Depression affects more than 6.5 million (or 18 percent) of the 35 million Americans aged 65 years or older.1 Most people in this age group who experience depression have battled the condition on and off throughout their lives, but for others, even those in their 80s and 90s, it may be their first bout of the disease. The risk of depression in the elderly rises with a person's age, with the prevalence of other illnesses and as their ability to function decreases. The rate of depression among elderly people with a level of functional disability that requires home health care is 14 percent (the rate among nursing home residents is 22 percent).2
Unfortunately, much of the depression in the elderly goes unrecognized, and therefore untreated, by medical professionals. Even family caregivers who are intimately involved in care often mistake depression as an expected response to the loss, illness or difficult life changes the elderly often experience. Many caregivers think depression is a normal part of the aging process, but it is not.
The Visiting Nurse Service of New York (VNSNY) offers a special behavioral health program to identify and treat elderly home care patients at risk for depression. Untreated depression can lead to worsening of physical illnesses, including poorer outcomes for hip fractures, heart attacks and cancer and lead to the decline of cognitive abilities, hastening the onset of dementia symptoms. Untreated depression even leads to an increased risk of suicide. In fact, while we tend to think of suicide as a teenage problem -- and teenagers are the age group who most often attempt suicide -- it is actually the elderly who succeed at suicide at the highest rate: 25 percent of suicides attempted by the elderly are successful, while less than 1 percent of suicide attempts by teens are successful. And of those elderly who attempt suicide, 80 percent are reported to have major depression. Suicide is an especial problem for depressed elderly men.
Depression in the elderly goes untreated for a variety of reasons. First, for many aging baby boomers and Korean War veterans, mental illness carries a stigma that is hard to overcome. This generation has been conditioned to "grin and bear it," and to "pull themselves up by the boot straps." They are family patriarchs and matriarchs who don't want to let family down or cause worry. Anything associated with "mental illness" is a sign of weakness, and it is very common for them to say they "are fine" and to refuse to talk with a mental health practitioner.
Behavioral health specialists who work with the elderly at VNSNY have been successful in their attempts to reach those suffering from depression by sidestepping the "D word" and instead offering simply to "have a talk" about the way recent events, such as the death of spouse, child or pet, the onset of a illness or a recent hospitalization are affecting the patient. They might discuss broadly the functional limitations brought on by aging, or a patient's fears associated with economics and their future financial situation.
The VNSNY team uses the PHQ-9, a nine-item questionnaire for diagnosing depression that has been shown to be a reliable tool for home care patients.3 The team follows evidence-based practice treatments, such as a combination of anti-depressive medication and Cognitive Behavior Therapy (CBT) for Late-Life Depression protocols developed by Aaron Beck at Stanford University. CBT patients are taught to identify, monitor and ultimately challenge negative thoughts about themselves or their situations and develop more adaptive and flexible thoughts.4 The program has proven successful in treating depression in the elderly and, as a result, in keeping people in their homes.
"Statistics show that untreated depression in home care patients is a major cause of re-hospitalization," states Rose Madden-Baer, vice president of Behavioral Health and Special Projects at the VNSNY. "We have seen statistically significant improvements in our re-hospitalization rate as well as in our patients' ability to perform their activities of daily living (ADLs)."
Indeed, the home can be the ideal environment in which to assess and treat depression. In many ways, it's even better than a primary care doctor's office, because the home care staff is in the patient's environment and can personally see changes in dress, hygiene, energy and attitude. Nurses can see if a person is limiting social interactions, such as talking on the phone, visiting with friends or grocery shopping, and if the patient has reduced interest in things previously enjoyed, such as reading, television photos on the wall, etc.
The VNSNY program employs psychiatric nurses, psychiatric nurse practitioners and in-home visiting psychiatrists and receives referrals from community primary care physicians, hospitals and family members. The staff works closely with family caregivers, who they consider to be integral to the healing process.
According to Rose Madden-Baer, "Treating depression is a family affair. Many caregivers have difficulty managing their family member's psychological symptoms but feel helpless to improve the situation. At VNSNY, we help caregivers understand their family member's depression and teach them how to be a positive force, providing support as their family member moves through the illness and starts to feel pleasure again."
Signs that someone you know might be depressed and need help:
- Loss of interest or pleasure in usual activities
- Change in weight or appetite
- Change in sleep patterns or extreme fatigue
- Thoughts of suicide
- Routine PHQ-9 Depression Screening in Home Health Care: Depression Prevalence, Clinical and Treatment Characteristics and Screening Implementation, Kathleen Ell, DSW, Jurgen Unützer, MD, Maria Aranda, PhD, Kathleen Sanchez, PhD, and Pey-Jiuan Lee, MS, Home Health Care Serv Q. 2005; 24(4): 1-19.
For more information on the VNSNY Behavioral Health program, please visit www.vnsny.org or call: 1-800-675-0391. For information on how adult day care can help ease depression in the elderly, visit the VNSNY blog page: http://blogs.vnsny.org/2010/10/06/adult-day-services-how-we-can-help-depression/