Late-Life Depression   15  

Glenise L. McKenzie and Theresa A. Harvath

OVERVIEW

Contrary to popular belief, depression is not a normal part of aging. Although depression is less likely in older adults when compared to younger adults it has serious consequences for the individual, his or her family, and our society. Depression in late life interferes with a person’s ability to function, decreases quality of life, increases risk of morbidity and mortality (including suicide), and increases use of health care services (Taylor, 2014). The prevalence of major depression and clinically significant depressive symptoms in adults older than 60 years of age varies depending on the clinical context (community-dwelling older adults: 5%−16%; primary care: 5%−10%; post–critical care hospitalization: up to 37%; first year in a nursing home: up to 54%; Hybels & Blazer, 2003; Jackson et al., 2014; Neufeld, Freeman, Joling, & Hirdes, 2014). The numbers of older adults with a diagnosis of clinical depression is increasing (Akincigil et al., 2011).

Late-life depression is common in individuals with coexisting medical conditions and in individuals with physical and/or cognitive disability, which contribute to the challenge of timely identification and treatment of depression in older adults (Lyness et al., 2007). Nurses in all health care settings are pivotal to the early recognition of depression and the facilitation of older patients’ access to mental health care. This chapter presents an overview of unipolar late-life depression, with emphasis on age-related assessment considerations, clinical decision making, and nursing intervention strategies. A standard-of-practice protocol for use by nurses in practice settings is presented.

BACKGROUND AND STATEMENT OF PROBLEM

What Is Late-Life Depression?

Late-life depression is a term that includes older adults with a history of depressive disorders in earlier years as well as those who develop symptoms for the first time in later life. Depression may range in severity from mild symptoms (subsyndromal) to severe symptoms (major depressive episode), both of which can persist over time with negative consequences for the older patient. Suicidal ideation, psychotic features (especially delusions), and excessive somatic concerns (hypochondriasis) frequently accompany more severe depression in older adults when compared to younger adults with depression (Grayson & Thomas, 2013). Symptoms of anxiety may also coexist with depression in many older adults (Beattie, Pachana, & Franklin, 2010). In fact, comorbid anxiety and depression have been associated with more severe symptoms, decreases in memory, poorer treatment outcomes (Beattie et al., 2010; DeLuca et al., 2005), and increased rates of suicidal ideation (Sareen et al., 2005).

Major Depression

The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013) lists the criteria for the diagnosis of a major depressive disorder, the most severe form of depression. These criteria are frequently used as the standard by which older patients’ depressive symptoms are assessed in clinical settings. Five criteria (or more) from a list of nine must be present nearly every day during the same 2-week period and must represent a change from previous functioning: (a) depressed, sad, or irritable mood; (b) anhedonia or diminished pleasure in usually pleasurable people or activities; (c) feelings of worthlessness, self-reproach, or excessive guilt; (d) difficulty with thinking or diminished concentration; (e) suicidal thinking or attempts; (f) fatigue and loss of energy; (g) changes in appetite and weight; (h) disturbed sleep; and (i) psychomotor agitation or retardation. For this diagnosis, at least one of the five symptoms must include either depressed mood, by the patient’s subjective account or observation of others, or markedly diminished pleasure in almost all people or activities. Concurrent medical conditions are frequently present in older patients and should not preclude a diagnosis of depression; indeed, there is a high incidence of medical comorbidity. The DSM-5 also provides criteria for persistent depressive disorder (dysthymia), which increases the risk of developing a major depression and manifests with depressive symptoms that occur on a majority of days for at least 2 years.

Major depression seems to be as common among older as younger cohorts. A recent review found diagnostic thresholds (number and type of symptoms) to be consistent between older adults (age 60 years and older) and middle-aged adults (age 40 years and older; Anderson, Slade, Andrews, & Sachdev, 2009). However, older adults may more readily report somatic or physical symptoms than depressed mood (Grayson & Thomas, 2013; Pfaff & Almeida, 2005). The somatic or physical symptoms of depression, however, are often difficult to distinguish from somatic or physical symptoms associated with acute or chronic physical illness, especially in the hospitalized older patient, or the somatic symptoms that are part of common aging processes (Kurlowicz, 1994). For instance, disturbed sleep may be associated with chronic lung disease or congestive heart failure. Diminished energy or increased lethargy may be caused by an acute metabolic disturbance or drug response. Therefore, a challenge for nurses in acute care hospitals and other clinical settings is to not overlook or disregard somatic or physical complaints while also “looking beyond” such complaints to assess the full spectrum of depressive symptoms in older patients.

Minor depression or subsyndromal depression is diagnosed in patients with clinically significant symptoms (causing impairment or distress) that do not meet DSM-5 standard criteria for major depression or persistent depressive disorder. The DSM-5 (APA, 2013, p. 183) classifies minor depression as an “other specified depressive disorder with insufficient symptoms” (depressed mood plus 1−3 other symptoms of major depression with at least 2 weeks of duration). Minor depression is at least two to three times as common as major depression for older adults in the community and is most prevalent for older adults residing in long-term care settings (Meeks, Vahia, Lavretsky, Kulkarni, & Jeste, 2011). Additionally, 8% to 10% of older adults with untreated minor depression develop major depression within 1 year and less than one third with minor depression have a remission of symptoms after 1 year (Meeks et al., 2011). Minor depression is serious and the majority of older adults will not improve without treatment.

