Shellman, J., Mokel, M., & Wright, B. (2007). Keeping the bully out: Understanding older African Americans’ beliefs and attitudes toward depression. Journal of the American Psychiatric Nurses Association, 13(4), 230–236.

Depression and suicide risk

Depression accounts for up to 70% of late-life suicides. The risk of suicide for men increases with age, particularly for white men ages 65 and older whose risk is 7 times that of females of the same age. The highest rate of suicide is in males 75 and older at 36 per 100,000; the rate of suicide for males and females aged 75 and older is about 16 per 100,000 (Centers for Disease Control and Prevention, 2012).

Even though the suicide rate among older adults is high, especially among white, non-Hispanic males (Figure 30-1), suicide in this group is probably underreported. The numbers also do not reflect those who passively or indirectly commit suicide by abusing alcohol, starving themselves, overdosing or mixing medications, stopping life-sustaining drugs, driving into bridge abutments, or simply losing the will to live. There is an ongoing effort to educate primary care providers to better recognize, treat, and refer older adults to mental health care providers. There is clear evidence that treating depression is cost effective and decreases health care expenditures (NIMH, 2004). Chapter 25 provides an in-depth discussion of suicide.

FIG 30-1 Suicide rates among persons 65 and older by race/ethnicity and sex, United States, 2005-2009. (From Centers for Disease Control. [2009]. Retrieved from http://www.cdc.gov/ViolencePrevention/suicide/statistics/rates05.html.)

Early identification and treatment for depression are key measures for suicide prevention. Risks for suicide include demographics, diagnosable psychiatric illness (psychosis, anxiety, substance abuse, previous suicide attempts), psychological well-being (personality, emotional reactivity, impulsiveness), biological status (dysfunction of neurotransmitters), and stressful life events (Nock et al., 2008). Other risk factors include access to weapons, access to large doses of medications, and chronic or terminal illness. Protective factors include religious beliefs and practices, spirituality, perception of social/family support, and having children.

Selective serotonin reuptake inhibitors (SSRIs) are the first-line treatment for depression; this category is often helpful if anxiety, worry, or rumination is problematic. If pain or diabetic neuropathy is a comorbid condition, serotonin norepinephrine reuptake inhibitors (SNRIs) are often prescribed. Tricyclic antidepressants (TCAs) are effective, but they are utilized judiciously for those with chronic pain due to side effects and lethality in overdose. Treatment-resistant depression can be treated with psychostimulants such as methylphenidate or with monoamine oxidase inhibitors. Electroconvulsive therapy is a good alternative in care for depression, particularly in the elderly who may not tolerate medication or fail to improve.

Anxiety disorders

Specific anxiety disorders peak at various ages (Lenze & Wetherell, 2011). This may be related to changes in brain structure or function. In older adults, anxiety disorders are even harder to diagnose, and prevalence estimates vary greatly. One unique anxiety in the elderly is the fear of falling; its impact on keeping the elderly at home is similar to agoraphobia. Psychosocial risk factors for anxiety include being childless, low socioeconomic status, and having experienced trauma. Protective factors may include social support, spiritual beliefs, physical activity, cognitive stimulation, and having acquired effective coping strategies.

Cassidy and Rector (2008) identify anxiety disorders in late life as “The Silent Geriatric Giant.” Older adults often have multiple physical complaints, medication problems, pain, sleep disturbances, and psychiatric illness. Anxiety is twice as prevalent as dementia and four to eight times as common as major depressive disorders.

Treatment for anxiety disorders typically includes an SSRI along with cognitive behavioral therapy. Roy-Byrne and colleagues (2010) showed that relaxation training was an effective intervention for older adults. Antianxiety (benzodiazepines) agents are also used and frequently overprescribed. They should be used cautiously, as side effects can result in confusion, oversedation, increased risk of falls, and paradoxical agitation. Anxiety disorders are discussed in greater detail in Chapter 15.

