When Suzette Santos, RN, a behavioral health nurse with the Visiting Nurse Service of New York (VNSNY), was assigned to the case of Grace*, an 89-year-old resident of Nassau County on Long Island, she had some idea what to expect. Suzette had cared for Grace a year earlier, as the elderly woman struggled to cope with depression brought on by the recent loss of her husband and lifelong partner. When Suzette reconnected with her patient this time, she could immediately see that Grace's depression had gotten worse.
"She had lost a lot of weight -- about 20 pounds," Suzette recalls. "She had no interest in cooking or eating, and wasn't sleeping well. I was concerned that she might need to be hospitalized."
With the holidays upon us, most of us will be spending more time with family, including older relatives like Grace. When you're with them, take some time to inquire about their health -- not just their physical condition, but their emotional state, especially if they've undergone a recent loss of a loved one or are coping with an illness. Major depression affects up to 5 percent of older Americans, while up to 16 percent of elderly individuals have significant depressive symptoms. Losing a spouse is a major risk factor for depression in this age group, as are chronic illnesses, including stroke, coronary heart disease, cancer, Parkinson's, Alzheimer's and dementia.
One difference in Grace's case was that her condition was diagnosed. Depression is frequently overlooked in older individuals, in part because their condition is often expressed in physical symptoms like fatigue, insomnia or loss of appetite, as opposed to overt sadness. Another reason is that the elderly are often dealing with other serious health conditions, with the result that signs of depression may be ignored or written off as a "natural" response to these other medical issues. Depression can also cause transient cognitive problems, leading people to mistake it for dementia.
Recognizing Signs of Depression in an Older Person
The good news is that there is a growing recognition in the U.S. of the importance of watching for and treating depression in older adults. It's now clear that depression increases the risk of other health problems in the elderly. For example, heart failure patients with depression are five times more likely to die from all causes than similar patients who aren't depressed. Research also shows that the cost of treating older patients with heart failure or diabetes doubles if they're also depressed. Reflecting this increased understanding of depression's consequences, Medicare recently began providing the same reimbursement for mental health services that it provides for other medical care.
At the same time, since older individuals typically don't recognize depression in themselves, and primary care physicians may sometimes fail to identify the condition as well, it's largely up to family members to call attention to a potential problem. In this regard, it's important to realize, first, that depression is not a natural part of aging. Second, you need to know its warning signs. According to the Centers for Disease Control and Prevention, if an elderly loved one exhibits any of the following, he or she could be suffering from depression:
• Feelings of hopelessness and/or pessimism
• Feelings of guilt, worthlessness and/or helplessness
• Irritability, restlessness
• Loss of interest in activities or hobbies once pleasurable
• Fatigue and decreased energy
• Difficulty concentrating, remembering details and making decisions
• Insomnia, early-morning wakefulness, or excessive sleeping
• Overeating or appetite loss
• Thoughts of suicide, suicide attempts
• Persistent aches or pains, headaches, cramps, or digestive problems that do not get better, even with treatment.
If you think depression may be an issue, you should connect your loved one with a clinician who has experience treating depression in older adults -- either a geriatric psychiatrist, or another physician with a geriatric background. Older individuals with depression tend to respond well to appropriate treatment, including antidepressant medication and/or psychotherapy. However, antidepressant dosages and potential side effects can differ in this population compared to younger adults, and interactions with drugs for other conditions can also be a factor.
Steps You Can Take to Protect Your Loved One
You can also take steps yourself to minimize an elderly family member's risk of depression and its effects. Here are some evidence-based suggestions:
See them frequently. A recent University of Michigan study of 11,000 adults found that those who visited with others at least three times a week were half as likely to develop depression as those who socialized less often -- and that those over age 70 benefited more from seeing family (as opposed to friends). The study also found that phone calls and email did nothing to lower depression risk.
Encourage them to walk several times a week. A Duke study of people aged 50 and older with major depression found that 30 minutes of brisk walking three days a week improved depression more than medication, and was also more effective in preventing a recurrence.
Consider suggesting folic acid and B12 supplements. Deficiencies in these two B vitamins has been strongly linked to increased depression risk in older adults.
Review possible medication side effects with their doctor. A number of medications have the potential to cause depressive symptoms in certain people, including statins, blood-lowering medications andcorticosteroids.
Make sure their bedroom is dark at night. Research of elderly populations has found a clear association between elderly people's exposure to light at night and increased symptoms of depression.
Be especially vigilant after the loss of a spouse or a hospitalization for serious illness. Risk of depression rises significantly following either of these events.
How Home Health Care Can Help
A certified home health agency can also be a valuable ally in helping a loved one overcome depression. As part of the growing nationwide effort to combat depression among the elderly, the leading home care agencies, including my own organization, VNSNY, are placing greater emphasis on identifying depression in older adults and treating it aggressively. Our nurses give a variety of mental health screens to our home care patients during their initial assessments, and also look for "triggers" such as crying and anxiety, irritability or agitation, sleeping difficulties, excessive fatigue, or behaviors that leave family caregivers overwhelmed.
If depression is suspected, we'll assign one of our behavioral health nurses to the patient's case for a period of time. This nurse will work with the patient and his or her doctor to make sure that any psychiatric medications are taken as prescribed, that the dose is effective, and that there aren't any problematic side effects. Since these nurses visit patients at least weekly in their homes, they can be alert to issues around these treatments that doctors may not be aware of.
In Grace's case, her behavioral health nurse Suzette observed that her medications were causing more problems than they were solving. "She was on several drugs for mood and sleep, and their combined side effects were upsetting her more," says Suzette. Realizing the single drug Remeron would address all of Grace's symptoms, Suzette suggested to Grace's primary care physician that this medication be substituted for the others, and Grace's primary care physician readily agreed. Suzette also explained to Grace about the new medication and the importance of taking it daily, and got her buy-in.
"Within three weeks Grace was doing much better," reports Suzette. "Today, her medication compliance is one hundred percent and she is a different person. She's regained her weight, is talking and eating more, and has started cooking again. Now, during my weekly visits, she asks what she can make for me!"
"Without Suzette, I wouldn't be in the good condition I am," adds Grace. "She's my soul mate."
*Name changed to protect privacy