RSI pioneered the idea of care management for the "whole person" for elderly residents of assisted living facilities. In the course of years of research, they developed a comprehensive training and care management program that helps the elderly person stay active physically and mentally.

Together, ElderCare Online and RSI have tailored key components of the Caring Community program to meet the needs of family caregivers. Over the next several months, we will be presenting a new series of Skill Builders that focus on how caregivers – at home and in residential facilities – can learn more about chronic conditions and improve quality of care to their loved ones.

Introduction

Depression greatly diminishes a person’s quality of life, personal joy and productivity. Frail elderly persons, the residents in assisted living facilities, too often experience depression. Their declining health and functioning, multiple life changes and diminished personal resources are factors predisposing the frail elderly to depression. Depression is a medical condition, which affects the whole person; body, mind and spirit. Societal stigma and misunderstandings continually affect detection, treatment and prevention of depression. Depression can be managed and treated so that the person’s quality of life, personal joy and productivity can return.

Because depression is a common and personally devastating condition for frail elderly people, it is essential that appropriate training and education be provided to caregivers. This Skill Builder equips the caregiver with the knowledge, skills, attitudes and competencies to prevent, improve and manage depression in the people you care for.

• Recognize depression in others and distinguish it from dementia.
• Appreciate the painful feelings that people have when they are depressed.
• Understand and carry out the medical regimen for alleviating depression.

Recognizing Depression

Depression is more than sadness and low mood, more than the "low feeling" we all experience now and then but goes away when we take a walk or have coffee with a friend. Depression is more than the grieving that occurs after the death of a loved one. Depression is the darkest of moods, an empty feeling, many things and people are no longer interesting, aches and pains that keep coming back and go on and on for weeks, months or years. Depression is a whole body disorder that affects the way you think, the way you feel, both physically and emotionally. It isn’t normal to feel depressed all the time when you get older—in fact, most older people feel satisfied with their lives.

Depression is difficult to recognize in the elderly because other changes are also occurring and these can mask real depression. Physical conditions, grieving and dementia are common changes that can mask depression. The way depression is expressed is also different in the elderly than in other populations. Instead of looking sad, elderly with depression will more often have physical ailments, headaches and stomach pain, with no medical cause and be tired or irritable.

• Withdraws from previously pleasurable family, friends and activities.
• Few relationships with others.
• Experiencing a relationship that is not supportive.
• Experienced a personal loss more than six months ago.

• Impaired concentration
• Worries about memory
• Can’t easily make decisions

• Generalized dissatisfaction with life (irritability)*
• Lacks hope for his/her future (suicidal thoughts)

• Weight changes unrelated to physical problems
• Preoccupied with aches and pains unrelated to physical problems (unexplained * headaches backaches, digestive upsets, stomach pains and constipation)
• Changes in sleep pattern (early morning awakening, sleeping too much, insomnia,* chronic fatigue and lack of energy.)

Is it Depression or Dementia?

Several of the symptoms related to changes in thinking or cognition. Knowing whether the main problem is depression or dementia is often difficult. Depression can imitate dementia and both depression and dementia can have depressive symptoms. Depression can also be superimposed on dementia. In the early stages of dementia, the person knows his/her memory is declining and this loss can lead to depression.

Depression: A Medical Condition

Depression is a biological condition in which there are real physical changes occurring. The brain is a powerful organ that controls body, mind and emotions. Brain chemical, neurotransmitters, are involved. The main neurotransmitters are norephinephrine and serotonoin. They send messages by traveling within the brain and body along nerve fibers. Brain chemicals out of balance can lead to depression.

What tips the balance?

• Medications—beta-blockers, methyldopa, thiazide diuretics, cimetidine, ranitidine, benzodiazepines, anti-cancer drugs and hormones.
• Alcoholism
• Chronic conditions—stroke, Parkinson’s Disease, diabetes, cancer, cardiovascular diseases and pain
• Personal loss and death of loved ones
• Cascade of life changes
• Social isolation

Depression is misunderstood

1. There is a widespread belief that depression is a natural consequence of aging rather than a treatable source of disability and suffering. This is not true. Depression is not a part of the aging process.
2. There is a widespread belief that depression is a personal weakness in which the depressed person should "snap out of it". The depressed person is personally ashamed and tries to hide his/her feelings by pretending nothing is wrong but inside they feel miserable.
3. There is widespread ignorance and inadequate recognition of the symptoms of depression because, especially in the elderly, a physical condition, grieving or dementia can mask them. Those who are depressed don’t even recognize their own symptoms of depression.

