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| 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 | + | 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" /> |
Revision as of 21:17, 28 October 2011
Depression and Suicide in the Elderly
RISK FACTORS
With suicide rates being highest in later life than at any other age, it is easy to see the importance in looking at the risk factors for depression and suicide in the elderly. As the risk factors for depression and suicide in elders can be quite complex, they have been broken down below by mental risk factors, physical risk factors, social risk factors and other risk factors. In many instances the risk factors for depression and suicide in the elderly population have overlap, and depression is one of the major risk factors for suicide in the elderly so the two will be discussed together as they often go hand-in-hand.
MENTAL RISK FACTORS
PHYSICAL RISK FACTORS
SOCIAL RISK FACTORS
OTHER 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[1]. Outwardly they may exhibit changes to their normal behaviors, such as; poor sleep patterns, malnutrition, decreased hygiene, and depressive mood[2]. 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.[3] The assessment asks yes/no questions such as, “Do you often feel helpless?”[1]. 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.[4] 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.[5]
FAMILY PRACTITIONER SCREENING
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.[4] 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. [6]
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 (1999) 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 (2003), 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 (1999) 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" (Belsky, 1999).
Cognitive behavioral therapy can also be used to treat elders who contemplate suicide according to Coon, DeVries and Gallagher-Thompson, (2004). 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 (Coon, DeVries and Gallagher-Thompson, 2004).
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 (Vanlaere, Bouckaert & Gastmans, 2007). 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 (2007) 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 (Vanlaere, Bouckaert and Gastmans, 2007).
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.
REFERENCES
1. Reynolds CF, Kupfer DJ (1999). Depression and Aging: A Look to the Future. Psychiatric Services 50(9),1167-1172.
2. Klausner EJ, & Alexopoulos GS (1999). The Future of Psychosocial Treatments for Elderly Patients: Psychiatric Services 50(9),1198-1204.
3. Belsky, J. (1999). The Psychology of Aging: Theory, Research and Interventions (3rd ed.). Pacific Grove CA: Brooks/Cole.
4. 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.
5. 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.
6. 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
Notes and References
- ↑ 1.0 1.1 1.2 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
- ↑ Sable, J., Dunn, L., & Zisook, S. (2002). Late life depression: How to identify its symptoms and provide effective treatment. Geriatrics, 57(2) 18.
- ↑ 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/
- ↑ 4.0 4.1 4.2 Gottfries, C. G. (2001). Late life depression. European Archives of Psychiatry and Clinical Neuroscience , 251(2), 51-61. doi: 10.1007/BF03035129
- ↑ 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
- ↑ 6.0 6.1 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
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