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	''FAMILY PRACTITIONER SCREENING''		''FAMILY PRACTITIONER SCREENING''
-	A family practitioner may also be to blame. Physicians are encouraged to screen all older adults for depression on a routine basis; unfortunately these simple screenings are often overlooked. A physician who does screen and finds a patient as depressive should then follow-up with further assessments to pinpoint the cause.<ref name="Sharp" /> A practitioner who fails to rule out vitamin B12 or folate deficiency as the cause of symptoms will be unable to properly treat the patient. Anti-depressants will not cure the patient, instead they simply require vitamin B12 and/or folate supplements in their diet.<ref name="Got" /> Depression and dementia have overlapping symptoms and can therefore be challenging to distinguish. Depression can cause [[Image:geriatrics.jpg|left]]impairments in cognitive function, such as tasks of organization, planning, abstract thinking, memory and social skills. Dementia also shows these same impairments. In addition, patients with dementia can develop depression. A possible method for differentiation is the Mini-Mental Status Exam. The assessment uses questions like; spell human backwards. Anyone with dementia will have a difficult time with the test, while depression patients can answer correctly with some encouragement. <ref name="Spires">Spires, R. A. (2006). Depression in the elderly. Modern Medicine, Retrieved from http://www.modernmedicine.com/modernmedicine/CE Library/Depression-in-the-elderly/ArticleStandard/Article/detail/329133</ref> Use the link provided to view the full Mini-Mental Status Exam. http://lifemanagement.com/nextsteps/Mini_Mental_Status_Exam.pdf	+	A family practitioner may also be to blame. Physicians are encouraged to screen all older adults for depression on a routine basis; unfortunately these simple screenings are often overlooked. A physician who does screen and finds a patient as depressive should then follow-up with further assessments to pinpoint the cause.<ref name="Sharp" /> A practitioner who fails to rule out vitamin B12 or folate deficiency as the cause of symptoms will be unable to properly treat the patient. Anti-depressants will not cure the patient, instead they simply require vitamin B12 and/or folate supplements in their diet.<ref name="Got" /> Depression and dementia have overlapping symptoms and can therefore be challenging to distinguish. Depression can cause [[Image:geriatrics.jpg|left]]impairments in cognitive function, such as tasks of organization, planning, abstract thinking, memory and social skills. Dementia also shows these same impairments. In addition, patients with dementia can develop depression. A possible method for differentiation is the Mini-Mental Status Exam. The assessment uses questions like; spell human backwards. Anyone with dementia will have a difficult time with the test, while depression patients can answer correctly with some encouragement. <ref name="Spires">Spires, R. A. (2006). Depression in the elderly. Modern Medicine, Retrieved from http://www.modernmedicine.com/modernmedicine/CE+Library/Depression-in-the-elderly/ArticleStandard/Article/detail/329133</ref> Use the link provided to view the full Mini-Mental Status Exam. http://lifemanagement.com/nextsteps/Mini_Mental_Status_Exam.pdf
	It should also be noted that dementia shows a gradual progression of symptoms and depression tends to show a sudden onset that may be linked to a specific event, such as death of a spouse. Therefore it is critical that practitioners obtain accurate documentation of the patient’s history. In addition to diagnosis, there is a need for specific differential diagnosis of the disorder. Elderly depression can be divided into subcategories; significant depression, sub-syndromal depression, old age melancholia, old age depression with hypochondria, organic depression and depression-anxiety syndrome.<ref name="Got" /> If these types are identified, doctors can individualize patients for the best possible treatment outcome. Accurate and differential diagnosis is crucial in older adults as depression carries risk of suicide. It is important that physicians directly ask their depressive patients if they ever have suicidal thoughts. With further questioning, the physician will determine their level of suicide risk and prescribe the appropriate treatment or therapy. <ref name="Spires" />		It should also be noted that dementia shows a gradual progression of symptoms and depression tends to show a sudden onset that may be linked to a specific event, such as death of a spouse. Therefore it is critical that practitioners obtain accurate documentation of the patient’s history. In addition to diagnosis, there is a need for specific differential diagnosis of the disorder. Elderly depression can be divided into subcategories; significant depression, sub-syndromal depression, old age melancholia, old age depression with hypochondria, organic depression and depression-anxiety syndrome.<ref name="Got" /> If these types are identified, doctors can individualize patients for the best possible treatment outcome. Accurate and differential diagnosis is crucial in older adults as depression carries risk of suicide. It is important that physicians directly ask their depressive patients if they ever have suicidal thoughts. With further questioning, the physician will determine their level of suicide risk and prescribe the appropriate treatment or therapy. <ref name="Spires" />

