Depression Depression is not a normal part of aging, and studies show that most older people are satisfied with their lives, despite physical problems (National Institute of Mental Health [NIMH], 2014b). To understand depression, the nurse must understand the influence of late-life stressors and changes and the beliefs older people, society, and health professionals may have about depression and its treatment. Prevalence Depression remains underdiagnosed and undertreated in the older population and is considered a significant public health issue (Abbasi & Burke, 2014). Depression is the fourth leading cause of disease burden globally and is projected to increase to the second leading cause by 2030 (World Health Organization, 2014). Approximately 1% to 2% of adults 65 years and older are diagnosed with major depressive disorder. An additional 25% have significant depressive symptoms that do not meet the criteria for major depressive disorder (Avari et al., 2014). Symptoms that do not meet the criteria for major depressive disorder have been referred to as minor depression, subsyndromal depression, dysthymic depression, and mild depression. The DSM-5 replaced the term dysthymia with the term persistent depressive disorder to describe symptoms that are long standing (lasting 2 years or longer) but do not meet the criteria for major depressive disorder. Recognition and treatment are important because persistent depressive disorder has a negative impact on physical and social functioning and quality of life for many older people and is associated with an increased risk of a subsequent major depression (Harvath & McKenzie, 2012; Uher et al., 2014). Rates of depression are higher in older adults who experience physical illness, who have cognitive impairment, or who reside in institutional settings. Fourteen percent (14%) of patients receiving home care meet the criteria for depression, and nearly half of all nursing home residents receive antidepressants for depression (Abbasi & Burke, 2014; Smith et al., 2015). Depression is a major reason why older people are admitted to nursing homes. Prevalence rates of depression in older adults likely underestimate the extent of the problem. The stigma associated with depression may be more prevalent in older people, and they may not acknowledge depressive symptoms or seek treatment. Many elders, particularly those who have survived the Great Depression, both world wars, the Holocaust, and other tragedies, may see depression as shameful, evidence of flawed character, self-centered, a spiritual weakness, and sin or retribution. Perceived stigma may be less of a concern for the future older population who are more aware of mental health concerns and more likely to seek treatment. Health professionals often expect older people to be depressed and may not take appropriate action to assess for and treat depression. The differing presentation of depression in older people, as well as the increased pr ...

1. Depression
Depression is not a normal part of aging, and studies show that
most older people are satisfied with their lives, despite physical
problems (National Institute of Mental Health [NIMH], 2014b).
To understand depression, the nurse must understand the
influence of late-life stressors and changes and the beliefs older
people, society, and health professionals may have about
depression and its treatment.
Prevalence
Depression remains underdiagnosed and undertreated in the
older population and is considered a significant public health
issue (Abbasi & Burke, 2014).
Depression is the fourth leading cause of disease burden
globally and is projected to increase to the second leading cause
by 2030 (World Health Organization, 2014).
Approximately 1% to 2% of adults 65 years and older are
diagnosed with major depressive disorder. An additional 25%
have significant depressive symptoms that do not meet the
criteria for major depressive disorder (Avari et al., 2014).
Symptoms that do not meet the criteria for major depressive
disorder have been referred to as minor depression,
subsyndromal depression, dysthymic depression, and mild
depression.
The DSM-5 replaced the term dysthymia with the term
persistent depressive disorder to describe symptoms that are
long standing (lasting 2 years or longer) but do not meet the
criteria for major depressive disorder.
Recognition and treatment are important because persistent
depressive disorder has a negative impact on physical and social
functioning and quality of life for many older people and is

