Nutrition Paper, Coursework Example

A major cause of disability, depression is an affective disorder and a disease, one that is responsible for a tremendous economic impact, suboptimal clinical outcomes, and—most importantly—a great deal of human misery. Depression strikes across many different populations, from the young to the old, but the elderly are especially at risk of depression. Specific risk factors for depression in the elderly include physical impairments and diseases, the loss of social supports, the loss of autonomy and freedom, and also cognitive impairment. Effective and prompt diagnosis is important to secure the most optimal treatment outcomes for depressive elderly patients.

Depression is considered a major cause of disability, small wonder in light of the devastating and debilitating effects that it has on those who suffer from it (Kramer, Beaudin, & Thrush, 2005, p. 296). Depression can, indeed, be conceptualized as a disease, a chronic one at that, due to “the severity and disabling nature of symptoms” (p. 296). As a disability and a disease, depression is responsible for truly staggering costs: “high medical expenditures, poor clinical outcomes, low productivity, and compromised quality of life” (p. 296). Some indication of these costs can be seen in estimates of the economic burden imposed by depression, which in the U.S. was marked at $US83 billion in 2000, including direct costs, workplace costs, and mortality costs (p. 296).

There are two principal types of depression, major and subthreshold, though these may be further subdivided. Major depression is diagnosed when the patient presents the symptoms of negative affect, specifically sadness “or an inability to experience pleasure”, in combination with “sleep or appetite disturbance, trouble concentrating, and feelings of guilt and hopelessness” (Casten & Rovner, 2008, p. 591). Subthreshold depression, or subsyndromal depression, consists of presenting depressive symptoms, but symptoms that do not fit the criteria of depressive disorders stipulated in the DSM-IV (p. 591). As Lamers et al. (2006) explained, there are two basic ways of treating depression: pharmacologically, with antidepressants, and psychologically, with psychological interventions (p. 2). Antidepressants have been proven to be efficacious in managing every kind of depression except minor depression (p. 2). With mild, moderate, and severe depression, cognitive therapy (CT) and antidepressants are about equally effective (p. 2). Lamers et al. noted that in fact, the effects of cognitive therapy appear to be enduring, indicating that this is a very powerful form of treatment indeed (p. 2).

And yet, there is a great need for improving depression treatments: despite the fact that there are effective interventions for depression in patients of all age cohorts, depression care is highly variable (Kramer et al., 2005, p. 296). Many primary and specialty care settings have rather poor rates of detection and use of evidence-based best practices, which impairs their ability to accurately diagnose their patients’ ailments and prescribe an efficacious intervention (p. 296). Here, a major problem is that all too often, individuals who are experiencing symptoms of depression do not go to a mental health specialist, but rather to a primary care physician (p. 296). This is a clinical problem of no small weight, inasmuch as such healthcare systems typically have well-attested poor track records in dealing with presenting symptoms of depression correctly (p. 296). Patients’ lack of knowledge and/or motivation also prevents many patients from being seen, or at least prolongs their suffering greatly: many who are afflicted with major depression labor under the misconception that they do not need help, or that there is no efficacious solution to their problems (p. 296). For others, the inconvenience and/or economic privations making them unable to pay for treatments interfere with their ability to access effective care (p. 296).

However, as Kramer et al. (2005) explained, there are models of care that are well-supported by the literature and by practice (p. 298). One very important finding here is that it is not enough to teach practitioners more about depression and interventions with a sound basis in evidence: although such instruction improves communication, it “does not change specific behaviors with regard to depression treatment” (p. 298). Treating depression from a disease management perspective entails organizing the strategies for patient care towards the needs of the patients (p. 298). Here, it is especially important that facilities determine who is responsible for conducting assessments of patients presenting symptoms of depression, since, again, so many primary care facilities have failed to deal adequately with depression in so many cases (p. 298). Another important change: prioritizing patient education, in order to enable patients to manage their condition and take responsibility for setting their own goals, changing their own behaviors, and generally taking charge of the process as appropriate and needful (p. 298).

