Nursing Interventions for depression in the Elderly

Depression in the elderly population (occurring in patients who are 60 years and older) although quite common -  doesn't mean it’s normal. Most elderly that suffer depression often don't receive treatment. This is mainly due to how symptoms of depression present themselves in the elderly. Symptoms can be masked by the effects of cognitive defects, multiple diseases, and the mediation to treat them. 

Depression can have a negative impact on the quality of life and is an increase risk for suicide, epically in elderly men. There’s also a correlation between depression and cardiovascular diseases resulting in an increase of deaths after a heart attack. Overall, adults who have high incidents of depressive symptoms had a greater risk for experiencing heart disease, stroke, and heart attack.

Factors that contribute to the depression in the elderly can include:  

• loss of social support, 
• loss of a spouse, 
• transitioning from work to retirement, 
• relocation from home to assisted living complex.

Along with these factors, chronic medical conditions, pain, thyroid issues, stroke, loss of mobility, Alzheimer's disease, and aging can increase the risk for depression. Other causes include chemical imbalances, vascular depression, family history of depression, and prolonged substance abuse. 

Sometimes the elderly do not always meet the full criteria for major depression (termed Subsyndromal depression). If not addressed, it can lead to major clinical depression. 

If you’re working with an elderly patient be aware of the following behaviours: 

1. Does not get dressed (often attributed to age related inability)
2. Does not answer the door or phone
3. Feelings of sadness and worthlessness
4. Sudden outburst of agitation, crying and anger
5. Labile mood
6. Sleeping too much or not enough
7. Increased appetite, decreased appetite
8. Somatic complaints
9. Lack of concentration
10. Difficulty coping
11. Memory issues
12. Self isolation
13. Loss of interest or enjoyment
14. Talking about suicide 

Nursing interventions for Depression

Nursing interventions for depression include standardized screening tools to assess the elderly for depression or risk for depression. These tools help identify key issues and enable health care professionals to intervene.

The Geriatric Depression Scale

Standard screening tools such as the Geriatric depression scale are extensively used with the elderly population. This is a brief questionnaire of 30 questions which the patient can answer either yes or no to how they felt within the last week.  It’s used to assess healthy, medically ill, and mildly to moderately cognitively impaired elderly adults. It's not a diagnostic interview, but a useful screening tool in a clinical, or home setting to assess depression and whether this assessment warrants intervention and or treatment.

The Nurses’ Global Assessment of Suicide Risk

Another effective nursing intervention is a tool designed to help assess depression and suicide risk in older adults. It’s a risk assessment screen for suicide. This assessment looks at the following categories:

• Suicidal ideations 
• Planning and implementation 
• Depressive symptoms
• Stressors ( triggering events)
• Physical illness, 
• Intoxication 
• Access to firearms or other lethal means

Risk assessment also identifies whether patients have protective factors to suicide prevention. Theses protective factors include the following:

• Family or community connections/support and resources
• Ongoing medical support and management
• Cultural beliefs, and connection to their community
• Responsibility for family/pets

This tool also identifies whether they have had thoughts of suicide and how pervasive these thought have been. It looks at the following:

• Suicidal ideation and implementation
• Intention, and planning
• Intention and when they plan to commit suicide

Collection of all this data can determine the patients risk level, whether they are high, moderate or low. This determination can help design a plan of intervention of either, hospital admission, and or outpatient care, crisis intervention, safety plan, and appropriate professional help.

DSMV: Diagnostic Statistical Manual of Mental Disorders

Another effective tool used mostly for diagnostic purposes is the DSMV: Diagnostic Statistical Manual of Mental Disorders. It contains descriptions, symptoms, and criteria for diagnosing mental disorders.

It’s designed for clinicians to be able to communicate about patients and establish consistent and reliable diagnostics that can be used in research of mental disorders.

Utilization of these screening tools can be an effective means in which nurses can assess for depression, suicide, and provide the appropriate interventions.

Client Centred Approach and Recovery Module

Nursing Interventions for depression should also include a client centred approach and recovery module. This approach takes into consideration the following:

• Respect for patients values, preferences, and expressed needs.
• Coordination and integration of care (interdisciplinary approach).
• Information and education (medication, treatments, symptoms).
• Physical comfort.
• Emotional support (alleviation of fear and anxiety).
• Inclusion of family, and friends (involved in decision making, support for family caregivers, and recognizing the need for friends and family).
• Discharge and transition (plan ongoing treatment and services).
• Access to care (able to access care when they need it ).
• Cultural and spiritual needs.