Delirium

Delirium is a medical condition caused by physiological changes due to underlying pathology. It causes fluctuations in consciousness and changes in cognition that develop over a short period of time (hours to days). There is usually evidence from history, examination, or diagnostic testing that will help identify the cause (Caplan et al., 2010). Patients may be disoriented and often assumed to be demented because of their age; therefore, it is crucial to obtain data from family or caregivers about a baseline level of functioning. A patient who is newly confused, falling, disrobing, and fighting with staff should be assessed for delirium. Asking questions such as “Has your mother been shopping and cooking for herself?” or “Does she pay her own bills?” or “Does she ever get lost when driving?” may give subtle clues about whether changes are acute or have been coming on slowly. Other questions that can be revealing include “Has your father been started on any new medication?” or “Has your father fallen or hit his head recently?”

Treatment of delirium begins with identifying the cause. Adverse drug reactions, infections, electrolyte imbalances, anemia, thyroid dysfunction, vitamin deficiencies, and a multitude of other problems must be ruled out. A multidisciplinary approach is often helpful to identify causation: doctors of clinical pharmacology are helpful in identifying possible drug-related effects; geriatricians provide a comprehensive approach to physical assessment; and psychiatric consultation can provide mental status evaluation and recommendations for treatment of behaviors. If agitation or combative behaviors are present, it is common to provide short-term use of antipsychotic medications. Benzodiazepines should be avoided due to side effects and possible worsening of delirium.

Dementia

Dementia is usually of the Alzheimer’s or vascular type. Both are characterized by aphasia (difficulty finding words), apraxia (difficulty carrying out motor functions despite intact functioning), agnosia (failure to recognize objects), and disturbances in executive functioning (organizing, planning, abstracting, insight, judgment) (Falk & Wiechers, 2010). Changes in executive functioning may include forgetting how to make old family recipes, the inability to manage bill paying, and limited insight and judgment, leading to increased vulnerability to exploitation.

Another symptom that often is not discussed is sexual disinhibition. Older patients may be overly flirtatious, grope caregivers or family during care, make sexually inappropriate comments, expose genitalia, or masturbate openly. These types of behaviors can cause staff and family to be uncomfortable and confused about how to respond. It is important for the nurse to be open and understanding about such behaviors and to recognize them as symptoms of a frontal lobe brain dysfunction. Chapter 23 presents a more complete description of delirium and dementia.

Alcohol abuse

Although heavy drinking tends to decline with age, it continues to be a serious problem that can create particular problems for older adults. The antecedents to late-onset alcohol abuse are often related to environmental conditions and may include retirement, widowhood, and loneliness. Previous work and family responsibilities may help keep a person with vulnerabilities from drinking too much. Once these demands are gone and the structure of daily life is removed, for some there is little impetus to remain sober.

The risk factors for heavy drinking in older adults are being male and single, having less than a high school education, low income, and smoking (Karlamangla et al., 2006). Additionally, depression often plays a role in increased alcohol consumption in the elderly (National Institute on Aging, 2012). Identifying alcohol and substance abuse is often difficult because the accompanying personality and behavioral changes associated with alcohol abuse frequently go unrecognized in older adults.

EVIDENCE-BASED PRACTICE

The Impact of Wishing to Die on Mortality

Raue, P. J., Morales, K. H., Post, E. P., Bogner, H. R., Have, T. T., & Bruce, M. L. (2010). The wish-to-die and five-year mortality in elderly primary care patients. American Journal of Geriatric Psychiatry, 18(4), 341–350.

Problem

We know that suicide rates increase dramatically in the white male geriatric population. There is also concern that the wish-to-die, or passive suicidal ideation, may influence mortality rate for those who die of natural causes.

Purpose of the study

A national study called PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) provided longitudinal data to explore the correlation of natural cause deaths for those with a prior death wish, regardless of baseline depressive status. The researchers also compared mortality rates for those receiving usual care and for those receiving the specialized PROSPECT intervention.

Methods

Study data were collected from 20 primary care practices in New York City, Philadelphia, and Pittsburgh over a 5-year period. The sample of 1202 were given tests to evaluate mood and cognition, slong with a structured clinical interview.

Key findings

• Rates of wish-to-die were 40% among depressed patients and 7% among nondepressed patients.

• Having a wish-to-die was linked with an increased mortality rate, regardless of whether depression was present or not.

