24.2 Depression

Development Task: Integrity versus Despair

One cannot discuss changes to the brain through aging without considering psychosocial changes. Integrity versus despair is the final stage of Erik Erikson’s stages of psychosocial development, beginning at age sixty-five and ending at death. (See 2.2 Interpersonal Theories and Therapies for more information on Erikson’s theory.) In this final phase, individuals reflect on their lives and achieve either integrity, when they feel fulfillment, or despair, when they identify regrets and missed opportunities.

The benefits of integrity are acceptance of life, peace and fulfillment, and wisdom. The successful resolution of crises of this stage is called ego integrity. With peace and fulfillment, people can reflect back on their lives with satisfaction and approach death with wisdom and no regrets. Wisdom is defined by Erikson (1964) as an “informed and detached concern with life itself even in the face of death itself” (p. 133).

The consequences of despair are increased depressive symptoms, increased regret, and decreased life satisfaction. These can have detrimental effects on a person’s health and well-being as they age. Increased depressive symptoms can lead to feelings of sadness, low mood, hopelessness, and feelings of worthlessness. Increased regret happens when people look back at their lives with guilt and fixate on mistakes. Feeling less satisfied with life can reduce resilience and hinder stress management.

People can improve their integrity and reduce their despair with counseling, seeking meaningful relationships, or working to repair damaged relationships. They also have the option to reframe their thinking by looking back at the mistakes and focusing on what can be learned from mistakes rather than thinking about personal failures.

Functional Ability and Comorbidities

Functional abilities are the fundamental self-care activities that people perform in their everyday lives. There are two types of functional abilities: activities of daily living (ADLs) and instrumental activities of daily living (IADLs), which are activities that are necessary to living independently. These specifically include using the telephone, shopping, preparing food, housekeeping, doing laundry, independently transporting oneself, managing medication, and handling finances.

The ability to provide for one’s care and be as independent as possible is very important for quality of life and for maintaining self-esteem and self-worth in many people. This is not the case for all older adults because some can maintain healthy outlooks even with low functional ability. Some adults who have lived independently for all or the majority of their lives have emotional difficulty when faced with dependence or with loss of functionality. This emotional difficulty can transition to depression in some older adults when the loss of function continues or becomes permanent. Chronic illness can also cause emotional difficulty that can lead to depression. This can be compounded when there is loss of functional ability and/or independence as well.

Common medical conditions that impair functional ability include cardiovascular diseases, neurological disorders, diabetes mellitus, cancer, obesity, dementia, emotional disorders, eye and hearing disorders, fractures, and stroke. The incapacitating effects of an ailment differ depending on what the client is trying to accomplish. Stroke can cause severe incapacitation and challenges with self-care. Arthritis is generally less serious but is more common and may make high-activity work (e.g., housework) difficult.

Socialization

Socialization is crucial for older adults. Those who have an active and fulfilling social life are less likely to experience many of the physical, cognitive, and emotional issues that isolated older adults face (WHO, 2023). Socially active older adults have higher levels of physical activity, more positive moods, and fewer negative feelings. They also frequently score higher on cognitive testing. There are many other benefits of socialization, including longer lifespan and reduced stress, which can result in better cardiovascular health and an improved immune system, better fitness, reduced risk of anxiety and depression caused by isolation, and greater self-esteem. The National Council on Aging (Garcia & Jordan, 2022) reports that social isolation and loneliness can increase the risk of mortality by 50 percent, which is higher than the effects of obesity and alcohol abuse.

As many benefits as there are to socialization of older adults, there are many barriers, too. Those with mobility issues may not be physically able to leave the home. The loss of a spouse or other close loved one may cause situational depression that can lead to isolation and loss of social contacts. Real or perceived cognitive decline can isolate older adults by the fear and anxiety of forgetting important social information or by altering inhibitions, which can upset peers. There are ways that older adults can increase their social sphere:

• maintaining relationships with children and grandchildren
• volunteering to increase social exposure and a sense of purpose
• taking advantage of community resources, such as church activities and senior centers
• going to a daycare center for older adults
• moving to a retirement or senior apartment complex that has activities and social events
• organizing events with other seniors, like a game night or book club
• having a dog or other pet to decrease loneliness; having a dog can increase socialization on walks, as well as help maintain physical activity

Physical Health

Maintaining functional mobility and physical condition is an important part of healthy aging and can help with the symptoms of depression. Mobility helps older adults achieve the best quality of life, by maintaining independence, helping prevent and manage chronic illness, and even helping with the pain of osteoarthritis. Being physically active can also lead to social interaction.

Resources for physical activity information with the goal of managing arthritis and other chronic conditions include the following:

• How Much Physical Activity Do Older Adults Need? from the CDC
• Physical Activity and Educational Programs Proven to Help Arthritis from the Arthritis Foundation
• Physical Activity from the WHO

Maintaining physical health also plays a large part in maintaining emotional health and preventing depression. A person who feels good physically will have more energy and is less likely to suffer from depression compared with a person who is chronically ill and with chronic fatigue. A physically healthy person is also much more likely to be engaged socially and with their family because they have the energy to do so.

Medications and Electroconvulsive Therapy

Selective serotonin reuptake inhibitors (SSRIs) are common antidepressants that increase the levels of serotonin in the brain to stabilize mood. This class of antidepressants is better tolerated by older adults than most other antidepressants and generally has successful outcomes in treating depression (APA, 2023). The most commonly used and best-tolerated SSRIs are sertraline, citalopram, and escitalopram. All antidepressants carry the possibility of side effects and there are a few specific side effects that may cause the person to feel that the medication is not worth the benefit. The inability to feel pleasure, anhedonia, is one of those unwanted side effects. Anhedonia can cause people to withdraw from social activities due to reduced pleasure from daily activities.

According to published research, ECT is a treatment that sends an electric current through the brain, in effect triggering a small seizure, and is a safe and effective therapy option for older adults with significant depression, even when are very old older than eighty-five years). When compared with younger individuals, the effectiveness of ECT is noticeably higher in older adults. Research revealed that older persons with serious depression who had ECT lived longer and showed more clinical recovery than those who just received medication (Kerner & Prudic, 2014). ECT can be done in the ambulatory or outpatient setting.

Nurses’ Role in Collaborative Care

The role of a nurse in treating older adult clients with depression is part of primary nursing care. Nurses also work with interprofessional teams that may include a psychiatrist, psychologist, social worker, or other health-care professionals. Each team member’s role and practice are defined in their professional licensure.

The duty of the psychiatric-mental health nurse includes a clinical component in both hospital and ambulatory settings. Nurses use their clinical assessment skills and by implementing treatments that will improve the client’s ability to care for themselves and advance toward optimal health, nurses who are serving in the capacity of case managers help the client function at their maximum level. Risk assessment; supportive counseling; problem-solving; instruction; medication and health status monitoring; comprehensive care planning; and linking to, identifying, and coordinating a variety of different health and human services are just a few examples of these interventions. Table 24.2 provides the most common signs and symptoms of depression with possible nursing interventions.