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Depression is common among older people in nursing homes. As many as half of all older people living in nursing homes have depression. Many of them severe enough to effect the older person's functioning and quality of life. Many older people who have a chronic, physical illness also have depression.

Although depression is common among older people, it is not a normal part of getting older. Depression can and should be treated.

Recognizing Depression
Depression in older people, including those living in nursing homes, often is not recognized. Some nursing homes may be understaffed and busy staff members may not notice behavioral changes in the nursing home resident. Sometimes, nursing home staff members may not know the older person well enough to realize that their behavior has changed.

You, as a family member, play an important role in recognizing a loved one's depression. Because of your personal relationship with the older person, you may be better able to notice even small changes in behavior or personality that indicate depression.

Signs and Symptoms of Depression
People who are depressed have different signs and symptoms. Some people will have a few of these, while others will display many of them. Some signs and symptoms of depression include:

• Agitation or irritability
• Feeling "down" or "blue"
• Loss of interest or pleasure in activities once enjoyed
• Changes in appetite -- eating more or less
• Weight loss or gain
• Trouble sleeping or sleeping too much
• Agitated movements or slow movements
• Lack of energy
• Feeling worthless or guilty
• Trouble concentrating or making decisions
• Thoughts of death or suicide

Depression can affect the older person's thinking, behavior, or the way he or she feels and functions. It is important to take notice of any change in behavior and personality that an older adult may exhibit. For example, if your loved one once enjoyed walking to the dining room in the nursing home for meals and suddenly prefers staying in his or her own room for meals, this change may be a sign of depression.

Diagnosing Depression
Sometimes, depression is mistaken for dementia, because both conditions can affect the older person's ability to concentrate and remember things. It is very important that an accurate diagnosis is made. Treatment for depression is different than dementia.

There is no lab test to diagnose depression, which is why your observations and accurate reporting of behavior are very important. When diagnosing depression, health care providers look for the signs of depression mentioned earlier. The health care provider can also use "screening" tests to diagnose depression and determine how severe it is.

Sometimes, depression is caused by or made worse by medical problems. For example, some signs of depression can also be signs of infection. For example, if someone stops watching television (which he or she once enjoyed very much), the health care provider might want to check to see if the resident has a problem hearing or seeing.

In general, if no medical cause is found for the nursing home resident's changes in behavior, and if the signs have been present for 2 weeks or more, depression may be diagnosed.

Facts About Screening for Depression Among Nursing Home Residents

• Nursing home residents should be screened for depression 2 to 4 weeks after they are admitted to the nursing home.
• Nursing home residents should be screened for depression every 6 months.
• There are scientifically proven tools that health care providers can use to help check for depression in older people. Some of these include the "Geriatric Depression Scale," the "Beck Depression Inventory," and the "Cornell Scale for Depression in Dementia."
• Nursing home residents who have ideas of suicide should be referred immediately to a mental health professional.

Because depression can take different forms in many patients, it is important for the family to describe what they believe are signs of depression in their loved one. For example, some older adults with depression may be nervous and agitated, some may be quiet and not talk, some may wander around and some may want to be alone.

Treating Depression
The treatment of depression depends on several factors, such as the severity of the depression, whether or not the person is suicidal, and the person's ability to reason and participate in conversation. For example, someone with severe depression should receive an antidepressant medication, whereas someone with mild depression may be treated successfully with non-drug therapies.

The most common treatments for depression include:

• Evaluation and treatment of the conditions that cause or worsen depression
  For example, some medications can cause depression. In these cases, the medication that causes depression can be stopped or the dosage can be decreased. Pain is an example of a medical condition that is associated with depression. Successful treatment of pain can decrease depression.
  
  
• Individual and group psychotherapy (neither is appropriate for persons with severe dementia)
  
  
• Engaging the depressed person in activities that they like (for example, religious activities, arts and crafts)
  
  
• Creation of a homelike atmosphere, including pet therapy and personalization of residents' rooms
  
  
• Antidepressant medication
  
  There are many types of medications for depression. Generally, the medicines that are most effective with the lowest chance for side effects are called selective serotonin-reuptake inhibitors (SSRIs), and related medications. Examples include paroxetine (Paxil®), sertraline (Zoloft®), and citalopram (Celexa®), but there are many medications to choose from. Older anti-depressants such as amitriptyline (Elavil®) and doxepin (Adapin®, Sinequan®) generally are not recommended because they cause too many troublesome side effects in older adults.

What you can do to help the nursing home resident with depression

• Help staff to identify activities that bring meaning and joy to the nursing home resident. For example, helping the depressed person engage in religious activities, volunteering, and social activities can be effective in treating depression. Let the staff know what specific activities have been important to your loved one in the past.
  
  
• Talk to the nursing home staff about what you are seeing. Ask the nursing assistants and nurses about behaviors they are seeing. Let them know if your loved one expresses feelings of sadness, depression or worthlessness. Tell them about things that may be useful in detecting and treating depression. For example, let them know if your loved one has been depressed the past, or if they are dealing with particular stressors such as a death in the family.
  
  
• Contact your loved one's social worker for additional help. Every resident in a nursing home has a social worker assigned to him or her. Contact a clergy person or chaplain if that's appropriate for your loved one.
  
  
• Tell the nursing home staff immediately if your loved one talks about committing suicide. In this circumstance, staff needs to make a thorough evaluation and treatment plan.
  
  
• Talk with your loved one about the treatment choices suggested by the doctor and nursing home staff. Help your loved one understand the choices and make decisions that reflect his or her values and desires.
  
  
• Look around at the environment of the nursing home. Does it feel like home? Making the nursing home environment feel more like home can improve a resident's mood. Plants, pets and other touches may help make it feel like home. You may want to bring in items, such as family photos and personal bedding that your loved one will enjoy and make their room more homelike. Ask the staff about animals that live in or visit the facility. Make sure your loved one has an opportunity to interact with these animals or with visitors and volunteers in the facility. Ask the staff about the rules for bringing in your own pets to visit. Encourage children to visit with your loved one.
  
  
• Help the staff to monitor the effect of the treatments. Does your loved one's mood and behavior improve after treatment? Remember that the effects of treatment may not be achieved for several weeks.
  
  
• Advocate for your loved one. Request that the facility conduct a care planning meeting to address your loved one's depression. Tell the staff that you would like to attend the meeting. Ask if all staff who care for your loved one will participate, for example, nursing assistants, activities staff, the social worker, and mental health providers. Including everyone involved in caring for your loved one is important to ensuring that a comprehensive care plan is developed and put into practice.

For additional information contact:
Alzheimer's Association
1 800 272-3900
www.alz.org

The National Long Term Care Ombudsman Resource Center
202-332-2275
www.ltcombudsman.org

The American Geriatrics Society
The American Geriatrics Society (AGS) is dedicated to improving the health and well-being of older adults. With a membership of over 6,000 health care professionals, the AGS has a long history of improving health care for older adults.

The AGS Foundation for Health in Aging
The Foundation for Health in Aging (FHA) builds a bridge between the research and practice of geriatrics health care professionals and the public. FHA advocates on behalf of older adults and their special needs through public education, clinical research, and public policy.

The Empire State Building
350 Fifth Avenue, Suite 801
New York, New York 10118
212-755-6810
FAX 212-832-8646
e-mail: staff@healthinaging.org
www.healthinaging.org