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Revision as of 19:58, 31 October 2011

Contents 1 Depression and Suicide in the Elderly 1.1 RISK FACTORS 1.2 DIAGNOSIS 1.3 TREATMENTS 1.4 Notes and References

Depression and Suicide in the Elderly

RISK FACTORS

Depression and suicide are common issues in older age making it important to know the risk factors. As the risk factors for depression and suicide in elders can be quite complex, they have been broken down into categories. In many instances the risk factors for depression and suicide in the elderly population overlap, and depression is actually one of the major risk factors for suicide, making it important to discuss risk factors for both issues together.

MENTAL RISK FACTORS

Mental risk factors have repeatedly been shown to play an important role in both depression and suicide. One important mental risk factor for both depression and suicide is mental disorders. Research shows mental disorders, especially dementia and anxiety disorders, put seniors at heightened risk for depression ^{[1] [2]} and mental disorders, especially mood disorders and schizophrenia, to put seniors at heightened risk for suicide. ^{[3] [4]} Severe feelings of hopelessness have also been shown to put this population at a higher risk for both depression and suicide.^{[5] [6]} Some other mental risk factors specifically related to depression are lack of sense of control ^[7] and feelings of guilt.^[3] Some mental risk factors specifically related to suicide are acute suicidal ideation and anxiety.^{[6] [4]} Depression has also been repeatedly shown to be risk factor for suicide in the elderly.^{[6] [7] [8]} One researcher estimated that nearly all elders who try to commit suicide have symptoms of depression, clearly showing why depression is such an important risk factor to recognize in terms of elderly suicide.^[7] The Globe and Mail also ran a great news article highlighting the role depression can often play in elder suicide, that article can be found here.

PHYSICAL RISK FACTORS

When it comes to physical risk factors, physical illness has been recognized as being applicable to both depression and suicide in the elderly ^{[7] [3] [8]} but what types of illnesses are risk factors, and to whom they are risk factors, has varied in the research. Some studies have found serious physical illness to be a risk factor for men only ^[8], some have found only illnesses that are terminal to be a risk factor^[7], and others refer to physical illness in general as a risk factor.^[3] Some physical risk factors for depression specifically are: physical retardation^[3], functional impairment^[4] and changes in health.^[2] One important physical risk factor specifically related to suicide is self-cutting.^[6]

SOCIAL RISK FACTORS

In terms of social risk factors for both depression and suicide in older adults, social isolation ^{[6] [7]}, being widowed ^{[2] [3]} and being lonely ^[7] all apply. In some research, being widowed was found to be a risk factor for men in particular^[3] whereas other sources list widowhood or bereavement in general as a risk factor.^{[5] [2]} Some depression-specific risk factors for the elderly include changes in social roles and abuse.^[2] Some suicide-specific risk factors for the elderly are family history of suicide ^[6], institutionalization ^[7], loss of independence ^[7], disruption of social ties^[4], family discord^[4], lack of social supports^[4] and low social interaction.^[8]

OTHER RISK FACTORS

When it comes to other risk factors that apply to both depression and suicide in this population, alcohol abuse is believed to be very important. ^{[6] [7] [2]} In recent research, it was mentioned that although alcohol is often used as an alternative to suicide it can often end up contributing to suicide attempt and/or completion.^[7] Another risk factor for both depression and suicide appears to be accumulation of losses, a term used to describe suffering multiple losses in important life areas such as loss of a loved one, loss of physical health, loss of independence and/or loss of self-esteem.^[7] It seems that when these losses start to pile up in an older person’s life, they are at higher risk for depression and suicide. Some depression-specific risk factors to take note of are medications and previous episodes of depression.^[2] Benzodiazepines, which are commonly used as medical treatments for anxiety or depression, can also put elderly citizens at a higher risk for depression, even more so if the medication is used for a long period of time and/or suddenly stopped.^[2] Some suicide-specific risk factors to be aware of are history of suicide attempts ^{[7] [6]} and substance abuse disorders or increased use of alcohol or drugs.^[3] Another important suicide-specific risk factor is presence of/access to firearms. ^{[6] [4]} One study found that 71% of older adults who committed suicide used a gun.^[4] When looking at suicide risk factors related to demographics, one researcher found being male increased risk of suicide ^[5] and another found being an older, unmarried, Caucasian male increased risk of suicide.^[8]

Below is an interesting video that focuses on depression in the nursing home and speaks to some of the risk factors.