Implications for nursing practice

Although elderly patients may not be depressed, assessing for a wish-to-die is an important intervention. This study also demonstrated that a targeted intervention for elderly individuals with depression is beneficial in increasing quality of life and reducing mortality.

Caution is required when medicating the older adult who abuses alcohol. Central nervous system toxicity from psychoactive drugs increases with aging. Ingestion of antidepressants or tranquilizers can be particularly harmful because their effect is further potentiated by alcohol. Whenever there is a suspicion or indication that an older adult is abusing alcohol, the health care provider should conduct a screening test. The MAST-G (Box 30-1) is an instrument commonly used to assess older adults’ alcohol use.

BOX 30-1

MICHIGAN ALCOHOLISM SCREENING TEST GERIATRIC VERSION (MAST-G)

Please answer “Yes” or “No” to each question by marking the line next to the question. When you finish answering the questions, please add up how many “Yes” responses you checked and put that number in the space provided at the end.

1. After drinking, have you ever noticed an increase in your heart rate or beating in your chest? _____ Yes _____ No

2. When talking to others, do you ever underestimate how much you actually drank? _____ Yes _____ No

3. Does alcohol make you sleepy so that you often fall asleep in your chair? _____ Yes _____ No

4. After a few drinks, have you sometimes not eaten or been able to skip a meal because you didn’t feel hungry? _____ Yes _____ No

5. Does having a few drinks help you decrease your shakiness or tremors? _____ Yes _____ No

6. Does alcohol sometimes make it hard for you to remember parts of the day or night? _____ Yes _____ No

7. Do you have rules for yourself that you won’t drink before a certain time of the day? _____ Yes _____ No

8. Have you lost interest in hobbies or activities you used to enjoy? _____ Yes _____ No

9. When you wake up in the morning, do you ever have trouble remembering part of the night before? _____ Yes _____ No

10. Does having a drink help you sleep? _____ Yes _____ No

11. Do you hide your alcohol bottles from family members? _____ Yes _____ No

12. After a social gathering, have you ever felt embarrassed because you drank too much? _____ Yes _____ No

13. Have you ever been concerned that drinking might be harmful to your health? _____ Yes _____ No

14. Do you like to end an evening with a nightcap? _____ Yes _____ No

15. Did you find your drinking increased after someone close to you died? _____ Yes _____ No

16. In general, would you prefer to have a few drinks at home rather than go out to social events? _____ Yes _____ No

17. Are you drinking more now than in the past? _____ Yes _____ No

18. Do you usually take a drink to relax or calm your nerves? _____ Yes _____ No

19. Do you drink to take your mind off your problems? _____ Yes _____ No

20. Have you ever increased your drinking after experiencing a loss in your life? _____ Yes _____ No

21. Do you sometimes drive when you have had too much to drink? _____ Yes _____ No

22. Has a doctor or nurse ever said he or she was worried or concerned about your drinking? _____ Yes _____ No

23. Have you ever made rules to manage your drinking? _____ Yes _____ No

24. When you feel lonely, does having a drink help? _____ Yes _____ No

TOTALS: _____ Yes _____ No

Scoring: A score of 3 points or less is considered to indicate no alcoholism; a score of 4 points is suggestive of alcoholism; a score of 5 points or more indicates alcoholism.

From Menninger, J. (2004). Assessment and treatment of alcoholism and substance-related disorders in the elderly. Bulletin of the Menninger Clinic, 66(2), 166–183.

The older person who misuses alcohol displays symptoms of confusion, malnutrition, self-neglect, weight loss, depression, and falls. Diarrhea, urinary incontinence, decreased functional status, failure to thrive, and dementia may also be present. Alcohol-induced dementia is caused by long-term excessive alcohol abuse. It typically presents with impaired executive function and significant lack of insight. This is in contrast to the memory or language problems of dementia.

