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Learning Objectives

By the end of this section, you will be able to:

  • Discuss the potential changes in mental status for older adults
  • Describe ways to prevent depression in older adults
  • Outline the approaches to treating an older adult with depression
  • Support the family with an older adult who has depression

Depression is not a normal part of aging, but it is also not an uncommon occurrence in older adults. There are many factors that can contribute to depression in older adults, but in many cases, depression is preventable. The signs and symptoms are frequently overlooked or dismissed as normal parts of aging. It is well within the nurse’s scope of practice to recognize when a client may be depressed or be at risk for depression.

Mental Changes Associated with Aging

Aging affects the entire body, including the brain, even in those with “normal” aging. With normal aging, certain parts of the brain shrink, and in certain brain areas, the neurons may not be able to communicate as effectively. Blood flow to the brain may be less due to cholesterol deposits or atherosclerosis and narrowing of blood vessels. Inflammation, which is a normal response to injury or disease, increases with age. All of these changes can affect a person’s mental function. Complex memory and learning tests may be more difficult. Learning new tasks may take more time. The brain does, however, maintain the ability to change and adapt to manage new challenges with aging.

Chronic illness can exponentially increase the changes to the brain. Microvascular changes, or tiny, microscopic strokes that occur with high blood pressure, add up over time and can lead to vascular neurocognitive disorder in some people. Larger strokes, such as those caused by atrial fibrillation, also have significant effects both short- and long-term. There are things that people can do to slow or reduce the chances of changes to the brain, such as not smoking, limiting alcohol use, being physically active, receiving proper medical care, taking medications as prescribed, keeping appointments with providers, and eating a healthy balanced diet.

The older a person becomes, the more loss they may encounter. They may lose pets, friends, family, possibly a spouse or even a child. The loss of independence and/or loss of function also happens to some aging adults. This may happen gradually or suddenly. All of this loss must be processed and grieved. Bereavement is associated with cognitive decline (Atalay & Staneva, 2020).

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.

Cultural Context

Culture and Instrumental Activities of Daily Living

There are several cultures where older adults are not required to perform household tasks or IADLs. For example, Hispanic culture traditionally is one of respect for one’s elders and dictates that it is the duty of the family to care for family members who can no longer care for themselves. The Korean culture is another example where the younger members have a duty to care for aging family members. In cultures such as these, a decline in IADLs can easily be overlooked and considered “normal aging.” Sometimes, it results in dementia being more advanced when discovered due to the person not having the responsibility of performing any of these activities.

Prevention of Depression in Older Adults

The first step in preventing depression is to understand the factors that lead to the onset of symptoms and to understand what those symptoms are in older adults. According to the World Health Organization (WHO, 2023), roughly 14 percent of those over sixty years old experience a mental health issue, most commonly anxiety and depression. Over 27 percent of deaths by suicide are those over the age of sixty, worldwide (WHO, 2023).

The risk of depression for older adults increases by factors, such as limited access to education, the adoption of risky lifestyle habits (such as substance use, inactivity, and obesity), poor social support, financial stress, a lack of a confidant, chronic medical conditions, significant life events (such as death, divorce, trauma, or abuse), and the effect of material or functional losses (WHO, 2023). Interventions that can have the most significant effect are social activities that improve positive mental health, quality of life, and life satisfaction. Supportive therapies and programs that aim to promote social interactions and decrease loneliness can improve mental health among older communities (WHO, 2023).

Older adults may have different symptoms than younger ones, making it challenging to identify depression in older adults. Sadness is not the major symptom of depression in some older adults. In contrast, they may experience more numbness or a lack of interest in activities. They might not be as eager to discuss their feelings.

Keep in mind, everyone experiences depression differently, and may have symptoms other than those listed here. However, the common symptoms include:

  • a persistently depressed, nervous, or “empty” feeling
  • a sense of powerlessness, guilt, or worthlessness
  • irritability, restlessness, or difficulties staying still
  • decreased energy or fatigue
  • slower movement or speech
  • difficulty concentrating, remembering, or making decisions
  • difficulty sleeping, waking up too early in the morning, or oversleeping
  • eating more or less than usual, typically with unplanned weight gain or loss
  • thoughts of death or suicide or attempts at suicide

Another possible sign and symptom of severe depression in an older adult is pseudodementia, a cognitive impairment that looks like dementia but is actually due to depression. The common symptoms include memory loss and impaired executive functioning. Unlike dementia, though, pseudodementia is reversible with treatment of the depression.


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:

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.

Treatment for Depression in Older Adults

The American Psychological Association’s (APA, 2023) clinical practice guidelines recommend a combination of psychotherapy interventions, including suicide assessment, and second-generation antidepressants. The three psychotherapy interventions most effective in treating depression for older adults include group cognitive behavioral therapy (Group-CBT), interpersonal psychotherapy (IPT), and group review/reminiscence therapy.

