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Depression in Older Patients: Avoiding Misconceptions, Understanding the Causes,

and Providing Intervention

Jill Tebbenkamp

James Madison University

NSG 325: Concepts In Aging

Professor Janelle Garman

November 15, 2020

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Abstract

Depression is the most prevalent mental illness among older adults yet can go undetected and

untreated. Triggers include common late life events, declining health, functional and cognitive

difficulties, psychosocial and living-arrangement transitions. In the face of such conditions,

health providers, family members and patients can wrongly assume that the depressive

symptoms are part of normal aging. Older adults are more susceptible to chronic diseases, thus

affecting their vulnerability to developing comorbid depression. Accurately attributing cause for

depressive symptoms, especially in the face of comorbidities and polypharmacy can pose

challenges. Recognizing these symptoms as divergent from the normal aging process and

intervening with appropriate treatment is paramount in preventing adverse outcomes, such as

further spiraling health and suicide. Studies prove efficacy of treatments including CBT, ECT,

and antidepressants versus deterioration in non-treated groups. Overlooking depressive

symptoms in older patients as part of the normal aging process and failing to provide proper

screening or tailored intervention negatively impacts the bidirectional causality of mental health

and quality of life. Nurses are in the position to screen all patients for symptoms of concern and

advocate for appropriate follow-up.

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Older adults are vulnerable to mental illnesses exacerbated by late-life transitions, losses

of loved-ones, polypharmacy, specific medications, and chronic illnesses. These compounding

triggers, risk factors, and causes coupled with misconceptions of normal-aging complicate and

obstruct diagnosis and treatment. Early recognition, and appropriate interventions are vital in

improving and preserving the mental health of older patients suffering with depression. Nurses

can use acute awareness and appropriate assessment tools to identify patients requiring mental

health intervention. Because depression is inextricably linked to overall health maintenance,

addressing or neglecting depression can make the difference in overall health outcomes.

Mental illness inflicts twenty percent of older adults in America, with higher rates

occurring in nursing homes (Eliopoulos, 2018). Depression is the most pervasive of these

illnesses, worsening and more prevalent with age, estimated to affect between 15-25% of

community-based and long-term care residents respectively (Bazrafshan et al., 2020; Eliopoulos,

2018). Additionally, there are potentially another 20-30% of assisted-care residents who have not

been diagnosed but yet display depressive symptoms. Diagnosis and intervention are critical in

curbing negative outcomes and addressing the risk of suicide, 20% of which occur in those age

65 years and older (Eliopoulos, 2018).

Symptoms of clinical depression may differ in older adults considering that the hallmark

of sadness may not be as apparent, and apathy may not warrant attention (Koekkoek et al, 2016).

Instead, more pronounced symptoms include sleep disturbance, irritability, restlessness, avolition

and anhedonia (Eliopoulos, 2018). Unfortunately, older adults are more vulnerable to having

these symptoms dismissed because they coincide with comorbid disease or are assumed to be

normal aging responses. Depression is not an expected part of aging and does not usually
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dissipate without treatment. Diagnostic challenges arise because the symptoms of depression can

mirror normal aging changes, pharmaceutical side-effects, or complications of comorbid

diseases. Risk for depression is increased by poor sleep, disability, social isolation, and chronic

medical illnesses often displayed in older patients (Eliopoulos, 2018).

Coping mechanisms, either developed or stymied throughout life, combined with genetic

predispositions affecting neurotransmitters are among the multiple underlying risk factors.

Biological rhythms, hormonal factors and inflammatory factors influence the development of

depression. Stress, lifestyle and normal aging impact circadian rhythms which is a major

predictive factor increasing the risk of depression in older patients (Eliopoulos, 2018). Because

depression can result from major multi-system disease states, both full physical examinations

and mental status evaluations are imperative. Lab tests are necessary for ruling out or identifying

underlying physiologic causes of depressive symptoms. Glycemic levels, inflammatory markers,

stress hormones, and anatomic nervous system indicators are all relevant conditions requiring

scrutiny. Physiologic changes caused by chronic diseases such as diabetes, cardiovascular

alterations, inflammatory processes, chronic pain and autonomic nervous system dysfunction can

be responsible for depression. Additionally, receiving a terminal prognosis, enduring prolonged

hospitalization, social isolation, and persistent pain can result in clinical depression. Aside from

the physiological factors, the psychological adjustment to chronic diagnoses can induce

depression (Airaksinen, 2020). Comorbidity between depression and other chronic diseases has

also proven increased mortality (Airaksinen, 2020).