Antidepressants constitute the basis of pharmacological intervention for patients with depression (Kenneth, Anderson, & Lam, 2006, p. 123). Selective serotonin reuptake inhibitors (SSRIs) are a powerful new generation of antidepressants, and of these, escitalopram is the most selective and generally one of the most efficacious (p. 123). Indeed, escitalopram was found to be more efficacious than an assortment of conventional SSRIs: “citalopram, fluoxetine, paroxetine or sertraline, with a difference in treatment effect of 1.22 points” (p. 125). This is particularly notable in light of the fact that so many patients in the studies analyzed by Kenneth et al. had severe depression (p. 128). Thus, escitalopram is a particularly effective intervention for depression, and in many circumstances it is one that specialists should have recourse to in order to ensure maximum efficacy.

Another new antidepressant, a member of the newer generation of antidepressants, is milnacipran, which is a dual serotonin-noradrenaline reuptake inhibitor (Nakagawa et al., 2008, p. 587). Nakagawa et al. found that in analyses of the efficacy of milnacipran vis-à-vis TCAs, an older and more established class of antidepressants, and SSRIs, milnacipran performed remarkably similar to these other antidepressants (pp. 591-594). Response and remission were the same across the board, with no statistical differences between them (p. 594). However, milnacipran had fewer adverse effects than its competitors, indicating that efficacy in treating depression alone is not the only measure of a successful, sound antidepressant (p. 594). That said, as Nakagawa et al. noted, there are antidepressants that are arguably considerably better: venlafaxine, for example, an SNRI, has evinced “differential effectiveness vis-à-vis the other antidepressants” (p. 597).

But as stated, patients often have difficulty understanding what is happening to them. Depression can feel like a part of the emotional landscape, the atmosphere of the mind, such that its provenance remains obscure to the patient (Bollini, Tibaldi, Teseta, & Munizza, 2004, p. 670). Other depressive patients have reported such causes as “psychological suffering in their childhood and adolescence,” as well as perceived weaknesses and defects in their character, stressors at work, especially a lack of understanding from others, and more besides (p. 670). For many patients, depression is mysterious, a presence that haunts the mind in response to certain stressors or difficulties, or even for no obvious reason at all (p. 670).

Bollini et al. (2004) found that in fact, most depressive patients in their study prioritized the use of medications (p. 671). The patients understood the importance of taking the antidepressants, because they could experience the effects in their own day-to-day lives (p. 671). Another important thing mentioned was the psychological support provided by the doctor, as well as interactions with other people suffering from depression (p. 671). Nonetheless, some patients did not adhere to treatment: for some, the psychiatric diagnosis was something that they could not accept (p. 671). Consequently, some of these patients did not wish to accept taking psychotropic drugs (p. 671). Information proved to be the most efficacious way to reduce non-adherence: by giving patients more information and more in-depth explanations about the character of their conditions and the nature of the treatment, doctors were able to reduce anxieties and misconceptions regarding the treatments (p. 672).

An important grounds for analysis pertains to the cognitive aspects of depression: the ways in which it is attendant on significant alterations in cognitive functionality. Depression-causing disorders such as major depressive disorder (MDD) and bipolar disorder cause profound changes in a variety of cognitive functions (Cusi et al., 2012, p. 154). In particular, these disorders may be expected to affect social cognition in very profound ways (p. 155). Individuals with these disorders may also be expected to present reduced ability to regulate emotions and the higher-order cognitive processes (p. 155). They should also show greater activity in both the subcortical regions and the limbic regions of the brain, these being responsible for the appraisal of emotions and the processes of generalization (p. 155).

Cusi et al. (2012) found that in fact, individuals with acute levels of depression have been shown to possess “a generalized emotion recognition deficit”, indicating very poor abilities to recognize the emotions of others in facial expressions (p. 156). The perception of emotions is thus much weaker in patients with major depressive disorder, especially (p. 156). This explains much of the basis of the cognitive and emotional differences between patients with these disorders and neurotypical individuals. With bipolar disorder, it is both the manic and the depressive phases of the disorder that are correlated with significant problems in identifying moods and emotions corresponding to facial expressions (p. 159).

