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[edit] Depression and Suicide in the Elderly

Depression is not a normative part of aging. Occasionally people experience 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 normal daily activities, then there is cause for concern. 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% of suicide deaths in 2004. http://www.nimh.nih.gov/health/publications/fact-sheets.shtml -

There are various risk factors for both depression and suicide in the elderly. Knowing the mental, physical, social, and other risk factors for both issues can allow for better diagnosis and treatment. Identifying depression in older adults can be difficult, but accurate diagnosis is a crucial step toward developing a treatment plan. Close relatives and family practitioners should look for key warnings signs of depression onset to prevent further progression of symptoms and possible suicide attempts. Treatments for depression include and can be administered through the use of medication (biochemicals),cognitive behavioural therapy and caregiver intervention which plays a crucial role in the lives of the elderly.

[edit] RISK FACTORS

Depression and suicide are common issues in older age [1] making it important to know the risk factors for these issues. 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. [2] [1] In fact, depression is actually one of the major risk factors for suicide [1], making it important to discuss risk factors for both issues together. The mental, physical, social, and other risk factors of depression and suicide in the elderly will be discussed.


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Some of the important elderly suicide risk factors broken up into similar categories.


MENTAL RISK FACTORS

Mental risk factors have repeatedly been shown to play an important role in both depression and suicide. Mental disorder is an important mental risk factor for both depression and suicide. Research shows mental disorders, especially dementia and anxiety disorders, put seniors at an increased risk for depression. [3] [4] Mood disorders and schizophrenia put seniors at heightened risk for suicide. [5] [6] Severe feelings of hopelessness have also been shown to put this population at a higher risk for both depression and suicide.[1] [7]

Mental risk factors specifically related to depression are perceived lack of control [8] and feelings of guilt.[5]

Some mental risk factors specifically related to suicide are acute suicidal ideation and anxiety.[7] [6] Depression has also been repeatedly shown to be a risk factor for suicide in the elderly.[7] [8] [9] 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.[8] The Globe and Mail also ran a news article highlighting the role that depression can play in elder suicide. That article can be found here.

PHYSICAL RISK FACTORS

When it comes to physical risk factors of depression and suicide in the elderly, physical illness has been recognized as being applicable to both issues. [8] [5] [9] However, what types of illnesses are risk factors, and who they put at risk, has varied in the research. With respect to depression and suicide, some studies have found serious physical illness to be a risk factor for men only [9], some have found only illnesses that are terminal to be a risk factor[8], and others refer to physical illness in general as a risk factor.[5]

Physical risk factors for depression specifically include physical retardation[5], functional impairment[6] and changes in health such as receiving a disease diagnosis.[4]

One important physical risk factor specifically related to suicide is self-cutting.[7]

SOCIAL RISK FACTORS

In terms of social risk factors for both depression and suicide in older adults, social isolation [7] [8], being widowed [4] [5] and being lonely [8] all apply. In some research, being widowed was found to be a risk factor for men in particular, [5] whereas other sources list widowhood or bereavement as risk factors for both sexes.[1] [4]

Some depression-specific risk factors for the elderly include changes in social roles (such as roles of worker, parent and spouse) and abuse.[4]

Suicide-specific risk factors for the elderly are family history of suicide [7], institutionalization [8], loss of independence [8], disruption of social ties[6], family discord[6], lack of social support[6] and low social interaction.[9]

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. [7] [8] [4] 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.[8] 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.[8] It seems that when these losses start to accumulate in an older person’s life, they are at higher risk for depression and suicide.

Depression-specific risk factors to take note of are medications and previous episodes of depression.[4] 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.[4] It is also important to note that having experienced depression before puts an elderly person at higher risk of experiencing it again, especially if it is not dealt with properly the first time.[4]

Suicide-specific risk factors to be aware of are history of suicide attempts [8] [7] and substance abuse disorders or increased drug use.[5] Another important suicide-specific risk factor is presence of, or access to, firearms. [7] [6] One study found that 71% of older adults who committed suicide used a gun.[6] When looking at suicide risk factors related to demographics, one researcher found that being male increased risk of suicide [1] and another found being an older, unmarried, caucasian male increased risk of suicide.[9]

For information on risk factors specific to depression in the nursing home, please see the video below.


As has been outlined, risk factors for both depression and suicide in the elderly include mental disorder, severe feelings of hopelessness, physical illness, social isolation, being widowed, being lonely, alcohol abuse, and accumulation of losses. Knowing the risk factors for these issues makes them easier to diagnose.