This ensures that the patient can take an active role in their recovery and treatment. Focusing on the dignity and respect for the patient. This is where they can feel empowered to facilitate their own personal growth, increase their self esteem and allow them to utilize their strengths and direct their own recovery as they define recovery.

Treatment and interventions include:

• home visits, 
• modifying risk factors,
• identifying the risk factors can help reduce the incidents of depression.

The following are some risks factors and interventions:

Isolation

Encouraging your patient to reach out and stay connected with friends, family and community supports.  This can be going outside for a walk, visiting family, or going out for lunch with friends.

Loss of meaning in life

Includes transition from work to retirement, loss of close family, friends, spouse, relocation away from social networks, financial, status, and physical health. Encouraging your patient to focus on what they can still do and what they can still offer (learning a new skill, something that they might have always wanted to do, like perhaps a new language, learning a musical instrument, going back to school, or maybe even traveling).

Lack of mobility

It may be difficult for some patients to be able to exercise as they once could, but there are plenty of inclusive and modified exercises that can be utilized. For example, joining an exercise group, as walking is a low impact exercise that can help with not only balance but continued independence. There are many safe exercises that your patient can engage to increase strength and increase mood. Eating a healthy diet can also influence mood. If your patient is unable to prepare healthy food, referring them to a community support like meals on wheels is beneficial.

Lack of sleep

Many older adults struggle with sleep issues and particular insomnia. This can increase the severity of the depression. Setting up a regular bedtime routine can help. Don't allow alcohol for a sleep aid, and ensure that the bedroom is dark, quiet, and cool.

Substance Abuse

Patients may use alcohol or other intoxicants to deal with emotional and physical pain. Substance abuse can have a negative impact and increase depression as it impairs brain functions, and can interact negatively with prescribed medications, (including antidepressants) and can negatively affect sleep.

Not seeking help  

Some elderly may not know what resources are available or when to seek help. Providing education on resources available can be beneficial.

It’s also very important to consider cultural beliefs when assessing depression in the elderly. Detection of depression in elderly minorities may be difficult. It's also often difficult in some cultures because of how it’s presented, for example, it might be socially acceptable to seek help for physical complaints but not for emotional ones. 

Barriers to seeking out help is the reservation of using western medicine, and strong beliefs in their own traditional healing practices. This can impact both their willingness to seek out other treatments and whether they would be compliant with prescribed medical management and treatment plans. Intervention must always take a patients cultural beliefs into consideration.

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Early detection

Early detection is an effective nursing intervention which can help identify depressive patients, and risk factors for depression. Following up with, and monitoring elderly patients can also ensure that they continue to be educated on social connections within the community. Educating elderly on resources they can access, and interactions with other seniors, can promote continued well being and optimal recovery. Some resources seniors can access are:

Support Group for depression illness, and bereavement

This can provide patients with various types of support, usually non professional and non material for a shared experience or burden. Members with the same issues can come together to share coping, strategies, and empower each other and offer a sense of community.

Senior Centers

They offer recreational programs, social events, concert nights, dancing, exercise programs, support and educational programs, day trips, computer tutorials, workshops, and clinics.

Home Support Groups

Non health-related services such as transportation services, for shopping, visiting, bookmobile, and shopping bus.

Meal Deliveries

Services for elderly who cannot prepare meals due to limited mobility, and/or cognitive deficits. There are many services that provide meals at reduced costs and delivered to the patients home. Check your local area to see if there’s any programs available you can share with your patients.

Homemaker Services

This service provides the following for seniors experiencing difficulty in maintaining their home, and either cannot afford to move into a retirement residence, or simply wish to remain in their home.

• Meal preparation
• Grocery shopping
• Dishes
• Garbage removal and yard maintenance
• Laundry and ironing
• Kitchen cleaning
• Changing bed linen
• Light housekeeping chores

Conclusion

Nursing Interventions such as utilizing the above screening tools and using resources can help reduce the risk factors for depression. These interventions can address psychosocial functioning, including loss. Use education to help your patient understand the symptoms of depression, and the reasons for following a treatment and medical management plan. 

Nurses can continue to employ interventions to monitor medical illness, assess and manage medications for effectiveness and adverse effects. Ongoing monitoring of a patient can ensure they have reduced episodes of depression, continued management of medication, access to resources, and increased security and wellbeing.

Author Bio 

Mance Granberg, RPN 

Mance Granberg is a First Nations Abenaki from Quebec and a RPN who has been nursing for over 18 years. He's had the opportunity to nurse in a variety of disciplines from correctional nursing to Geriatric nursing.