The elderly are particularly at risk for depression, as Kramer et al. (2005) explained (p. 296). Behavioral healthcare for the elderly is especially poor, and given the importance of such care this poses a significant challenge to effective care for depressed elderly patients (p. 296). This makes identifying the presenting symptoms of depression in the elderly particularly important. And as Choi, Wyllie, and Ransom (2009) found, there are a number of risk factors for depression that are consistently attested to amongst the elderly, risk factors which can cast a very great deal of light upon how to predict, diagnose and treat depression in elderly patients for the greatest efficacy.

The first risk factor identified by Choi et al. (2009) was social withdrawal (p. 672). Their study was conducted at a series of retirement homes, and they found that when residents isolated themselves from the society of others, this indicated the onset of depression (p. 672). The reason that this might be a particular indicator of depression amongst the elderly, at least in retirement homes, is not hard to see: these are people who have retired from their careers, and are unable to live their lives on their own without assistance (p. 672). In fact, this was established as one of the major themes in the residents’ depression: a “sense of loss and grief”, typically pertaining to such factors as “loss of control over their body and onset of dependence” (p. 672).

This, then, is a major risk factor for depression that is relevant to the elderly specifically: the loss of their previous lives, everything they have worked to create for themselves (Choi et al., 2009, p. 672). The loss of their previous, independent lives is devastating for so many residents, both because it forces them to be dependent upon others instead of being able to live on their own, and because of the fact that, as stated, they are faced with the loss of possessions, homes, and personal space (p. 672). Many are frustrated with the living arrangements in retirement homes: they often feel ‘managed’, as if on an assembly line, and shortages and turnover amongst the staff are sources of great frustration to them (p. 672).

Depression is particularly common after a stroke; as such, post-stroke depression (PSD) is of especial interest with regard to the elderly (Burvill et al., 1997, p. 219). However, Burvill et al. did find that in a study of first-time stroke patients, there were higher rates of post-stroke depression amongst males less than 60 years of age (48%) than there were amongst males 60 years of age or older (20%) (p. 221). However, the pattern was the opposite for female patients, 23% of whom under the age of 60 were depressed, as opposed to 31% of those 60 years of age or older (p. 221).

However, there was a curious difference with regard to living arrangements: 4 months after the experience of having a stroke, 17% of the patients who were living alone were depressed; the figure was 25% for patients living in rehabilitation hospitals, “31% living with their spouse or relatives, and 45% in nursing homes” (Burvill et al., 1997, p. 221). Here is delineated a major pattern of social risk factors for depression: amongst elderly patients, living in a self-reliant condition is correlated with significantly lower rates of depression than is living in any other arrangement. The fact that there were higher rates of depression for those patients living with spouse or relatives than there were for patients living either in-hospital or on their own is puzzling, however. It is possible, though the authors do not specify, that those individuals living on their own may have been individuals who prized doing so very highly; it is also possible that these individuals were simply in a better position to accept their situation of being alone precisely because doing so entailed more control over the course of their own lives. At any rate, it is scarcely surprising, in light of aforementioned findings, that nursing homes were correlated with the highest rates of depression.

Kivela, Viramo, and Pahkala (2000) assessed an assortment of risk factors for depressive relapses in old age (p. 114). Men were overrepresented in the group of patients who had relapsed; ergo, being male is one risk factor for depression late in life (p. 114). The authors did find that relapse was not correlated with such demographic factors as “educational level, previous occupation, marital status, living alone, frequency of visiting, contacts or intimacy of relationships with spouse or neighbors” (p. 114). Indeed, relapse was correlated with practically no other predicted risk factors. Instead, the authors found that factors such as low self-confidence and “diurnal variation of symptoms” could predict the intensity and severity of the depression, while diseases and other health impairments pertained more to the course of the depressive affect over time (p. 117). In particular, they found that a major risk of relapse was major depressive disorder (p. 117).