2. associated with an increased risk of a subsequent major
depression (Harvath & McKenzie, 2012; Uher et al., 2014).
Rates of depression are higher in older adults who experience
physical illness, who have cognitive impairment, or who reside
in institutional settings. Fourteen percent (14%) of patients
receiving home care meet the criteria for depression, and nearly
half of all nursing home residents receive antidepressants for
depression (Abbasi & Burke, 2014; Smith et al., 2015).
Depression is a major reason why older people are admitted to
nursing homes.
Prevalence rates of depression in older adults likely
underestimate the extent of the problem. The stigma associated
with depression may be more prevalent in older people, and
they may not acknowledge depressive symptoms or seek
treatment. Many elders, particularly those who have survived
the Great Depression, both world wars, the Holocaust, and other
tragedies, may see depression as shameful, evidence of flawed
character, self-centered, a spiritual weakness, and sin or
retribution. Perceived stigma may be less of a concern for the
future older population who are more aware of mental health
concerns and more likely to seek treatment.
Health professionals often expect older people to be depressed
and may not take appropriate action to assess for and treat
depression. The differing presentation of depression in older
people, as well as the increased prevalence of medical problems
that may cause depressive symptoms, also contributes to
inadequate recognition and treatment. Primary care providers
accurately recognize depression in less than half of individuals
with depression (Mental Health America, 2014a). Even if
depression is identified, only about 25% of patients receive
treatment consistent with current guidelines (Unutzer et al.,
2013). The U.S. Preventive Services Task Force recommends
screening for depression in the general adult population
(USPSTF, 2016). It is important that all health care
professionals receive adequate education about depression in

3. older adults.
Racial, Ethnic, and Cultural Considerations
Studies have consistently found that older racial and ethnic
minorities are less likely to be diagnosed with depression than
their white counterparts but are also less likely to get treated
(Akincigil et al., 2012; Woodward et al., 2013). Hispanic adults
aged 50 and older are reported to experience more depression
than white, non-Hispanic adults; black, non-Hispanic adults; or
other, non-Hispanic adults. Gender differences are also present
in depression prevalence, and older women suffer depression at
twice the rate of older men (Hall & Reynolds, 2014).
Differences in the prevalence of major depressive disorder and
other mental disorders may be due to differences in the
presentation of self-reported symptoms or other aspects of
cultural context (Box 24.3). The new criteria in the DSM-5
addressing culturally based explanatory models will assist in
better understanding differences in presentation, help-seeking
behavior, and provision of more culturally appropriate treatment
for all individuals. Racial, ethnic, and gender differences in
mental illness, as well as differences within racial groups, have
not received adequate attention in the United States (see
Chapter 2).
Consequences
Depression is a common and serious medical condition second
only to heart disease in causing disability and harm to an
individual's health and quality of life. Depression and
depressive symptomatology are associated with negative
consequences, such as delayed recovery from illness and
surgery, excess use of health services, cognitive impairment,
exacerbation of coexisting medical illnesses, malnutrition,
decreased quality of life, and increased suicide and non–

4. suicide-related deaths (Abbasi & Burke, 2014; Alexopoulos,
2014; Sacuiu et al., 2016). It is highly likely that nurses will
encounter a large number of older people with depressive
symptoms in all settings. Recognizing depression and enhancing
access to appropriate mental health care are important nursing
roles to improve outcomes for older people.
Etiology
The causes of depression in older adults are complex and must
be examined in a biopsychosocial framework. Factors of health,
gender, developmental needs, socioeconomics, environment,
personality, losses, and functional decline are all significant to
the development of depression in later life. Depression can
occur for the first time in late life or can be part of a long-
standing mood disorder with onset in earlier years (Harvath &
McKenzie, 2012). Compared with patients 323with early-life
depression, older patients with late-onset major depression have
less frequent family history of mood disorders. Biologic causes,
such as neurotransmitter imbalances, have a strong association
with many depressive disorders in late life. This may be a factor
in the high incidence of depression in individuals with
neurological conditions such as stroke, Parkinson's disease, and
Alzheimer's disease (Abbasi & Burke, 2014; Alexopoulos,
2014). High rates of depression are seen in individuals with
dementia, and depression is also a risk factor for dementia,
particularly early-onset, recurrent, severe depression (Morimoto
et al., 2014). Serious symptoms of depression occur in up to
50% of older adults with Alzheimer's disease, and major
depression occurs in about 25% of cases. Depression in
individuals with Alzheimer's disease may be due to an
awareness of progressive decline, but research suggests that
there may be a biological connection between depression and
Alzheimer's disease as well (Harvath & McKenzie, 2012).
Among patients who have suffered a cerebral vascular accident,
the incidence of major depressive disorder is approximately