Depression in Late Life Is Serious

Depression (major, persistent, and minor) is associated with serious negative consequences for older adults, especially for frail older patients, such as those recovering from a severe medical illness or those in nursing homes (Mezuk et al., 2012). Consequences of late-life depression include heightened pain and disability, delayed recovery from medical illness or surgery, worsening of medical symptoms, risk of physical illness, increased health care use, alcoholism, cognitive impairment, worsening social impairment, protein–calorie subnutrition, loss of bone mineral density, functional decline, and increased rates of suicide- and non-suicide-related death (Hoogerduijn, Schuurmans, Duijnstee, de Rooij, & Grypdonck, 2007; Smalbrugge et al., 2006; Wu, Magnus, Liu, Bencaz, & Hentz, 2009). The “amplification” hypothesis proposed by Katz, Streim, and Parmelee (1994) stated that depression can “turn up the volume” on several aspects of physical, psychosocial, and behavioral functioning in older patients, ultimately accelerating the course of medical illness. For example, Gaynes, Burns, Tweed, and Erickson (2002) found that major depression and comorbid medical conditions interacted to adversely affect health-related quality of life in older adults, and Courtney, O’Reilly, Edwards, and Hassall (2009) identified depression as one of the factors most often associated with poorer quality of life for older adults in nursing homes. For older nursing home residents, depression is also associated with poor adjustment to the nursing home, resistance to daily care, treatment refusal, inability to participate in activities, and further social isolation (Achterberg et al., 2003).

Mortality by suicide is higher among older persons with depression than among their counterparts without depression (Juurlink, Herrmann, Szalai, Kopp, & Redelmeier, 2004). Rates of suicide among older adults (15–20 per 100,000) are the highest of any age group and even exceed rates among adolescents (American Association of Suicidology, 2012; McKeowen, Cuffe, & Schulz, 2006). This is, in large part, caused by the fact that White men older than the age of 85 years are at the greatest risk for suicide, when rates of suicide are estimated to be 80 to 113 per 100,000 (American Association of Suicidology, 2012; Erlangsen, Vach, & Jeune, 2005). In the oldest old (80 years and older), men and women had higher suicide rates than nonhospitalized older adults in the same age range, this age group had significantly higher rates of hospitalization than younger cohorts; three or more medical diagnoses were associated with increased suicide risk (Erlangsen et al., 2005). Among older psychiatric inpatients, increased risk for suicide was associated with affective disorders and first versus later admission (Erlangsen, Zarit, Tu, & Conwell, 2006).

Predictors of late-life suicide include: depressive symptoms (Rorup, Deeg, Poppelaars, Kerkhof, & Onwuteaka-Philipsen, 2011), previous suicide attempt (Wiktorsson, Runeson, Skoog, Ostling, & Waern, 2010), poor self-reported quality of life (Chen et al., 2011), perception of lower health status, poor sleep quality (Bernert, Turvey, Cornwell, & Joiner, 2014), and absence of a confidant (Turvey et al., 2002). Although physical illness and functional impairment increase risk for suicide in older adults, it appears that this relationship is strengthened by comorbid depression (Conwell, Duberstein, & Caine, 2002; Rorup et al., 2011). Disruption of social support (Conwell et al., 2002; Szanto et al., 2012), perceived burdensomeness (Cukrowicz, Cheavens, Van Orden, Ragain, & Cook, 2011; Jahn & Cruckowiz, 2011; Jahn, Cukrowicz, Linton, & Prabhu, 2011), family conflict, and loneliness (Waern, Rubenowitz, & Wilhelmson, 2003) are also significantly associated with suicide in late life.

Recent research has also identified a growing list of cognitive and psychological variables associated with increased risk for suicide among older adults. Decreased decision-making skills (Clark, Dombrovski, Sahakian, & Szanto, 2011), dysfunctional coping skills and poor cognitive control (Richard-Devantoy, Szanto, Butters, Kalkus, & Dombrowski, 2014) have all been correlated with increased risk for suicide. In addition, several social factors may place some older adults at greater risk: lower income and financial strain (Gilman 2012; Rorup et al., 2011), history of childhood physical and sexual abuse (Sachs-Ericsson, Corsention, Rushing, & Sheffler, 2013), and low receipt of filial piety (Simon, Chen, Chang, & Dong, 2014) are associated with increased suicidal ideation in older adults.

Studies have also shown that contact between suicidal older adults and their primary care provider is common (Luoma, Martin, & Pearson, 2002). Almost half of older suicide victims had seen their primary care provider within 1 month of committing suicide (Luoma et al., 2002), whereas 20% had seen a mental health provider. Most of the suicidal patients experienced their first episode of major depression, which was only moderately severe, yet the depressive symptoms went unrecognized and untreated. Older adults with clinically significant depressive symptomatology presented with physical rather than psychological symptoms, including patients who, when asked, admitted having suicidal ideation (Pfaff & Almeida, 2005).