In addition to causative disease processes, pharmaceutical side-effects can be responsible

for clinical depression. The challenges of disease-related physiology and medication induced

depression can be further increased by polypharmacy utilized in older populations. Medications

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that cause depression include antihypertensives, other cardiac drugs, beta-blockers, hormone

replacements, CNS depressants, and other common OTC remedies such as ranitidine and

cimetidine (Elipolous, 2018). Performing thorough and periodic medication reconciliations can

address pharmaceutical induced depression at the cause. 

Augmentation of physical assessments and lab diagnostics with specific depression

assessment tools such as The Geriatric Depression Scale (GDS), available in both a 30-item or

15-item form, Hamilton Depression Rating Scale (HAM-D), Zung Self-Rating Depression Scale,

and Hospital Anxiety and Depression Scale (HADS) can reveal depressive states (Kellner et al.,

2016; Hummel et al., 2017; Pocklington et al., 2016). Using meta-analysis, Pocklington et al.

determined that abbreviated versions of the GDS provide efficient diagnostic accuracy and

encourages screening the entire population (2016). Providers should be aware that cultural

implications can impact perception of symptoms and hence reporting or lack thereof and can

hinder diagnosis (Bazrafshan et al, 2020).

Effective treatments include cognitive behavior therapy (CBT), antidepressants,

electroconvulsive therapy (ECT), and lifestyle alterations. CBT sessions aim to transform

negative thought processes and ineffective health maintenance patterns. Hummel et al.

demonstrated the effectiveness of weekly CBT sessions following hospitalization, notable in

comparison to the control group which deteriorated without intervention (2016). Antidepressants

can also provide relief, but older adults are more prone to adverse outcomes due to

pharmacokinetic differences (Eliopoulos, 2018). A meta-analysis of the antidepressant risk-

benefit profile for older patients concluded that the benefits do not necessarily outweigh the

complications they pose for older, particularly frail patients and that alternative therapies should

be considered instead (Mallery et al., 2019).

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Electroconvulsive therapy (ETC) is a particularly useful intervention for elderly patients

considering the superior efficacy and quick response time, especially suitable for those with

acute depressive symptoms and suicidal ideation. The Prolonging Remission in Depressed

Elderly (PRIDE) study demonstrated that ETC in combined with pharmacotherapy improved

relapse rates versus medication alone (Kellner et al., 2016).

Other nonpharmacological interventions involve respectful treatment by care providers,

assisting clients to identify realistic life and health related goals, provision of information to

support informed decision making, and educating clients about symptoms of illnesses and

medications, and assisting the client to develop confidence in their ability to manage ADL’s and

health conditions can enhance coping techniques and reduce health care use (Ackley et al.,

2020). Reinforcing the benefit of such interventions aimed at improving self-perception and

perceived social support, Bazrafshan et al. demonstrated that social support enhancements reduce

depression by bolstering self-esteem, hope and life-satisfaction (2020). Developing collaborative

interprofessional partnerships, identifying useful psychosocial resources to support daily living

and financial and emotional needs such as church groups, senior day centers, and financial

support can improve the quality of life for older adults (Bazrafshan, 2020).

Normal alterations of the aging process, hormonal changes, sleep disturbance, sensory

decline, physical function deterioration, and susceptibility to chronic disease, combine to make

older adults more prone to depression, yet depression itself is not a normal part of the aging

process. Early and accurate diagnosis, pharmacologic or therapeutic intervention, appropriate

treatment follow-up, and securing psychosocial supports are all critical roles of healthcare

providers to decrease adverse outcomes. Addressing this under-recognized issue can reduce

burden on the patients, caregivers and healthcare resources.

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