Group-CBT focuses on the relationship between behaviors, ideas, and feelings; tackles existing issues and symptoms; and seeks to change those patterns that limit pleasure and hinder a person’s capacity for optimal performance. IPT focuses on resolving challenging situations and relationships that are most directly related to the current depressive episode. Group review/reminiscence therapy assists older adults in focusing on their life’s journey while analyzing and reflecting on changes and difficulties in order to have a more balanced and accepting outlook on life. Group therapy can provide peer support, reduce social isolation, and enhance coping skills (APA, 2023).

Most importantly, assess suicide potential with an evidence-based lethality assessment for suicide ideation. Clients with suicidal ideation vary widely in their risk for a suicide attempt depending upon whether they have a plan, intent, or past history of attempts. In-depth assessment of clients who screen positive for suicide risk will help providers make a plan to keep them safe from harm. Assessment for suicide risk includes asking about their suicidal ideation (i.e., thoughts of suicide), if they have a plan for committing suicide, their intent on completing the plan, previous suicidal or self-harm behaviors, risk factors, and protective factors. When assessing for a suicide plan, the goal is to determine if they have a plan, if it is specific, and if they have thought of a method that they plan to use. The risk of acting on suicidal thoughts increases with a specific plan. The risk also increases if the plan includes the use of a lethal method that is accessible to the client.

An example of an evidence-based suicide risk assessment tool is the Columbia Protocol, also known as the Columbia-Suicide Severity Rating Scale (C-SSRS). The C-SSRS is a six-question tool containing a series of simple, plain-language questions that anyone can ask. The answers can provide insight into suicide risk and needed support.

Treatment for depression can be provided in the hospital setting or in the outpatient setting. Psychotherapy may be used alone for treatment of mild depression or in combination with antidepressant medications for moderate to severe depression. Psychotherapy may involve only the individual, but it can include others, such as family members or couples therapy to help address issues within these close relationships. Depending on the severity of the depression, significant improvement can be made in ten to fifteen sessions. Group therapy brings people with similar disorders together in a supportive environment to learn how others cope in similar situations.

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.

Signs and Symptoms Nursing Interventions
Sleep disturbance Teach to prepare for sleep by stopping use of electronics, avoiding caffeine or alcohol, setting a bed time and engaging in relaxing activity, such as slow breathing or stretching exercise to encourage sleep
Reduced interest and pleasures Encourage participation in activities
Feelings of guilt or of worthlessness Have the client think of and list positive self-characteristics
Reduced energy or fatigue; appetite or weight change Educate to eat healthy and monitor intake; schedule rest periods; monitor weight; consult nutritionist
Decreased concentration and attention Engage the client in a therapeutic relationship
Depressed mood Reinforce therapy and medication teaching; review and evaluate coping strategies and support systems
Suicidal thoughts Monitor for suicide risk; keep the environment safe and free of objects that could be used to self-harm
Slowed movements and speech Assist mobility; use empathy when communicating
Withdrawal from normal activities Have the client set a realistic goal for the day and the means of goal achievement; include family in care if client is agreeable
Psychomotor disturbances Monitor medication effectiveness; collaborate with prescriber
Table 24.2 Nursing Interventions for Signs and Symptoms of Depression

Family Support for an Older Adult with Depression

To assist a loved one living with depression, the family may consider the following:

  • Encourage your loved one to remain in treatment by encouraging them to take their medication as directed and to fulfill their scheduled visits.
  • When asked, be prepared to listen without passing judgment. Pay close attention when they are speaking. Avoid making too many judgments or offering too much advice. Being receptive and understanding can be a very effective healing strategy.
  • Give encouraging feedback. Remind them of their strengths and how much they mean to others.
  • Offer to help. It can be difficult for someone with depression to perform some activities. Offer to help with the chores that they are struggling to complete.
  • Aid in creating a routine. An older person may find it challenging to make good decisions if they are depressed. It becomes essential to establish routines and make time for daily tasks. Make a timetable for meals, medication, physical exercise, sleep, time outdoors or in nature, and other duties.
  • Make plans together. Invite them to go on a stroll, to a movie, or to work on a hobby or other activity together. Don’t try to compel the person to act in a certain way.
  • Do not rush. After beginning medication, symptoms for some people may immediately become better. Others will find it takes a lot longer.
  • Do not forget to look after yourself. It’s difficult to watch a loved one battle with depression while realizing you can’t help. Recognize that whatever feelings you feel, including irritation, helplessness, anxiety, guilt, or wrath, are normal reactions. It’s crucial to look after your needs as well.

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