Although the risk for suicide increases with advancing age (Hybels & Blazer, 2003), a growing body of evidence suggests that depression is also associated with higher rates of nonsuicide mortality in older adults (Kronish, Rieckmann, Schwartz, Schwartz, & Davidson, 2009; Schulz, Drayer, & Rollman, 2002); however, evidence is inclusive regarding depression as predictive of mortality in hospitalized older adults (Cole, 2007). Depression can also influence decision-making capacity and may be the cause of indirect life-threatening behavior such as refusal of food, medications, or other treatments in older patients (McDade-Montez, Christensen, Cvengros, & Lawton, 2006; Stapleton, Nielsen, Engelberg, Patrick, & Curtis, 2005). Furthermore, depressive symptoms in older adults have been associated with cognitive impairment and, in some cases, progression to dementia (Walker & Steffens, 2010). These observations suggest that accurate diagnosis and treatment of depression in older patients may reduce the mortality rate in this population. It is in the clinical setting, therefore, that screening procedures and assessment protocols have the most direct impact.

Depression in Late Life Is Misunderstood

Despite its prevalence and associated negative outcomes, depression in older adults continues to be underrecognized, misdiagnosed, and subsequently undertreated (Licht-Strunk et al., 2009; Unützer, 2007). Barriers to care for older adults with depression exist at many levels. In particular, some older adults refuse to seek help because of perceived stigma of mental illness. Others may simply accept their feelings of profound sadness without realizing that they are clinically depressed. Lack of care-provider training in the identification and diagnosis of depression in older adults is also a barrier to timely recognition and treatment (Ayalon, Fialová, Areán, & Onder, 2010). Depressive disorders may also be missed due to overlapping anxiety disorders and/or various somatic or dementia-like symptoms or because patient or provider believe that depression is a “normal” response to medical illness, hospitalization, relocation to a nursing home, or other stressful life events (Taylor, 2014). However, depression—major, persistent, or minor—is not a necessary or normative consequence of life adversity (Snowdon, 2001). When depression occurs after an adverse life event, it represents pathology that should be treated.

Treatment Works for Late-Life Depression

The goals of treating depression in older patients are to decrease depressive symptoms, reduce relapse and recurrence, improve functioning and quality of life, improve medical health, and reduce mortality and health care costs. Significant and equivalent improvements in depressive symptoms occur with both pharmacotherapy and psychotherapy interventions (individually or in combination) in older adult populations (Pinquart, Duberstein, & Lyness, 2006). In addition, treatment of depression improves pain and functional outcomes in older adults (Lin et al., 2003). Recurrence of depression is a serious problem and has been associated with reduced responsiveness to treatment and higher rates of cognitive and functional decline (Driscoll et al., 2005). When compared to younger patients, older adults demonstrate comparable treatment response rates; however, they tend to have higher rates of relapse following treatment (Mitchell & Subramaniam, 2005). Therefore, continuation of treatment to prevent early relapse and longer term maintenance treatment to prevent later occurrences is important. Even in those patients with depression who have a comorbid medical illness or dementia, treatment response can be good (Iosifescu, 2007). Depressed older patients who have mild cognitive impairment may be at greater risk of developing dementia if their depression goes untreated (Modrego & Ferrandez, 2004).

CAUSE AND RISK FACTORS

Several biological and psychosocial factors have been associated with increased risk for late-life depression. Medical comorbidity is a hallmark of depression in older patients and this factor represents a major difference from depression in younger populations (Alexopoulos, Schultz, & Lebowitz, 2005) (see Table 15.1). Biological contributors to depression in late life include vascular disease (myocardial infarction, coronary heart disease, cerebrovascular accident), general health (obesity, pain, new medical illness, insomnia, prior depression, history of suicide attempt, and poor health status), dementia (Alzheimer and vascular dementia), diabetes mellitus, Parkinson’s disease, arthritis, and urological problems (Aziz & Steffens, 2013; Cole & Dendukuuri, 2003; Hasin & Grant, 2002; Huang, Dong, Lu, Yue, & Liu, 2010; Vink, Aartsen, & Schoevers, 2008). Genetic factors seem to play more of a role when older adults have had depression throughout their lives versus older adults with onset in later life (Blazer & Hybels, 2005). Neuroanatomic correlates (volume reduction in hippocampus, orbitofrontal cortex, putamen, and thalamus), and the presence of apolipoprotein E have also been associated with late-life depression (Butters et al., 2003; Sexton, Mackay, & Ebmeier, 2013). The link between late-life depression and cognitive impairment is thought to be bidirectional. For example, a history of depression doubles the risk of developing dementia in late life and cognitive symptoms of severe depression can be misinterpreted as symptoms of an early-stage dementia (Morimoto & Alexopoulous, 2013). In an evidence-based review, Cole (2005) found that disability, older age, new medical diagnosis, and poor health status were among the most robust and consistent of all correlates of depression among older medical patients. Those with functional disabilities, especially those with new functional loss, are also at risk.