Moos and colleagues (2010) conducted a study where participants were followed over a 20-year span. Drinking excessively late in life was found in about 33% of participants. Indicators of excessive use were past drinking history, reliance on substances for stress reduction, and support of peers in drinking behavior. There is evidence that older adults respond to treatment as well as, if not better than, younger adults. Intentional brief intervention by a health care provider or participation in a group setting can impact older adults to decrease alcohol consumption. Group therapy along with self-help groups like Alcoholics Anonymous can be effective. It is important that health care providers recognize this recovery potential.

Pain

Pain is common among older adults and affects their sense of well-being and quality of life. Up to 85% of the older population is thought to have conditions that predispose them to pain. These conditions include arthritis, peripheral vascular disease, and diabetic neuropathy. Pain is also associated with depression. Jann and Slade (2007) describe three categories of depressive symptoms: emotional (mood, motivation, apathy, anxiety), cognitive (concentration, memory), and physical (insomnia, fatigue, headache, and stomach, back, and neck pain).

The older adult’s functioning and ability to perform activities of daily living such as walking, toileting, and bathing can be affected by pain, especially pain from musculoskeletal disease. Pain can lead to increased stress, delayed healing, decreased mobility, disturbances in sleep, decreased appetite, and agitation with accompanying aggressive behaviors. Chronic pain can cause depression, low self-esteem, social isolation, and feelings of hopelessness (Wynne et al., 2000). There is mounting evidence that treatment of pain improves mood and treatment of mood improves pain.

Barriers to accurate pain assessment

The appropriate assessment and treatment of pain in older adults may have complications. They may believe that pain is a punishment for past behaviors, an inevitable part of aging, indicative of pending death, related to serious illness, expensive to test and diagnose, or a sign of weakness. External obstacles include inadequate assessment by health professionals, complicated clinical presentation, assumptions by health care professionals that pain is part of aging, and communication deficits due to cognitive impairment.

McDonald and colleagues (2009) demonstrated that the phrasing of pain-related questions with older adults influenced their report. The use of open-ended questions such as “Tell me about your pain, aches, soreness, or discomfort” yielded significantly more information than use of a pain scale alone.

Changes in behavior may indicate pain and should be assessed, especially in patients who have language impairment (e.g., dementia, stroke). Unlike younger adults, older adults may understate pain using milder words such as discomfort, hurting, or aching. Multiple painful problems may occur together, making differentiation of new pain from preexisting pain difficult. Sensory impairments, memory loss, dementia, and depression can add to the difficulty of obtaining an accurate pain assessment. Interviews with family members, caregivers, or friends may be helpful.

Assessment tools

When pain is suspected, the nurse begins with a physical assessment for medical origins of the pain and assesses the level of pain. The Wong-Baker FACES Pain Rating Scale (Hockenberry & Wilson, 2012) (Figure 30-2) is an active assessment instrument. The FACES scale shows facial expressions on a scale from 0 (a smile) to 5 (crying grimace). Respondents are asked to choose the face that depicts the pain they feel.

FIG 30-2 Wong-Baker FACES Pain Rating Scale. (From Hockenberry, M., & Wilson, D. [2013]. Wong’s essentials of pediatric nursing [9th ed.]. St. Louis, MO: Mosby.)

The present pain intensity (PPI) rating from the McGill Pain Questionnaire (MPQ) (Davis & Srivastana, 2003) is another tool accepted for use with older patients. Patients are asked to respond by selecting the description (from “no pain” [0] to “excruciating pain” [5]) that they believe identifies the pain they feel.

The Pain Assessment in Advanced Dementia (PAINAD) scale is used to evaluate the presence and severity of pain in patients with advanced dementia who no longer have the ability to communicate verbally (Figure 30-3). The scale evaluates five domains: breathing, negative vocalization, facial expression, body language, and consolability (Box 30-2). The score guides the caregiver in the appropriate pain intervention.

BOX 30-2

THE FIVE ELEMENTS OF THE PAIN ASSESSMENT IN ADVANCED DEMENTIA (PAINAD) SCALE

1. Breathing

Normal breathing is effortless breathing characterized by quiet, rhythmic respirations.

Occasional labored breathing is characterized by episodic bursts of harsh, difficult, or wearing respirations.

Short period of hyperventilation is characterized by intervals of rapid, deep breaths lasting a short period of time.