Medications

Depression can be dangerous for a lot of reasons. And it’s all unnecessary because depression responds extremely well to treatment. People don’t have to be depressed. But they do have to know that, and they do have to seek help.

The first course of action is to prescribe the right antidepressant drug. Pharmaceutical companies have developed a long list of antidepressants, as well as stimulants. Doctors decide which ones to use based on the severity of the depression and on the patient’s other conditions; then they make adjustments in the prescription as they monitor its effect.

Medications have become the most effective treatment for depression with 65-75% clinical improvement. There are several categories of medications to treat depression but Selective Serotonin Inhibitors (SSRI’s) are effective, relatively safe to use and most commonly prescribed for elderly persons.

It is important to know that it can take 4-8 weeks before there is any relief from depression. For any long-term benefit, SSRI’s must be taken for 6-9 months. When depression has occurred more than once, the duration of treatment is 1-5 years. Antidepressant medications are helpful in 60% of cases, and take 6-12 weeks to work. But they have numerous side effects in elderly people.

Side effects from taking antidepressant drugs often are more noticeable during the first few weeks but usually diminish after that. They include:

• Dry mouth
• Constipation or diarrhea
• Drowsiness
• Nervousness or sleeplessness
• Dizziness

If your loved one has pain, chills, rash, fever, blurred vision or other troublesome symptoms, call your doctor.

There are a few rules for managing depression medication well:

• Take your medicine accurately, the right number of pills at the right time.
• Never stop taking medications or change your dosage without consulting your doctor first.
• Never drink alcohol while you are on antidepressants. That can be dangerous.

While antidepressant drugs can work wonders in most cases, they nevertheless may have varied and surprising effects, or toxic accumulation, and so must be closely monitored by a physician.

Cognitive Therapies

Once a person is started on medications, counseling can help. Sadness due to loss or the worry that goes with being sick can trigger depression, so we also need to deal with those feelings and not just the chemical imbalance.

"Cognition" means knowing or perceiving. Basically, that’s thinking. Cognitive-behavioral therapy tries to identify and correct errors in thinking, where the person is seeing things as bad, when really they aren’t so bad.

Some of those thinking errors are:

• over-generalizing (Thinking that because one thing is bad, everything is bad.)
• "awfulizing" (Seeing the worst in any situation.)
• demanding of others (Expecting other people to do more for you than is appropriate.)
• expecting mind reading (Not telling people what you want or need, and then being angry at them for not knowing.)
• self-blame (Holding yourself responsible for everything bad that happens.)
• unrealistic expectations (Expecting immediate improvement.)

The counseling that works on those problems can be either in individual sessions with a doctor or other professional or in a group. A key factor is restoration of the sense of control and autonomy in every possible aspect of a person’s life. Depressed people must be helped to see that they have choices, that they are in control of their own lives.

It’s much better if the person can talk about his/her symptoms and be involved in assessing his/her own problems, rather than having professionals confer and issue orders without the person’s involvement.

Social Interaction

For the same reasons that counseling helps, increased contact with friends and family will help lift depression, too. People need people. Although it’s very hard when you are depressed to make yourself move and do things, it is important to try. Remember what you used to like to do, and get it started again.

Spiritual Renewal

And finally, spiritual renewal and rediscovery of meaning in your life are powerful tools for overcoming the fear and the sadness that go along with depression.

• Reading the Bible or other books about religion.
• Talking to a pastor or a friend who has a strong belief system.
• Remembering what your faith has meant to you earlier in your life, what strength it gave you.
• Reminiscing about the events of your life so that you can see how you have learned and grown, how you have loved and been loved, how you have helped other people in large and small ways.

While some people seem to think that there is something wrong with talking about the past, in fact, there is a lot of evidence that reminiscing has strong therapeutic potential for people of all ages, and especially for elderly people. The people who criticize reminiscing call it "living in the past," when it isn’t that at all. People who reminisce are living their present lives but learning from the past. The past helps all of us understand the present.

By reminiscing, people can resolve old conflicts, disappointments and guilts, and also strengthen their self-esteem and celebrate the good in their lives. It has even been found that people who do life review -- that is, think back over their entire life -- experience less death anxiety and a stronger sense of satisfaction with who they are.

Conclusion