Psychosocial risk factors for depression in late life include personality attributes (personality disorder, low self-efficacy), life stressors (trauma, low income, less education, poor functional status, disability), and social stressors (bereavement, loneliness, lack of a confidante, impaired social support, being a caregiver; Aziz & Steffens, 2013; Cole, 2007; Cole & Dendukuuri, 2003; Heisel, Links, Conn, van Reekum, & Flett, 2007; Onrust & Cuijpers, 2006; Pinquart & Sorensen, 2004; Vink et al., 2008). It is interesting to note that in a meta-analysis of the impact of negative life events on depression in older adults, Kraaij, Arensman, and Spinhoven (2002) found that although specific negative life events (e.g., death of significant others, illness in self or spouse, or negative relationship events) were moderately associated with increases in depression, the total number of negative life events and daily hassles had the strongest relationships with depression in older adults. This suggests that clinicians should pay close attention to the accumulation of negative life events and daily hassles when developing programs and targeting interventions to mitigate depression in older adults who are at risk for developing depression.

TABLE 15.1

Physical Illnesses Associated With Depression in Older Patients

Sources: Alexopoulos et al. (2005); Cole (2005); Holmes and House (2000).

Depression Among Minority Older Adults

Rates of depression among minority older adults are not well understood. Beals et al. (2005) found that the rates of major depressive episodes among older American Indians were 30% of the national average. In a review, Kales and Mellow (2006) found lower rates of depression and higher rates of psychotic diagnoses among African American older adults. In a systematic review of studies of older Asian immigrants, Kuo, Chong, and Joseph (2008) found that the prevalence of depression among Asian Americans ranged from 18% to 20% with significant variability among different Asian minority groups. For example, studies of Vietnamese older adults estimated depression at 50%, whereas studies of older Japanese Americans estimated depression at 3%. Depression was linked to gender, recent immigration status, English proficiency, acculturation, service barriers, and social support.

Baker and Whitfield (2006) reported that depressive symptoms were significantly associated with increased physical impairment among older Blacks. Williams et al. (2007) found that when African American and Caribbean Blacks experience a major depressive disorder, it is usually untreated, more severe, and more disabling than for non-Hispanic Whites. Furthermore, significant disparities exist in the quality of mental health services received by minority older adults (Virnig et al., 2004). A study of managed care enrollees revealed that minority older adults received substantially less follow-up for mental health problems following hospitalization (Virnig et al., 2004).

Although misdiagnosis and subsequent inappropriate treatment can lead to poor health outcomes for minority older adults (Kales & Mellow, 2006), it is not clear that “simple” bias alone can explain the disparities in depression management that exist. For example, Beals et al. (2005) point out that differences in the social construction of depressive experiences may confound the measurement of depression in ethnic older adults. Older American Indians may be reluctant to endorse symptoms of depression because cultural norms associate these complaints with weakness (Beals et al., 2005). In a thoughtful analysis of health disparities, Cooper, Beach, Johnson, and Inui (2006) explore the complex interactions and relationships between patients and providers that frame the context in which disparities can occur. They point out that many historical, cultural, and class-related factors can influence the development of therapeutic relationships between providers and patients. Until more research clarifies the symptom pattern of late-life depression in minority populations (Sadule-Rios, 2012), it is important that clinicians be culturally sensitive and open to atypical presentations of depression that warrant closer scrutiny.

ASSESSMENT OF THE PROBLEM

Protocol 15.1 presents a standard-of-practice protocol for depression in older adults that emphasizes a systematic assessment guide for early recognition of depression by nurses in hospitals and other clinical settings. Early recognition of depression is enhanced by targeting high-risk groups of older adults for assessment methods that are routine, standardized, and systematic by use of both a depression screening tool and individualized depression assessment or interview (Smith, Haedtke, & Shibley, 2015).

It can be challenging to differentiate depression symptoms from dementia symptoms because cognitive impairment is frequently a symptom of depression and significant cognitive impairment in older depressed adults has been implicated in later development of dementia. Therefore, assessment for presenting symptoms indicative of both depression and dementia requires focused attention on the historical progression of symptoms, getting collateral information from a reliable informant (family or caregiver), and using a screening tool sensitive to change in mood symptoms in cognitively impaired individuals (Steffens, 2008).

Depression Screening Tools

Because older adults may not present with the same symptoms as younger adults (Pfaff & Almeida, 2005), it is important that screening for depression among older adults is incorporated into routine health assessments. In a recent meta-analysis (comparing 11 studies with a combined sample of 2,000 subjects) the authors reported that depressed symptoms in older adults are more likely to include agitation, somatic complaints (especially gastrointestinal symptoms), and hypochondriasis and less likely to include feelings of guilt or low sexual interest compared with younger adults with depression (Hegeman, Kok, Van der Mast, & Giltay, 2012). Nursing assessment of depression in older patients can be facilitated by the use of a screening tool designed to detect symptoms of depression. Several depression screening tools have been developed for use with older adults; this review focuses on two common screening tools used with cognitively intact older adults in hospital, clinic, and long-term care settings and one common tool for older adults with cognitive impairment. The Geriatric Depression Scale—Short Form (GDS-SF; Sheikh & Yesavage, 1986) takes a few minutes to complete and was developed specifically for older adults. The GDS-SF is ritten in a simple yes/no format with 15 items that can be self-administered or administered by a clinician; a score of 5 or more is considered positive screen for depression. The GDS has been shown to be valid in inpatient and outpatient settings, with an 84% sensitivity and 95% specificity (Glover & Srinivasan, 2013). Given the brevity, focus, and validity of GDS-SF, it is a good choice for either inpatient or outpatient populations (Mitchell et al., 2010). The GDS-SF has been a reliable screening tool for depressive symptoms in mild cognitive impairment but not in older adults with moderate to severe dementia (Debruyne et al., 2009).

