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Understanding depression in older people

Lynne Walsh

Lecturer in Mental Health and Public Health Studies
Swansea University

Depression in older people is increasing; yet it is often unrecognised and untreated. With an ageing population, and more people being diagnosed with chronic conditions, Lynne Walsh argues that there is a need for depression in older people to be managed more effectively.

People are living longer and increasing numbers of older people are being diagnosed with chronic physical and mental health conditions, including heart disease, stroke, cancer, depression and dementia. Major depression is considered to be a chronic condition when it lasts for more than two years without full recovery. Some older people may have been diagnosed with a chronic physical illness and become depressed as a result, while others may have been depressed before diagnosis.

[[Box 1 depression]]

Correct diagnosis of mental health conditions is just as important as diagnosing chronic physical illness, as both can have a serious impact upon the wellbeing of the person. It is important to provide holistic care, considering the physical, psychological and social needs of older people. Some older people with dementia may also have undiagnosed depression.

The roles of practice nurses, health visitors, nurse practitioners, community nurses and carers in community settings are very important in the management of depression in older people, and a clear understanding of the symptoms of depression is vital, enabling them to support both older people and their carers. It is important to listen to patients, their families and carers when supporting older people with physical and mental chronic conditions.

Causes of depression
Depression affects one in five people over the age of 65 and two in five people over the age of 85.1 The impact of depression in older people needs to be carefully considered, as it affects thought processes and ability to function; as a result older people can become increasingly vulnerable. It is important to maintain dignity and respect in vulnerable older people.2 Many older people are unable to speak for themselves, particularly if they have depression and dementia, which can also make them feel disempowered. Respecting older people can be achieved by speaking to them politely and communicating appropriately. It is also important to ensure that they have all of their basic care needs addressed with dignity.

Some older people will experience symptoms of depression as a reaction to a stressful event in their life, such as the death of a spouse or close friend, moving home (ie, into a care home environment), moving in with family, any type of loss, or untimely death of family members. Other events may include chronic physical illness causing immobility and social isolation. Experiences of loss and grief are important aspects to consider in these situations.3

In a study on depression in people with multiple sclerosis (MS), the patients' experience of loss included a variety of aspects, such as loss of freedom, faith, health and social interaction as well as loss of bodily control.4 In addition to these experiences and feelings the older person may also be experiencing pain. Physical symptoms are more easily recognisable, allowing pain, for example, to be treated initially through appropriate pain management. However, psychological symptoms may be harder to recognise; thus, the symptoms of depression may go unrecognised and untreated.

Being able to recognise the symptoms of depression is important and will help practitioners to understand the condition and influence their decisions about planned care.

Depression and chronic illness
Many of the symptoms of depression (see Box 2) may also be symptoms of physical chronic illness where an older person has experienced pain, discomfort, immobility or problems with dexterity.

[[Box 2 depression]]

McEvoy and Barnes have suggested that routine care for depressed older adults with long-term physical conditions is poor, and advocate the use of a chronic care model to address this group.6 They highlight the importance of improving service delivery, provider agency relationships, decision-making, clinical information and community resources and better organisation of healthcare. They recognise that, to achieve these conditions, radical changes in working practices would be required.

Some of these changes in working practices identified by McEvoy and Barnes include a change from reactive care to planned care and prevention. This would include some tasks being delegated to ancillary staff and undertaking screening of high-risk groups in conjunction with a stepped-care approach. This would help to ensure increased efficiency of resources. Other changes include closer working relationships with mental health workers and improved referrals within the PCT. This can be supported by routine discussions of cases by phone preventing the need for more formal referrals. This also promotes the flexible use of alternative treatments.

Depression is prevalent in many people with other chronic long-term conditions, including chronic obstructive pulmonary disease (COPD), diabetes, cancer and neurological conditions. In fact, having depression as well as a physical chronic illness could also increase a person's chance of further illness. A study in 2007 showed that diabetes and depression increased the risk of dying from cardiovascular disease.7 Thus, it is no surprise that many older people may feel depressed as a consequence of having multiple chronic conditions.