5. 25%, with rates being close to 40% in patients with Parkinson's
disease. Medical disorders and medications can also result in
depressive symptoms (Boxes 24.11 and 24.12). Other important
factors influencing the development of depression are alcohol
abuse, loss of a spouse or partner, loss of social supports, lower
income level, caregiver stress (particularly caring for a person
with dementia), and gender. Some common risk factors for
depression are presented in Box 24.13.
Medical Conditions and Depression
• Cancers
• Cardiovascular disorders
• Endocrine disorders, such as thyroid problems and diabetes
• Metabolic and nutritional disorders, such as vitamin B12
deficiency, malnutrition, diabetes Neurological disorders, such
as Alzheimer's disease, stroke, and Parkinson's disease
• Viral infections, such as herpes zoster and hepatitis
• Vision and hearing impairment
Medications and Depression
• Antihypertensives Angiotensin-converting enzyme (ACE)
inhibitors
• Methyldopa
• Reserpine
• Guanethidine
• Antiarrhythmics
• Anticholesteremics
• Antibiotics
• Analgesics
• Corticosteroids
• Digoxin
• L-Dopa

6. Risk Factors for Depression
• Chronic medical illnesses, disability, functional decline
• Alzheimer's disease and other dementias
• Bereavement
• Caregiving
• Female (2 : 1 risk)
• Socioeconomic deprivation
• Family history of depression
• Previous episode of depression
• Admission to long-term care or other change in environment
• Medications
• Alcohol or substance abuse
• Living alone
• Widowhood
Implications for Gerontological Nursing and Healthy Aging
Assessment
Making the diagnosis of depression in older people can be
challenging, and symptoms of depression present differently in
older people. Older people who are depressed report more
somatic complaints such as insomnia, loss of appetite, weight
loss, memory loss, and chronic pain. It is often difficult to
distinguish somatic complaints from the physical symptoms
associated with chronic illness. In medically ill individuals,
assessment should focus on nonsomatic complaints such as
sadness, helplessness, hopelessness, difficulty making

7. decisions, and irritability (Avari et al., 2014).
Hypochondriasis is also common, as are constant complaining
and criticism, which may actually be expressions of depression.
Older depressed individuals also have a higher rate of psychotic
and severe depression with more weight loss and decreased
appetite (Abbasi & Burke, 2014).
Decreased energy and motivation, lack of ability to experience
pleasure, increased dependency, poor grooming and difficulty
completing activities of daily living (ADLs), withdrawal from
people or activities enjoyed in the past, decreased sexual
interest, and a preoccupation with death or “giving up” are also
signs of depression in older people.
Feelings of guilt and worthlessness, seen in younger depressed
individuals, are less frequently seen in older people.
Individuals often present with complaints of memory problems
and a cognitive impairment of recent onset that mimics
dementia but subsides upon remission of depression (previously
called pseudodementia).
It is important to note that a large percentage of these patients
progress into irreversible dementia within 2 to 3 years, so
recognition and treatment of depression are important. It is
essential to differentiate between dementia and depression, and
older people with memory impairment should be evaluated for
depression.
Symptoms such as agitated behavior and repetitive
verbalizations in persons with dementia may be an indicator of
depression (see Chapter 25).
Comprehensive assessment involves a systematic and thorough
evaluation using a depression screening instrument, interview,
psychiatric and medical history, physical (with focused
neurological exam), functional assessment, cognitive
assessment, laboratory tests, medication review, determination
of iatrogenic or medical causes, and family interview as
indicated (Avari et al., 2014).
Assessment for depressogenic medications, for alcohol and