However, Casten and Rovner (2008) found that in fact, one particular physical disability is a major predictor of depression amongst the elderly: age-related macular degeneration (AMD) (p. 591). AMD is a considerable problem for the elderly, a major cause of disability with tremendously deleterious consequences for their quality of life (p. 591). Depression is staggeringly high amongst those afflicted with AMD: nearly one-third of all patients, according to two separate studies (p. 591). Another study indicated that those afflicted with AMD reported rates of depression that were twice those of the non-impaired elderly population (pp. 591-592). And the reasons why are not hard to see—indeed, they are practically intuitive: with loss of vision comes loss of independence and thus, loss of control over one’s own life (p. 592). With this comes a diminution of independence and autonomy, the ability to live on one’s own as one sees fit (p. 592). Such a loss of vision may force many individuals to give up pursuits that they have long cherished (p. 592).

Consequently, elderly patients with AMD should be screened for depression, given the overwhelming evidence that there is a powerful correlation between the two (Casten & Rovner, 2008, p. 593). Other than negative affect in mood, predictive risk factors of depression in elderly patients with AMD include hypochondria, insomnia, and guilt (p. 593). Moreover, subthreshold depression is a significant predictor of more major depression (p. 593). After identifying depressive elderly patients with AMD, it is important that they be referred to an appropriate mental health specialist (p. 594). It is of the utmost importance that they be reassured: it is sound and indeed essential practice to encourage patients by telling them that their feelings of depression are perfectly understandable in light of the circumstances (p. 594).

The personality trait of neuroticism is a major risk factor for depression amongst elderly patients with AMD (Casten & Rovner, 2008, p. 595). Neuroticism as a trait is stable, but it is a stable trait “defined by emotional instability, a tendency toward negative emotions, and an inclination to be easily stressed” (p. 595). For these individuals, strategies for intervention should focus on helping them to deal with these feelings of negativity and stress (p. 595). Cognitive behavioral therapy, for example, is an important strategy for teaching patients how to manage their feelings and their emotional affect (p. 595).

It has been suggested that depression amongst the elderly may occur by means of two different and distinct aetiological pathways: cerebral deterioration, also known as cognitive impairment, and social stress (Cervilla & Prince, 1997, p. 995). Cervilla and Prince set out to ascertain this, hypothesizing that the concomitance or comorbidity of both factors would yield higher rates of depression (p. 995). What these authors found was a 17% rate of pervasive depression amongst the elderly participants, a rate that is indeed significant (p. 997). There was an independent association between depression and social support deficits, specifically two or more of these (p. 997). There was also an association between life-threatening events and depression (p. 997).

And indeed, to some degree cognitive deterioration does effect rates of depression, exacerbating them when present along with social stress risk factors (Cervilla & Prince, 1997, p. 997). The effect proved quite significant, with the values increasing as cognitive function deteriorated (pp. 997-998). What this suggests is that in fact, the impairment of cognitive functions does have a very real impact on rates of depression, as do social risk factors (pp. 997-998). However, they also found that with increasing cognitive impairment, the association between either “exposure to life events or to social support deficits and depression” actually decreased, indicating that cognitive impairment became the more important (p. 998). In fact, this fits well with evidence for a particular biological, organic aetiology of depression in the elderly: “depression associated with cardiovascular disease is less likely to be associated with major life events in the year prior to onset” (p. 999). Thus, depression in the elderly occurs by means of varying aetiologies, a fact that is indisputably essential for effective diagnosis and treatment for optimal success.

Depression in the elderly is varied, as are the elderly themselves: it may occur due to cognitive deterioration, loss of autonomy, loss of social supports, and physical impairment. Of course, quite often it is simply a psychological and emotional disorder. Both antidepressants and behavioral interventions can be very efficacious in combating depression in the elderly. What is most clear is that it is essential to watch for the risk factors of depression in the elderly, in order to secure optimal clinical outcomes through an efficacious plan of treatment.

References

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Lamers, F., Jonkers, C. C. M., Bosma, H., Diederiks, J. P. M., & Ejik, T. Th. M. (2006). Effectiveness and cost-effectiveness of a minimal psychological intervention to reduce non-severe depression in chronically ill elderly patients: The design of a randomized controlled trial. BMC Public Health, 6(1), pp. 161-170. DOI:10.1186/1471-2458-6-161

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