The Patient Health Questionnaire-9 (PHQ-9) is evidence based and was originally designed for use in primary care settings (Kroenke & Spitzer, 2002). The PHQ-9 is recommended for screening cognitively intact older adults for depressive symptoms in primary care, nursing homes, and community settings and can be either self- or clinician administered (Richardson, He, Podgorski, Tu, & Conwell, 2010; Smith et al., 2015). The nine items of the PHQ-9 correspond with the DSM-5 (APA, 2013) major depressive disorder criteria and scores are based on frequency as well as number of symptoms (scores less than 5 suggest no depression; 5–9 = mild depression; 10–14 = moderate depression; and 20–27 = severe depression). Sensitivity and specificity of the PHQ-9 have both been reported to be more than 80%. The PHQ-9 has also been abbreviated to include just the first two items (PHQ-2) that ask about depressed mood and loss of pleasure (anhedonia); the PHQ-2 has similar sensitivity and specificity to the PHQ-9 (Kroenke, Spitzer, & Williams, 2003; Richardson et al., 2010). Overall, the PHQ is easy to administer, valid in cognitively intact older adults in different settings, and can also be used to monitor response to treatment (Richardson et al., 2010; Smith et al., 2015). The PHQ is not recommended for screening older adults with cognitive impairment.

The Cornell Scale for Depression in Dementia (CSDD) is an interviewer-rated scale that was developed specifically to detect symptoms of depression in older adults with dementia (Alexopoulos, Abrams, Young, & Shamoianl, 1988). The CSDD contains 19 items and a score of 12 or greater suggests depression in an individual with dementia. Screening tools are helpful in identifying depressive symptoms in older adults but do not replace the need for a comprehensive nursing assessment.

Individualized Assessment and Interview

Central to the individualized depression assessment and interview is a focused assessment of the full spectrum of symptoms (nine) for major depression as delineated by the DSM-5 (APA, 2013). Furthermore, patients should be asked directly and specifically if they have been having suicidal ideation—that is, thoughts that life is not worth living—or if they have been contemplating or have attempted suicide. The number of symptoms, type, duration, frequency, and patterns of depressive symptoms, as well as a change from the patient’s normal mood of functioning, should be noted. Additional components of the individualized depression assessment include evidence of psychotic thinking (especially delusional thoughts), anniversary dates of previous losses or stressful events, previous coping style (specifically alcohol or other substance abuse), relationship changes, physical health changes, a history of depression or other psychiatric illness that required some form of treatment, a general loss and crises inventory, and any concurrent life stressors. Subsequent questioning of the family or caregiver is recommended to obtain further information about the older adult’s verbal and nonverbal expressions of depression.

DIFFERENTIATION OF MEDICAL OR IATROGENIC CAUSES OF DEPRESSION

Once depressive symptoms are recognized, medical- and drug-related causes should be explored. As part of the initial assessment of depression in the older patient, it is important to obtain and review the medical history and physical and/or neurological examinations. Key laboratory tests should also be obtained and/or reviewed and include thyroid-stimulating hormone levels, chemistry screen, complete blood count, and medication levels, if needed. An electrocardiogram, serum B₁₂, a urinalysis, and serum folate should also be considered to assess for coexisting medical conditions. These conditions may contribute to depression or might complicate treatment of the depression (Alexopoulos, Katz, Reynolds, Carpenter, & Docherty, 2001; Taylor, 2014; Table 15.2). In medically ill older patients, who frequently have multiple medical diagnoses and are prescribed with multiple medications, these “organic” factors in the cause of depression are a major issue in nursing assessment. In collaboration with the patient’s physician, efforts should be directed toward treatment, correction, or stabilization of associated metabolic or systemic conditions. When medically feasible, depressogenic medications should be eliminated, minimized, or substituted with those that are less depressogenic (Dhondt et al., 1999; Taylor, 2014). Even when an underlying medical condition or medication is contributing to the depression, treatment of that condition or discontinuation or substitution of the offending agent alone is often not sufficient to resolve the depression, and antidepressant medication is often needed.

TABLE 15.2

Drugs Used to Treat Physical Illness That Can Cause Symptoms of Depression in Patients

^aBy causing dehydration or electrolyte imbalance.

^bBy causing toxicity.

^cBy causing hypoglycemia.

Adapted from Dhondt et al. (1999).

INTERVENTIONS AND CARE STRATEGIES

Clinical Decision Making and Treatment

Regardless of the setting, older patients who exhibit the number of symptoms indicative of a major depression, specifically suicidal thoughts or psychosis, and who score above the established cutoff score for depression on a depression screening tool (e.g., 5 on the GDS-SF or 8−10 on the GHQ-9) should be referred for a comprehensive psychiatric evaluation. Older patients with less severe depressive symptoms without suicidal thoughts or psychosis but who also score more than the cutoff score on the depression screening tool (e.g., 5 on the GDS-SF or 8−10 on the GHQ-9) should be referred to available psychosocial services (i.e., psychiatric liaison nurses, geropsychiatric advanced practice nurses, social workers, psychologists, a clergy member) for psychotherapy or other psychosocial therapies, as well as to determine whether medication for depression is warranted. It is also important to note that older adults at risk for depression may benefit from brief psychosocial interventions that focus on preventing the development of major depression (Forsman, Jane-Llopis, Schierenbeck, & Wahlbeck, 2009; Lee et al., 2012) with increased social activity interventions being most effective (Forsman, Nordmyr, & Wahlbeck, 2011). Findings have been mixed for prevention efforts focused specifically on minor depression (Krishna et al., 2013).