[edit] DIAGNOSIS OF DEPRESSION

Depression is currently an under-diagnosed condition, despite its high prevalence. Depression that goes undiagnosed and untreated leads to poor quality of life. Suicide may become a major threat for a depressed individual. Consequently, it is important that anyone diagnosed with depression also be tested for suicide risk. [10]


IDENTIFYING THE SYMPTOMS OF DEPRESSION

Family members and family practitioners should be aware and look for the key warning signs of depression in aging individuals. Inside, an aging person may be feeling:

  • lonely
  • worthless
  • hopeless
  • agitated
  • guilty[11]

Outwardly, the person may exhibit changes in their normal behaviors, such as:

  • poor sleep patterns
  • malnutrition
  • decreased hygiene
  • depressive mood[12]

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 over the age of 60. The questions are formatted to allow for simple comprehension. However this tool, like others, cannot assess people with significant cognitive impairments.[13] The assessment asks yes/no questions such as, “Do you often feel helpless?”[11]. The following link provides the full assessment task. http://www.chcr.brown.edu/GDS_SHORT_FORM.PDF


SEVERE UNDER-DIAGNOSIS AND MISDIAGNOSIS OF DEPRESSION

Depression in older adults can look quite different from depression in younger people. Disease and loneliness is a common cause for depression in aging individuals, while younger people find stress in other aspects of their lives. Depression among the elderly is a widespread problem, yet only one third of these people seek help from their doctors. Of the people who do go to their doctor, up to 60% are misdiagnosed, and are therefore, treated incorrectly.[14] Depression that goes undetected poses a major problem. The undiagnosed individual may have reduced quality of life and may be at heightened risk for suicide. Why is this happening?

Often symptoms of depression can be mistaken for typical elderly behaviour. Physical changes in the body cause aging people to slow down naturally and isolate themselves from a busy social life. When family members do not 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 [10]. A family practitioner may also be to blame for the under-diagnosis of depression. Physicians are encouraged to screen all older adults for depression on a routine basis; unfortunately, these simple screenings are often overlooked. [11]


COMPLEXITIES INVOLVED IN DIAGNOSING DEPRESSION

A physician who does screen and finds the patient to be depressive should then follow-up with further assessments to pinpoint the cause.[11] 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 help the patient in such cases. Instead, they simply require vitamin B12 or folate supplements in their diet.[14]

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. Individuals with dementia also show these same impairments. In addition, patients with dementia can develop depression. A possible tool that can be used to differentiate between dementia and depression is the Mini-Mental Status Exam. The assessment requires participants to complete tasks such as, spelling a word backwards. Anyone with dementia will have a difficult time with the test, while depressed patients can answer correctly with some encouragement. [15] 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 depression that accompanies dementia shows a gradual progression of symptoms, whereas purely 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. [14]

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.[14] If these types are identified, doctors can individualize treatment plans for the best possible outcome.

Accurate and differential diagnosis is crucial in older adults as depression carries risk of suicide. It is important that physicians directly ask their depressed patients if they ever have suicidal thoughts. With further questioning, the physician can determine their level of suicide risk and prescribe the appropriate treatment or therapy. [15]

[edit] TREATMENTS

Depression is not always preventable and treatable, and when diagnosed a number of treatments can be administered. The benefits of medical treatment for depression are better than the risks associated with other medical illnesses. In addition, 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. Caregiver intervention is very important in the lives of the elderly. When the elderly say for example, “I do not want to live anymore.”, “My life is worth nothing.” or “There is no purpose in life.”, caregivers should not attribute that to silly talk due to aging.


BIOCHEMICAL

A study by Reynolds and Kupfer (1999) [16] regarding the state of affairs and knowledge about geriatric depression showed that older individuals responded to antidepressant medication such as Selective Serotonin Reuptake Inhibitors (SSRIs). SSRIs are used in the treatment of depression in the elderly because they are often effective. However,research has shown that if one medication does not work, then a different one may work. Szanto, Mulsant, Houck, Dew and Reynolds (2003) [17], showed an association between suicidal thoughts and depression in several populations of elderly people. This study demonstrated that after 12 weeks of treatment with medication, thoughts of death and feelings of emptiness were no longer present. For information related to depression and antidepressants click on this link.