8. substance abuse, and for related comorbid physical conditions
that may contribute to or complicate treatment of depression
must also be included (Box 24.14).
Assessment of Depression
• Utilize a depression screening tool (GDS or Cornell if
cognitive impairment).
• Assess for suicidal thoughts.
• Investigate somatic complaints and look for underlying acute
or chronic stressful events.
• Investigate sleep patterns, changes in appetite or weight,
socialization pattern, level of physical activity, and substance
abuse (past and present).
• Ask direct questions about psychosocial factors that may
influence depression: elder abuse, poor environmental
conditions, and changes in the patient role after death or
disability of a spouse/partner.
• Obtain psychiatric and medical histories.
• Perform a physical exam including a focused neurological
exam.
• Complete a functional assessment (pay close attention to
changes in ADL function).
• Perform a cognitive assessment; depressed patients may show
little effort during examination, answer “I don't know,” and
have inconsistent memory loss and performance during exam.
• Conduct a medication review (assessment for medications that
may cause depressive symptoms).
• Ask about psychotic symptoms (delusions, hallucinations) and
symptoms of bipolar disorder.
• Perform laboratory work as appropriate to rule out other
causes of symptoms (e.g., TSH, T4, serum B12, vitamin D,
folate, complete blood count, urinalysis).
• Utilize family/significant others in obtaining key information
to correlate patient's symptoms with others' observations;
always assess and interview patient first.

9. Screening of all older adults for depression should be
incorporated into routine health assessments across the
continuum of care in hospitals, primary care, long-term care,
home care, and community-based settings.
The Geriatric Depression Scale (GDS), a self-report scale, was
developed specifically for screening older adults and has been
tested extensively in a number of settings (see Chapter 8, Table
8-3).
It is only appropriate for cognitively intact individuals and
those with mild to moderate cognitive impairment.
The Cornell Scale for Depression in Dementia (CSD-D) is
recommended for the assessment of depression in individuals
with severe cognitive impairment and includes an interview
with an informant followed by an attempted interview with the
individual with dementia. If he or she is unable to respond to
the questions, many can be completed through observation. The
instrument takes about 20 minutes to administer.
Additional research is needed to develop and validate a
depression screening instrument that will accurately detect
depression symptoms across varying levels of dementia (Brown
et al., 2015
Interventions
The goals of depression treatment in older adults are to decrease
symptoms, reduce relapse and recurrence, improve function and
quality of life, and reduce mortality and health care costs
(Harvath & McKenzie, 2012).
When compared with younger individuals, older people
demonstrate comparable treatment response rates, although they
may have higher rates of relapse following treatment. As a
result, treatment may need to be longer to prevent recurrences
(Abbasi et al., 2014).
If depression is diagnosed, treatment should begin as soon as
possible, and appropriate follow-up should be provided.
Depressed people are usually unable to follow through on their
own and without appropriate treatment and monitoring may be

10. candidates for deeper depression or suicide. Interventions are
individualized and are based on history, severity of symptoms,
concomitant illnesses, and level of disability.
Nonpharmacological Approaches
Current evidence shows that both cognitive-behavioral therapy
(CBT) and second-generation antidepressants have similar
effectiveness, but the medications are more likely to cause harm
than the utilization of CBT alone. The American College of
Physicians recommends that clinicians choose between either
CBT or second-generation antidepressants to treat patients with
major depressive disorder after discussing treatment effects,
adverse effect profiles, cost, accessibility, and preferences with
the patient (Garthlehner et al., 2016).
Other types of nonpharmacological treatment that have been
found to be helpful in depression include family and social
support, education, grief management, exercise, humor,
spirituality, CBT, brief psychodynamic therapy, interpersonal
therapy, reminiscence, life review therapy (see Chapter 4),
problem-solving therapy, and complementary therapy (e.g., tai
chi) (Abbasi & Burke, 2014; Chan et al., 2014; DeKeyser &
Jacobs, 2014).
The development of effective, simplified, and accessible
psychotherapeutic approaches, including telephone or Internet-
based programs, is important. Despite evidence-based
guidelines calling for combined pharmacological and
psychotherapeutic treatment, and the fact that older adults often
prefer psychotherapy to psychiatric medications, psychological
interventions are often not offered as an alternative treatment of
depression (American Psychological Association, 2014).
Reasons for this include time, reimbursement constraints, and a
limited well-trained geriatric mental health workforce
(McGovern et al., 2014).