The type and severity of depressive symptoms influence the type of treatment approach. In general, more severe depression, especially with suicidal thoughts or psychosis, requires intensive psychiatric treatment, including hospitalization, medication with an antidepressant or antipsychotic drug, electroconvulsive therapy (ECT), and intensive psychosocial support (Taylor, 2014)). Less severe depression without suicidal thoughts or psychosis may require treatment with psychotherapy or medication, often on an outpatient basis. Collectively, these data also suggest that patients who have depression complicated by multiple medical and psychiatric comorbidities may benefit from a referral to an interdisciplinary treatment team with specific expertise in geropsychiatry.

The four major categories of treatment for depression in older adults are lifestyle change (exercise and diet); somatic therapies (e.g., pharmacotherapy ECT, and light therapy), psychosocial interventions (e.g., cognitive-behavioral, psychodynamic, social engagement, and reminiscence therapy), and collaborative care interventions. A compelling body of evidence supports the efficacy of these diverse treatment modalities for older adults with depression.

Lifestyle-Change Interventions

In less severe depression, lifestyle change may be effective and carries less risk of adverse effects compared to those related to pharmacological interventions. Physical exercise has been established as an effective treatment for depression in the general population, and this includes older adults who are physically able to participate. Two recent systematic reviews of physical exercise interventions concluded that exercise programs decrease depressive symptoms and quality of life in older adults with major and minor depression (Seong-Hi, Kuem Sun, & Chang-Bum, 2014; Sjosten & Kivela, 2006). Tai chi and qigong are specific meditative exercise methods that also may decrease depressive symptoms and reduce stress (Rogers, Larkey, & Keller, 2009; Wang et al., 2010). Studies showing potential benefits of improved nutrition and diet supplements on depression in late life are building (Nyer et al., 2013; Sanhueza, Ryan, & Foxcroft, 2013). For example, a systematic review on 10 studies on the relationship between vitamin D₃ supplementation and depressive symptoms in older adults reported positive results but more studies are required to make any solid recommendations (Farrington & Moller, 2013). Fish oil and folic acid supplementation have also shown promising results in studies that include older adults (Nyer et al., 2013). Although lifestyle changes (increase in exercise and a healthy diet) are reasonable recommendations, they may be inadequate in older adults who have disabilities and more significant depressive symptoms. Additional interventions, such as pharmacotherapy and psychotherapy, may also be necessary.

Somatic Therapy in Treatment of Late-Life Depression

Somatic therapy for remission of the symptoms of late-life depression includes pharmacotherapy, ECT, and light therapy. Pharmacotherapy or ECT are both shown to be very effective and are recommended for more severe depression. Pharmacotherapy and light therapy may also be recommended for older adults with less severe symptoms and for individuals who have not responded to nonpharmacological treatments (Kok, 2013).

In a recent meta-analysis of 80 controlled trails, antidepressants were found effective for treating depression in older adults and all classes of antidepressants were reported to be superior to placebo (Kok, Nolen, & Heeren, 2012). This meta-analysis also showed a response rate for antidepressants in older adults of 48% and a remission rate of 33.7%, which are similar to rates found in younger adults (Kok et al., 2012). The selective serotonin-reuptake inhibitors (SSRIs) are considered the first-line pharmacotherapy for late-life depression, based on their relatively low side-effect profile and low cost (Kok, 2013; Taylor, 2014). SSRIs have been effective in treating poststroke depression (Chen, Guo, Zhan, & Patel, 2006; Hackett, Anderson, House, & Xia, 2008) and depression in persons with Alzheimer’s disease (Thompson, Herrmann, Rapoport, & Lanctôt, 2007). In a systematic review of the literature, Wilson, Mottram, and Vassilas (2008) found that although SSRIs are generally well tolerated in older adults, a significant minority experience serious side effects, including nausea, vomiting, dizziness, and drowsiness. Judicious use of tricyclic antidepressants (TCAs) may be an effective alternative for older adults who cannot tolerate SSRIs (Kok, 2013; Wilson et al., 2008).

Older patients should be closely monitored for therapeutic response to and potential side effects of antidepressant medication to assess whether dose adjustment of antidepressant medication may be warranted. Kok, Nolen, and Heeren (2012) reported that about two thirds of older adults with depression require a change or augmentation to initial treatment to achieve remission. Although, in general, it is advised to start antidepressant medication at low doses in older patients, it is also necessary to increase doses to ensure that older adults with persistent depressive symptoms receive adequate treatment and appropriate follow-up (Kok, 2013).

Research that has suggested that the use of SSRIs in adolescents can increase suicidality has raised concerns about a similar dynamic with older adults. Several studies, however, have found that the use of SSRI antidepressants to treat late-life depression is not associated with increases in suicidal ideation (Barbui, Esposito, & Cipriani, 2009; Nelson, Delucchi, & Schneider, 2008; Stone et al., 2009). In fact, treatment of late-life depression with SSRIs has been shown to significantly reduce suicidal ideation and behavior in older adults (Barbui et al., 2009; Nelson et al., 2008; Stone et al., 2009).