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. Klausner and Alexopoulos (1999) [18] showed that cognitive behavioral therapy (CBT) reduced depressive symptoms among 70% of elderly patients. A number of approaches are used in CBT that are ideal for older people. CBT changes negative thinking processes. For example, a depressed person, alone at night and feeling miserable, may have 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.[19]. CBT changes those thoughts and emotions towards a more positive outlook.

CBT can also be used to treat elders who contemplate suicide according to Coon, DeVries and Gallagher-Thompson (2004) [20]. This specific model utilizes several approaches including medication to reduce symptoms, distraction techniques to change behaviour and also provide assistance 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. [20]

Demonstration of how CBT works:



CAREGIVER INTERVENTION

During the stages of human development people become independent, have a sense of who they are and take control of their own lives. The elderly however, may perceive moving into a nursing home as losing control of their own lives and as a loss of their identity as they now have to depend on others. Caregivers play a crucial role in the lives of the elderly. 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 [21]. The Canadian Mental Health Association suggested that when seniors complain about emotional and physical problems, caregivers should pay attention and not simply assume it as part of the natural process of aging.

http://www.ontario.cmha.ca/seniors.asp?cID=5800

Vanlaere, Bouckaert and Gastmans (2007) [21] 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 these researchers, listening can be an effectual tool when dealing with elderly suicidal thoughts. Caregivers have the most contact with the elderly, and by intervening can play an important role in helping the elderly to alleviate feelings of isolation, contribute toward making their lives more meaningful, and help them to regain their identity and continue to be valuable members of society [21].

[edit] CONCLUSION

According to the American Psychological Association, as large cohorts of middle aged people grow older, the instances of elderly depression and suicide will continue to rise. Therefore it is important the public is provided with information on its risk factors, diagnosis and treatment to increase awareness for the growing problem. 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.cma.ca/index.php?ci_id=3205&la_id=1 Suicide is not a normative response to aging and can be prevented if depression in the elderly is recognized, diagnosed and treated early.

[edit] Notes and References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 Szanto, K., Prigerso, H.G., & Reynolds III, C.F. (2001). Suicide in the elderly. Clinical Neuroscience Research, 1 (5), 366-376.
  2. 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.
  3. 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.
  4. 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 Canadian Mental Health Association. (n.d.). Seniors and Depression. Retrieved from http://www.ontario.cmha.ca/seniors.asp?cID=5800
  5. 5.0 5.1 5.2 5.3 5.4 5.5 5.6 5.7 Thobaben, M. (2005). Older Adults: Suicide. Home Health Care Management Practice, 18, 68-69.
  6. 6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 Conwell, Y., Duberstein, P.R., & Caine, E.D. (2002). Risk Factors for Suicide in Later Life. Society of Biological Psychiatry, 52, 193-204.
  7. 7.0 7.1 7.2 7.3 7.4 7.5 7.6 7.7 7.8 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.
  8. 8.00 8.01 8.02 8.03 8.04 8.05 8.06 8.07 8.08 8.09 8.10 8.11 8.12 Chima, F.O. (2002). Elder suicidality. Journal of Human Behavior in the Social Environment, 6 (4), 21-45.
  9. 9.0 9.1 9.2 9.3 9.4 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.
  10. 10.0 10.1 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
  11. 11.0 11.1 11.2 11.3 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
  12. Sable, J., Dunn, L., & Zisook, S. (2002) Late life depression: How to identify its symptoms and provide effective treatment. Geriatrics, 57(2) 18.
  13. 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.
  14. 14.0 14.1 14.2 14.3 Gottfries, C. G. (2001). Late life depression. European Archives of Psychiatry and Clinical Neuroscience , 251(2), 51-61. doi: 10.1007/BF03035129
  15. 15.0 15.1 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
  16. Reynolds C.F., Kupfer DJ (1999). Depression and aging: A look to the future. Psychiatric Services 50(9),1167-1172.
  17. Szanto K., Mulsant B.H., Houck P., Dew M.A. and Reynolds III C.F., (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
  18. Klausner E.J., & Alexopoulos G.S., (1999). The future of psychosocial treatments for elderly patients. Psychiatric Services, 50(9),1198-1204.
  19. Belsky, J. (1999). The psychology of aging: Theory, research and interventions(3rd ed.). Pacific Grove CA: Brooks/Cole.
  20. 20.0 20.1 Coon D.W., DeVries H.M., & Gallagher-Thompson D., (2004). Cognitive behavioral therapy with suicidal older adults, Behavioral and Cognitive Psychotherapy, 32, 481-493. doi:10.1017/s135246580400165
  21. 21.0 21.1 21.2 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.
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