11. Collaborative care.
Few older adults with mental health disorders receive care from
mental health specialists and most prefer treatment in primary
care settings. More than 70 randomized controlled trials have
shown collaborative care, an evidence-based approach for
integrating physical and behavioral health services in primary
care, is more effective and cost-efficient than usual care across
diverse practice settings and patient populations (Hall &
Reynolds, 2014; Unutzer et al., 2013). Some research suggests
that collaborative care may improve ethnic and economic
disparities in the diagnosis and treatment of depression (Hall &
Reynolds, 2014). Collaborative care models include a primary
care provider (PCP, an MD or NP), care management staff
(often nurses), and a psychiatric consultant working in an
interprofessional team. Care managers are trained to provide
evidence-based care coordination, brief behavioral
interventions/psychotherapy, and treatment support initiated by
the PCP, such as medications. The psychiatric consultant, either
through face-to-face or by telemedicine consult, advises the
team and provides guidance on patients who present diagnostic
challenges or who are not yet showing improvement (Hall &
Reynolds, 2014; Unutzer et al., 2013).
Pharmacological Approaches
Choice of medication depends on comorbidities, drug side
effects, and the type of effect desired. People with agitated
depression and sleep disturbances may benefit from medications
with a more sedating effect, whereas those who are not eating
may do better taking medications that have an appetite-
stimulating effect. There are more than 20 antidepressants
approved by the FDA for the treatment of depression in older
adults. 326 The most commonly prescribed antidepressants are
the selective serotonin reuptake inhibitors (SSRIs). These
agents work selectively on neurotransmitters in the brain to
alleviate depression. The SSRIs are generally well tolerated in

12. older people. Many are now available in both tablet and oral
concentrate forms for easier use. Side effects are manageable
and usually resolve over time; most cause initial problems with
nausea, vomiting, dizziness, dry mouth, or sedation.
Hyponatremia can also occur. If sexual dysfunction occurs, it
will resolve only with discontinuation; therefore, if the person
is or plans to become sexually active, a different drug may be
necessary. For those who do not respond to an adequate trial of
SSRIs, there is another group of antidepressants that combines
the inhibition of both serotonin and norepinephrine reuptake
inhibitors (SNRIs) (e.g., venlafaxine [Effexor]). These also may
be preferred by those who are engaged in or who anticipate
sexual activity because they are less likely to have sexual side
effects. One of the atypical antidepressants, such as bupropion
(Wellbutrin) or trazodone, may also be used. In the context of
reducing polypharmacy, Wellbutrin also reduces nicotine
dependency, and trazodone is sedating—for the person who has
difficulty getting to or staying asleep. Since the development of
the SSRIs and SNRIs, the older monoamine oxidase (MAO)
inhibitors and tricyclic antidepressants are no longer indicated
because of their high side effect profile including risk for falls.
If depression is immobilizing, psychostimulants may be used
but cardiac function must be monitored closely because there
are limited data on safe use in the older adult (Abbasi & Burke,
2014). All antidepressant medications must be closely
monitored for side effects and therapeutic response. Side effects
can be especially problematic for older people with comorbid
conditions and complex drug regimens. There is a wide range of
antidepressant medications, and several may have to be
evaluated. Only about one-third of depressed older adults
achieve remission with any single agent (McGovern et al.,
2014). Similar to other medications for older people, doses
should be lower at first (50% of the target does) and titrated as
indicated while adequate treatment effect is ensured. A patient
who has responded to antidepressant treatment should continue
treatment for approximately 1 year after a first depressive