DIAGNOSIS

IDENTIFYING THE SYMPTOMS

Family members and family practitioners should be aware and look for the key warning signs of depression in aging individuals. Inside, your loved one may be feeling lonely, worthless, hopeless, agitated or guilty.^[9]. Outwardly they may exhibit changes to their normal behaviors, such as; poor sleep patterns, malnutrition, decreased hygiene, and depressive mood.^[10]. When relatives notice any or all of these signs, they are advised to notify their loved one’s doctor, allowing professionals to further screen the patient. The Geriatric Depression Scale (short form) is often used by practitioners to evaluate patients because it is valid, and it caters specifically to adults aged over sixty. The questions are formatted to allow for simple comprehension. However this tool, like others, cannot assess people with significant cognitive impairments.^[11] The assessment asks yes/no questions such as, “Do you often feel helpless?”^[9]. Use the link provided to see the full assessment task. http://www.chcr.brown.edu/GDS_SHORT_FORM.PDF

SEVERE UNDER-DIAGNOSIS AND MISDIAGNOSIS

Depression in older adults can look quite different from younger people. Anxiety over death is typical of the aging population while younger people find stress in other aspects of their lives. Depression among the elderly is a common problem, yet only one third of these people seek help from their doctor. Of the people who do go to their doctor, up to 60% are misdiagnosed and are therefore treated incorrectly.^[12] Why is this happening? Often symptoms of depression can be mistaken for typical elderly behavior. Physical changes in the body cause aging people to slow down naturally and isolate themselves from a busy social life. When family members don’t notice these changes as an indicator of depression, they will not bring their relative to see a doctor for further assessment and possible treatment. Also, family members may avoid seeking help because they are afraid of the stigma associated with a psychiatric disease.^[13]

FAMILY PRACTITIONER SCREENING

A family practitioner may also be to blame. Physicians are encouraged to screen all older adults for depression on a routine basis; unfortunately these simple screenings are often overlooked. A physician who does screen and finds a patient as depressive should then follow-up with further assessments to pinpoint the cause.^[9] A practitioner who fails to rule out vitamin B12 or folate deficiency as the cause of symptoms will be unable to properly treat the patient. Anti-depressants will not cure the patient, instead they simply require vitamin B12 and/or folate supplements in their diet.^[12] Depression and dementia have overlapping symptoms and can therefore be challenging to distinguish. Depression can cause impairments in cognitive function, such as tasks of organization, planning, abstract thinking, memory and social skills. Dementia also shows these same impairments. In addition, patients with dementia can develop depression. A possible method for differentiation is the Mini-Mental Status Exam. The assessment uses questions like; spell human backwards. Anyone with dementia will have a difficult time with the test, while depression patients can answer correctly with some encouragement. ^[14] Use the link provided to view the full Mini-Mental Status Exam. http://lifemanagement.com/nextsteps/Mini_Mental_Status_Exam.pdf

It should also be noted that dementia shows a gradual progression of symptoms and depression tends to show a sudden onset that may be linked to a specific event, such as death of a spouse. Therefore it is critical that practitioners obtain accurate documentation of the patient’s history. In addition to diagnosis, there is a need for specific differential diagnosis of the disorder. Elderly depression can be divided into subcategories; significant depression, sub-syndromal depression, old age melancholia, old age depression with hypochondria, organic depression and depression-anxiety syndrome.^[12] If these types are identified, doctors can individualize patients for the best possible treatment outcome. Accurate and differential diagnosis is crucial in older adults as depression carries risk of suicide. It is important that physicians directly ask their depressive patients if they ever have suicidal thoughts. With further questioning, the physician will determine their level of suicide risk and prescribe the appropriate treatment or therapy. ^[14]

TREATMENTS

Depression is not a normative part of aging. We may experience occasional bouts of grief especially with the loss of loved ones or feel the “blues” during the winter season. However, if these feelings persist or interfere with our normal daily activities then there is cause for concern. Studies have shown that depression when undetected in the elderly can lead to suicidal thoughts. According to the National Institute of Mental Health fact sheet “Older Adults: Depression and Suicide Facts (Fact Sheet)", people age 65 and older accounted for 16 percent of suicide deaths in 2004 http://www.nimh.nih.gov.