Long period of hyperventilation is characterized by excessive rate and depth of respirations lasting a considerable time.

Cheyne-Stokes respirations are characterized by rhythmic waxing and waning of breathing from very deep to shallow respirations with periods of apnea.

2. Negative Vocalization

None is characterized by speech or vocalization that has a neutral or pleasant quality.

Occasional moan or groan: Occasional moaning is characterized by mournful or murmuring sounds, wails, or laments. Occasional groaning is characterized by louder than usual inarticulate involuntary sounds, often abruptly beginning and ending.

Low-level speech with negative or disapproving quality is characterized by muttering, mumbling, whining, grumbling, or swearing in a low volume with a complaining, sarcastic, or caustic tone.

Repeated, troubled calling out is characterized by phrases or words being used over and over in a tone that suggests anxiety, uneasiness, or distress.

Loud moaning or groaning: Loud moaning is characterized by mournful or murmuring sounds, wails, or laments in a much-louder-than-usual volume. Loud groaning is characterized by louder-than-usual inarticulate involuntary sounds, often abruptly beginning and ending.

Crying is characterized by an utterance of emotion accompanied by tears. There may be sobbing or quiet weeping.

3. Facial Expression

Smiling or inexpressiveness: Smiling is characterized by upturned corners of the mouth, brightening of the eyes, and a look of pleasure or contentment. Inexpressive refers to a neutral, at ease, relaxed, or blank look.

Sad is characterized by an unhappy, lonesome, sorrowful, or dejected look. Eyes may be teary.

Frightened is characterized by a look of fear, alarm, or heightened anxiety. Eyes may appear wide open.

Frown is characterized by a downward turn of the corners of the mouth. Increased facial wrinkling in the forehead and around the corners of the mouth may appear.

Facial grimacing is characterized by a distorted, distressed look. The brow is more wrinkled, as is the area around the mouth. Eyes may be squeezed shut.

4. Body Language

Relaxed is characterized by a calm, restful, mellow appearance. The person seems to be taking it easy.

Tense is characterized by a strained, apprehensive, or worried appearance. The jaw may be clenched.

Distressed pacing is characterized by activity that seems unsettled. There may be a fearful, worried, or disturbed element present. The rate may be faster or slower.

Fidgeting is characterized by restless movement. Squirming about or wiggling in the chair may occur. The person might be hitching a chair across the room. Repetitive touching, tugging, or rubbing body parts can also be observed.

Rigid is characterized by stiffening of the body. The arms and/or legs are tight and inflexible. The trunk may appear straight and unyielding (exclude contractures).

Fists clenched are characterized by tightly closed hands. They may be opened and closed repeatedly or held tightly shut.

Knees pulled up is characterized by flexing the legs and drawing the knees upward toward the chest (exclude contractures).

Pulling or pushing away is characterized by resistiveness upon approach or to care. The person is trying to escape by yanking or wrenching himself or herself free or by shoving you away.

Striking out is characterized by hitting, kicking, grabbing, punching, biting, or other forms of personal assault.

5. Consolability

No need to console is characterized by a sense of well-being. The person appears content.

Distracted or reassured by voice or touch is characterized by a disruption in the behavior when the person is spoken to or touched. The behavior stops during the period of interaction, with no indication that the person is at all distressed.

Unable to console, distract, or reassure is characterized by the inability to soothe the person or stop a behavior with words or actions. No amount of verbal or physical comforting will alleviate the behavior.

Scoring: (See Figure 30-5 on p. 577 for point allocation.)

FIG 30-5 Visual analogue scales used in the management of cancer pain. (From Jacox, A., et al. [1994]. Management of cancer pain [Clinical Practice Guideline No. 9, AHCPR Publication No. 94-0952]. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research.)

0-1 = No significant pain

2-3 = Mild to moderate pain

4-6 = Moderate to severe pain

7-10 = Severe to very severe pain

From Lane, P., Kuntupis, M., MacDonald, S., McCarthy, P., Panke, J., Warden, V., & Volicer, L. (2003). A pain assessment tool for people with advanced Alzheimer’s and other progressive dementias. Home Healthcare Nurse, 21(1), 36.