Electroconvulsive Therapy

When older adults are not able to take antidepressants for treatment of late-life depression, clinicians are increasingly looking to the use of ECT to reduce symptoms of depression and improve function. ECT involves the induction of a mild, therapeutic seizure under general anesthesia. For many individuals, the use of ECT conjures up images of barbaric treatments that leave patients severely cognitively impaired. However, ECT is becoming a more widely accepted treatment option for older adults with depression, especially older adults with severe depression that is resistant to pharmacotherapy or has psychotic features (Greenberg & Kellner, 2005; Navarro et al., 2008; Spaans et al., 2015; Van der Wurff, Stek, Hoogendijk, & Beekman, 2003). In fact, because of the relatively low side-effect profile, some researchers suggest that ECT should be considered a front-line treatment (Plakiotis, Barson, Vengadasalam, Haines, & O’Connor, 2013). In a recent systematic review of literature on maintenance of ECT, Van Shaik et al. (2010) found that long-term ECT use was not associated with increases in cognitive impairment and was well tolerated in older adults, even older adults with cardiac conditions.

Light Therapy

The efficacy of bright light therapy to decrease depressive symptoms in older adults with major depression was tested in a recent clinical trial (Lieverse et al., 2011). This 3-week randomized trial compared bright light treatment with placebo (dim light) in 89 older adults with nonseasonal affective disorder. The intervention was well tolerated and showed a positive treatment response (58% vs. 34%). A small pilot study in long-term care also reported significant improvement in mood when comparing bright light treatment versus placebo effects (Royer et al., 2012). This is a promising area for further research and consideration when working with older adults who are depressed.

PSYCHOSOCIAL APPROACHES

The term psychosocial encompasses a wide array of approaches. This section provides an overview of the three major psychosocial approaches used in studies with older adult populations: (a) cognitive behavioral, (b) psychodynamic, and (c) reminiscence or life-review therapy.

Cognitive behavioral therapies (CBTs) seek to change the cognitive and/or behavioral context in which depression occurs through the use of various specific techniques such as providing new information, teaching problem-solving strategies, correcting skills deficits, modifying ineffective communication patterns, or changing the physical environment. Although specific treatment protocols vary, CBT approaches tend to be active and focused on solving specific, current day-to-day problems, rather than seeking global personality change in the client. Based on a large and growing evidence base, CBT has been shown to be effective in decreasing depression in clinically depressed older adults with major, dysthymic, and minor depression (Gould, Coulson, & Howard, 2012). Studies of computerized delivery of CBT with older adults are limited; however, there are promising findings, and older individuals may be less likely to drop out than younger individuals (Crabb et al., 2012). Training caregivers (family or paid caregivers) to use CBT approaches (improved communication, increasing pleasant events, and problem-solving behaviors) has also been shown to decrease depression and related behaviors in older adults with dementia (Teri, McKenzie, & LaFazia, 2005). Gallagher-Thompson and Coon (2007) also identified CBT interventions as effective in decreasing depression in the older adults who are caregivers for family members with dementia. A meta-analysis of nonpharmacological treatments reported that individual and group CBT interventions compared to usual treatment significantly reduced depression for people with chronic physical health conditions (Rizzo, Creed, Goldberg, Meader, & Pilling, 2011).

Psychodynamic approaches focus on establishing a therapeutic relationship as a mechanism of change, as well as the historical causes of current client mood and behavior. The client’s psychological insight and ongoing emotional experience are considered critical for psychological progress. The evidence for effectiveness of psychodynamic approaches with older adults has increased over the past 5 years. In a recent meta-analysis, a medium effect size was reported for psychotherapy in reducing symptoms of depression in older adults who reside in residential care settings (Cody & Drysdale, 2013). A systematic review of the impact of psychotherapy on symptoms of community-dwelling older adults with minor (subthreshold) depression also found psychotherapy to be effective, safe, and cost-effective (Lee et al., 2012). Additionally, Bharucha, Dew, Miller, Borson, and Reynolds (2006) reviewed 18 studies of psychodynamic approaches (“talk therapy”) with residents of long-term care settings and reported significant positive outcomes on measures of depression, hopelessness, and self-esteem. Marital and family therapy may also be beneficial in treating older adults with depression, especially older spouses engaged in caregiving (Buckwalter et al., 1999).

It is important to note that positive social relationships (Neufeld, Hirdes, Perlman, & Rabinowitz, 2015) and church attendance (Rushing, Corsentino, Hames, Sachs-Ericsson, & Steffens, 2013) may provide protection against suicidal ideation for some older adults. Treatment of depression rapidly decreased suicidal ideation in older adults (Bruce et al., 2004; Szanto, Mulsant, Houck, Dew, & Reynolds, 2003). However, older adults in higher risk groups (male, older) needed a significantly longer response time to demonstrate a decrease in suicidal ideation (Szanto et al., 2003).