Depression is preventable and curable and when diagnosed a number of treatments can be administered. The benefits of medication as treatment for depression is better than the risks associated with other medical illnesses for the elderly. Cognitive behavioral therapy is used successfully to alleviate and resolve feelings of helplessness and isolation. It also gives the elderly a sense of purpose and adds meaning to their lives. Caregivers play a crucial role in the lives of the elderly by listening attentively and not ignoring for example, “I do not want to live anymore.”, “My life is worth nothing.” or “There is no purpose in life.”, as silly talk due to aging.

BIOCHEMICAL

A study by Reynolds & Kupfer ^[15] regarding the state of affairs and knowledge about geriatric depression showed that older individuals respond to antidepressant medication such as Selective Serotonin Reuptake Inhibitors (SSRI’s). SSRI’s are used in the treatment of depression in the elderly because they are effective, according to the study. Research has shown that if one medication does not work then a different one may work. Another study by Szanto, Mulsant, Houck, Dew & Reynolds ^[16], showed an association between suicidal thoughts and depression in several populations of elderly people. This study concluded that after 12 weeks of treatment with medication, thoughts of death and feelings of emptiness were removed.

http://www.webmd.com/depression/ssris-myths-and-facts-about-antidepressants

COGNITIVE BEHAVIORAL THERAPY

Feelings of isolation, hopelessness and a decrease in self-worth are hallmarks of depression. Depression affects moods, thoughts and emotions in a negative way. A study by Klausner & Alexopoulos ^[17] showed that cognitive behavioral therapy (CBT) can reduce depressive symptoms among 70 percent of elderly patients. A number of approaches are used in cognitive behavioral therapy that are ideal for older people. An example of how CBT works is to change "a depressed person, alone at night feeling miserable, may have negative thoughts about missing a loved one, see no reason to go on living, feels life is a mess, is needed by no one and thinks he/she should kill himself/herself" ^[18].

Cognitive behavioral therapy can also be used to treat elders who contemplate suicide according to Coon, DeVries and Gallagher-Thompson ^[19]. Their model utilizes several approaches including techniques to reduce symptoms using medication and distraction, to change behavior, to assist with financial, transportation and social issues. These techniques provide the elderly with ways and means of coping, provide external support and assist with goal setting in order to facilitate changes. ^[19]

CAREGIVER INTERVENTION

During the stages of human development we become independent, have a sense of who we are and take control of our own lives. The elderly perceive, for example, moving into a nursing home as losing control of their own lives and a loss of their identity as they now have to depend on others. Several studies have shown that depression in the elderly is detected only after a suicide attempt. Seventy percent of older people who commit suicide had contact with a caregiver in the month prior to their deaths, 20% on the day itself and 40% in the week prior to their deaths ^[20]. The Canadian Mental Health Association suggested that when seniors complain about emotional and physical problems, caregivers should pay attention and not perceive it as part of the natural process of aging. http://www.ontario.cmha.ca/seniors.asp?cID=5800

The study by Vanlaere, Bouckaert and Gastmans ^[20] recommended that when suicide is detected, primary caregivers should do the following: listen attentively, communicate with the elderly, act as a mentor and create a relationship of trust. According to this study, listening can be an effectual tool when dealing with elderly suicidal thoughts. Caregivers have the most contact with the elderly and by intervening would play an important role in helping the elderly to alleviate feelings of isolation, contribute in making their lives more meaningful and help them to regain their identity and continue to be valuable members of society ^[20].

CONCLUSION

According to the American Psychological Association, as large cohorts of middle aged people grow older the demand for psychological services and treatment will increase. http://www.apa.org/pi/aging/resources/guides/psychology-and-aging.aspx According to the Canadian Medical Association, Statistics Canada predicted that the senior population in Canada will increase from 10% to 23% by the year 2041, http://www.cmaj.ca

This forecasted change in demographics will have a huge financial impact on the health care system if the depressed elderly goes undiagnosed. It would require, for example, increased visits for treatment (more physical than emotional), use of several medications and lengthy stays in hospitals. Suicide is not a normative response to aging and can be prevented if depression in the elderly is diagnosed and treated early.