13. episode because recurrence rates are high after earlier
discontinuation. After a second or third episode, treatment
should be extended after remission and some may require
lifelong treatment. Often, older people may be resistant to take
medication for depression, and it is helpful to stress that
although there may be circumstances precipitating the
depression, the final effect is a biochemical one that
medications can correct (Abbasi & Burke, 2014).
Other Treatments
Electroconvulsive therapy (ECT) is considered an excellent,
safe therapy for older people with depression that is resistant to
other treatments and for patients at risk for serious harm
because of psychotic depression, suicidal ideation, or severe
malnutrition. ECT results in a more immediate response in
symptoms and is also a useful alternative for frail older people
with multiple comorbid conditions who are unable to tolerate
antidepressant treatment.
ECT is much improved, but older people will need a careful
explanation of the treatment because they may have many
misconceptions.
Rapid transcranial magnetic stimulation (rTMS) is a treatment
approved in 2008 by the FDA to treat major depressive disorder
in adults for whom medication was not effective or tolerated.
The treatment consists of administering brief magnetic pulses to
the brain by passing high currents through an electromagnetic
coil adjacent to the patient's scalp. The targeted magnetic pulses
stimulate the circuits in the brain that are underactive in
patients with depression with the goal of restoring normal
function and mood. For most patients, treatment is administered
in 30- to 40-minute sessions over a period of 4 to 6 weeks. The
effectiveness of the treatment is still being evaluated in older
adults (Abbasi & Burke, 2014).
Family and Professional Support for Depression

14. • Provide relief from discomfort of physical illness.
• Enhance physical function (i.e., regular exercise and/or
activity; physical, occupational, recreational therapies).
• Develop a daily activity schedule that includes pleasant
activities.
• Increase opportunities for socialization and enhance social
support.
• Provide opportunities for decision-making and the exercise of
control.
• Focus on spiritual renewal and rediscovery of meanings.
• Reactivate latent interests or develop new ones.
• Validate depressed feelings as aiding recovery; do not try to
bolster the person's mood or deny his or her despair.
• Help the person become aware of the presence of depression,
the nature of the symptoms, and the availability of effective
treatments.
• Emphasize depression as a medical, not mental, illness that
must be treated like any other disorder.
• Provide easy-to-use educational materials to older adults and
family members, such as those available through NIMH.
• Involve family in patient teaching, particularly younger family
members who may have different life experiences related to
depression and its treatment.
• Provide an accepting atmosphere and an empathic response.
• Demonstrate faith in the person's strengths.
• Praise any and all efforts at recovery, no matter how small.
• Assist in expressing and dealing with anger.
• Do not stifle the grief process; grief cannot be hurried.
• Create a hopeful environment in which self-esteem is fostered
and life is meaningful.
Topic Mental Health.
Answer the Question(s):

15. What is likely to be different in the appearance of depression in
a person who is 70 years old compared to its appearance in a
person who is 20 years old? (mention at least 4).
• Fully explained your answers in a professional way.
• Please, do not mention the signs and symptoms of
depression.
• You need to mention the characteristics / symptoms that
are common on a depressed 70 years old person than are
different in a 20 years old depressed individual (do a
comparison between the depressed 70 years old with the
depressed 20 years old) (mention at least 4)
Guidelines:
· APA Format. New time Roman 12 font.
· The answer should be based on the knowledge obtained from
reading the book, no just your opinion.
· I am expecting minimum of 500 words.
· You must answer the question completely, in a professional
and well written presentation.
· I am expecting to answer the question and justified it based on
peer review literature or information from the book.
· The chapter of the Book was attached and online literature
with references included.
· APA style will be strictly enforced.
References Guidelines :
1. Book: Ebersole and Hess' Gerontological Nursing and
Healthy Aging 5th
Author: Theris A. Touhy; Kathleen F. Jett
Edition: 5th, Fifth, 5e Year: 2017
2. If other Reference are used in addition to the book must

16. have:
• Serial/journal articles
• Volume number, in italics.
• Issue number. This is bracketed immediately after the
volume number but not italicized.
• Month, season or other designation of publication if there
is no volume or issue number.
• Include all page numbers. Ex: 7(1),24 Sergiev, P. V.,
Dontsova, O. A., & Berezkin, G. V. (2015). References