, whereas younger adults may respond to antidepressant therapy within 4 weeks. Once initiated and remission is achieved, antidepressant therapy should be continued for 9 months to 1 year for the first depressive episode. Elderly individuals who have had two or more episodes of depression may benefit from several years to lifelong therapy.30
Conclusion
Depression is a global problem. In the recent past, depressive symptoms were considered a natural consequence of aging, but depression is never normal and is a cause of significant functional decline in the elderly. Fortunately, it is also one of the most treatable chronic diseases in this population. The diligent monitoring of this disease and aggressive treatment often produces a good prognosis and an improved quality of life. Healthcare providers in the LTC setting need to recognize that passive self-harming behaviors, such as refusing food or medical treatment, may be a suicide attempt. Because individuals may live for years in a LTC setting, improved recognition and treatment of depression provides an opportunity to increase their quality of life despite the presence of other medical problems.
The author reports no relevant financial relationships.
Amanda Adams-Fryatt is nurse practitioner, Kildonan Personal Care Centre, Winnipeg, Manitoba, Canada.
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