Notes and References

1. ↑ Beekman, A., de Beurs, E., van Balkom, A., Deeg, D., van Dyck, R., & van Tilburg, W. (2000). Anxiety and depression in later life: Co-occurrence and communality of risk factors. The American Journal of Psychiatry, 157 (1), 89.
2. ↑ ^{2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7} Canadian Mental Health Association. (n.d.). Seniors and Depression. Retrieved from http://www.ontario.cmha.ca/seniors.asp?cID=5800
3. ↑ ^{3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7} Thobaben, M. (2005). Older Adults: Suicide. Home Health Care Management Practice, 18, 68-69.
4. ↑ ^{4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7} Conwell, Y., Duberstein, P.R., & Caine, E.D. (2002). Risk Factors for Suicide in Later Life. Society of Biological Psychiatry, 52, 193-204.
5. ↑ ^{5.0 5.1 5.2} Szanto, K., Prigerso, H.G., & Reynolds III, C.F. (2001). Suicide in the elderly. Clinical Neuroscience Research, 1 (5), 366-376.
6. ↑ ^{6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8} Brown, L.M., Bongar, B., & Cleary, K.M. (2004). A Profile of Psychologists’ View of Critical Risk Factors for Completed Suicide in Older Adults. Professional Psychology: Research and Practice, 55 (1), 90-96.
7. ↑ ^{7.00 7.01 7.02 7.03 7.04 7.05 7.06 7.07 7.08 7.09 7.10 7.11 7.12} Chima, F.O. (2002). Elder suicidality. Journal of Human Behavior in the Social Environment, 6 (4), 21-45.
8. ↑ ^{8.0 8.1 8.2 8.3 8.4} Garand, L., Mitchell, A.M., Dietrick, A., Hijjawi, S.P., & Pan, D. (2006). Suicide in Older Adults: Nursing Assessment of Suicide Risk. Issues in Mental Health Nursing, 27, 355-370.
9. ↑ ^{9.0 9.1 9.2} Sharp, L. K., & Lipsky, M. S. (2002) Screening for depression across the lifespan: A review of measures for use in primary care settings. American Family Physician, 66(6), 1001-1009. Retrieved from http://www.aafp.org/afp/2002/0915/p1001.html
10. ↑ Sable, J., Dunn, L., & Zisook, S. (2002) Late life depression: How to identify its symptoms and provide effective treatment. Geriatrics, 57(2) 18.
11. ↑ Watson, L. C., & Pignone, M. P. (2003). Screening accuracy for late-life depression in primary care: A systematic review. The Journal of Family Practice, 52(12), 956-964. Retrieved from http://web.ebscohost.com.proxy.library.brocku.ca/
12. ↑ ^{12.0 12.1 12.2} Gottfries, C. G. (2001). Late life depression. European Archives of Psychiatry and Clinical Neuroscience , 251(2), 51-61. doi: 10.1007/BF03035129
13. ↑ Falagus, M. E., Vardakas, K. Z., & Vergidis, P. I. (2007). Under-diagnosis of common chronic diseases: Prevalence and impact on human health. International Journal of Clinical Practice, 61(9), 1569-1579. doi: 10.1111/j.1742-1241.2007.01423.x
14. ↑ ^{14.0 14.1} Spires, R. A. (2006). Depression in the elderly. Modern Medicine, Retrieved from http://www.modernmedicine.com/modernmedicine/CE+Library/Depression-in-the-elderly/ArticleStandard/Article/detail/329133
15. ↑ Reynolds CF, Kupfer DJ (1999). Depression and Aging: A Look to the Future. Psychiatric Services 50(9),1167-1172.
16. ↑ Szanto K, Mulsant BH, Houck P, Dew MA & Reynolds III CF (2003). Occurrence and Course of Suicidality During Short-Term Treatment of Late-Life Depression: Arch Gen Psychiatry, 60, 610-617. Retrieved from http://www.archgenpsychiatry.com
17. ↑ Klausner EJ, & Alexopoulos GS (1999). The Future of Psychosocial Treatments for Elderly Patients: Psychiatric Services 50(9),1198-1204.
18. ↑ Belsky, J. (1999). The Psychology of Aging: Theory, Research and Interventions (3rd ed.). Pacific Grove CA: Brooks/Cole.
19. ↑ ^{19.0 19.1} Coon DW, DeVries HM, & Gallagher-Thompson D, (2004). Cognitive Behavioral Therapy with Suicidal Older Adults, Behavioral and Cognitive Psychotherapy, 32, 481-493. doi:10.1017/s135246580400165.
20. ↑ ^{20.0 20.1 20.2} Vanlaere, L., Bouckaert, F., & Gastmans, C. (2007) Care for suicidal older people: current clinical-ethical considerations. Journal of Medical Ethics, 33, 376-381. Retrieved from http://www.jmedethics.com.