Depression has a greater effect upon health than any other long-term physical condition, including angina, asthma and diabetes.8 Not surprisingly, there is a higher incidence of depression in people with long-term chronic illness. Due to an ageing population, diagnosis of long-term chronic conditions has increased.9

Stroke is the largest cause of disability in the UK, which can have major implications for an older person's physical and mental health.10 Nurses and practitioners in both primary and secondary care need to be able to recognise post-stroke depression as it can delay the rehabilitative process. In research looking at the incidence of depression in stroke patients, of the 289 patients who had suffered a stroke, 17% were still experiencing post-stroke depression five years later and many of these people were not taking antidepressants.

Depression and dementia
Depression in older people is often not well recognised or managed, despite it being one of the most common psychiatric illnesses in older people.11 There has been recent interest in recognising depression in older people with dementia. In the past it was rarely considered; however, the Cornell Scale for Depression in Dementia (CSSD) was developed to identify major signs. It evaluates a broad spectrum of signs and symptoms of depression used in other depression scales. This is achieved by interviewing the carer, observing and asking the patient questions. Sometimes the older person had dementia before the depression; however, the demented person may also have become depressed at different stages of the dementia.
It can be difficult to diagnose depression in dementia due to poor cognitive function. There has been much discussion in the media about different treatments and medication in older people with dementia; however, it is vital to provide evidence-based care that considers the individual patient's condition and circumstances. Older people may also have other chronic mental health conditions and appropriate treatments need to be considered in relation to these.

Research has been undertaken and advice provided by the Department of Health regarding concern about the use of antipsychotic drugs in older people with dementia.12 Healthcare professionals need to consider care based on the best up-to-date evidence. Another important factor to consider when providing care for older people in relation to treatment and medication is compliance. This is important when considering not only the patient but also the family and carers who look after their loved ones in the community.

Treatment options and adherence
The National Institute for Health and Clinical Excellence (NICE) provides guidance on the management of depression in adults.13 This is supported by the Mental Health Foundation, which highlights that treatment failure in older people occurs due to the fact that depression is often wrongly considered part of the ageing process.1

There is a need for increased awareness regarding older people not taking their medicines correctly.14 Non-adherence may occur as a result of the older person being confused or unable to open medication bottles. It can also be a result of adverse side-effects of medication or the perception that the medication is not doing them any good.

If the perception is that the medication is not working, some older people may make a conscious decision not to take it.15 This needs to be balanced with the risk of not taking medication, such as suicide.14 Hoarding medication provides potential for overdose, and research has shown that older people are more likely to succeed in committing suicide than any other age group.16 For every two older people who attempt suicide, one will be successful.

Healthcare professionals have a key role to play in patient education and raising awareness of treatment options. It is important to support the patient and their carers when advising and promoting adherence with treatment, and carers may highlight reasons as to why their relative is not taking medication. Thus, early intervention needs to be encouraged to prevent deterioration of the patient's current condition and to ensure the best treatment option is available to them.

For milder depression, alternative treatments may be considered, which include psychological therapies such as cognitive behavioural therapy (CBT). CBT may be adapted for use with physically ill, frail older people with mild cognitive impairment but it is recognised that further research is needed on this.17 NICE highlights other treatment options for older people, which include exercise therapy. Mead et al also state that exercise improves the symptoms of depression; however, evidence warrants further study regarding the benefits of exercise on prescription.18 NICE recommends combining both drug treatments and psychotherapy for adults with depression.13

Mental health conditions in older people cannot be ignored. Dementia is often associated with old age, but depression is less easily diagnosed. This may be because chronic physical illnesses are more easily recognised and easier to treat. A report on dementia undertaken on behalf of the Alzheimer's Research Trust earlier this year highlights how, compared with stroke, cancer and heart disease, funding for research on dementia remains low, despite the high economic burden of the condition on the NHS and the emotional impact on sufferers and their families.19

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