In a systematic review by Lapierre et al. (2011) it was found that most efforts at suicide prevention target the reduction of risk factors (e.g., through screening and treatment of depression). The authors found that few studies focused on improving protective factors (e.g., resilience) that may be useful in reducing depression in older adults. A recent study by Van Orden et al. (2014) suggests that the desire for death and a sense that life is not worth living is not a normative finding among older adults. This suggests that assessment for a desire for death may be an important part of mental status assessment for older adults in order to identify those individuals who may be at risk for suicide.

In reminiscence therapy, older adults are encouraged to remember the past and to share their memories, either with a therapist or with peers, as a way of increasing self-esteem and social intimacy. It is often highly directive and structured, with the therapist picking each session’s reminiscence topic. According to a recent meta-analysis that included 128 trials with older adults participants, reminiscence interventions showed moderate improvement in depression when compared to control groups and effects were maintained at 6-month follow-up (Pinquart & Forstmeier, 2012). In another meta-analysis, group delivery of reminiscence was analyzed and the results showed significant improvement in depressive symptoms when compared to control interventions; however, the effect disappeared after 6 months (Song, Shen, Xu, & Sun, 2014). Nursing interventions to encourage reminiscence include asking patients directly about their past or by linking events in history with the patient’s life experience. The use of photographs, old magazines, scrapbooks, and other objects can also stimulate discussion.

In summary, psychosocial treatment has been found effective and safe in decreasing depression in cognitively intact older adults. There is also empirical evidence for the efficacy of cognitive behavioral-based therapies and reminiscence therapy in decreasing depression in individuals with dementia and for the older adults who are caregivers of individuals with dementia. Current meta-analysis also demonstrated the utility of working closely with caregivers—whether family or staff—to introduce psychosocial interventions with resulting reduction in depression in persons with dementia (Orgeta et al., 2014). There is also a small but growing body of evidence related to the use of psychodynamic approaches aimed at decreasing depression in older adults associated with specific comorbid illnesses such as heart disease (Kang-Yi & Gellis, 2010)

Collaborative Care

Collaborative depression care programs focus on multiprofessional teams that include nurses trained as care or case depression managers and have been effective in improving outcomes for older adults with depression (Dreizler, Koppitz, Probst, & Mahrer-Imhof, 2014). A recent meta-analysis that included 14 studies (4,440 participants) comparing nurse-delivered collaborative depression care approaches to usual care for older adults with chronic illness found a moderate impact on depression severity that remained at follow-up (Ekers et al., 2013)

Ethnic minority older adults experienced improved treatment of depression when treated by an interdisciplinary treatment team (Areán et al., 2005) as did low-income older adults (Areán, Gum, Tang, & Unützer, 2007). Similarly, patients with multiple comorbid medical conditions responded positively to a collaborative approach to depression management (Harpole et al., 2005; Unützer et al., 2002). Although older adults with comorbid anxiety disorders took longer to respond to treatment, they experienced greater reductions in depression when treated by a multiprofessional team than similar patients receiving usual primary care (Hegel et al., 2005).

Individualized Nursing Interventions for Depression

Psychosocial and behavioral nursing interventions can be incorporated into the plan of care, based on the patient’s individualized need. Provision of safety precautions for patients with suicidal thinking is a priority. In acute medical settings, patients may require transfer to the psychiatric service when suicidal risk is high and staffing is not adequate to provide continuous observation of the patient. In outpatient settings, continuous surveillance of the patient should be provided while an emergency psychiatric evaluation and disposition is obtained.

Promotion of nutrition, elimination, sleep/rest patterns, physical comfort, and pain control has been recommended specifically for depressed medically ill older adults (Voyer & Martin, 2003). Relaxation strategies should be offered to relieve anxiety as an adjunct to pain management. Nursing interventions should also focus on enhancement of the older adult’s physical function through structured and regular activity and exercise; referral to physical, occupational, and recreational therapies; and the development of a daily activity schedule (Barbour & Blumenthal, 2005). Enhancement of social support is also an important function of the nurse. This may be done by identifying, mobilizing, or designating a support person, such as a family member, a confidant, friend, volunteer or other hospital resource, church member, support group, patient or peer visitor, and particularly by accessing appropriate clergy for spiritual support.

Nurses should maximize the older adult’s autonomy, personal control, self-efficacy, and decision making about clinical care, daily schedules, and personal routines (Lawton, Moss, Winter, & Hoffman, 2002). The use of a graded task assignment in which a larger goal or task is subdivided into several small steps can be helpful in enhancing function, assuring successful experiences, and building older patients’ confidence in their performance of various activities (Areán & Cook, 2002). Participation in regular, predictable, and pleasant activities can result in more positive mood changes for older adults with depression (Koenig, 1991). A pleasant-events inventory, elicited from the patient, can be used to incorporate pleasurable activities into the older patient’s daily schedule (Koenig, 1991). Music therapy customized to the patient’s preference is also recommended to reduce depressive symptoms (Siedliecki & Good, 2006).

Nurses should provide emotional support for depressed older patients by providing empathetic, supportive listening; encouraging patients to express their feelings in a focused manner on issues such as grief or role transition; supportive adaptive coping strategies; identifying and reinforcing strengths and capabilities; maintaining privacy and respect; and instilling hope. In particular, it is important to increase the patient’s and family’s awareness of the symptoms as part of a depression that is treatable and not the person’s fault as a result of personal inadequacies.

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