and institutionalization (Rodda, Walker, & Carter, 2011). For a diagnosis of a major depressive disorder, the DSM-5 requires that a patient has experienced five or more of the following symptoms nearly every day for the preceding two weeks: ● Depressed mood for most of the day. ● Decreased interest or pleasure in nearly all activities for most of the day. ● Marked loss or gain of weight or markedly increased or decreased appetite. ● Excessive sleep or not enough sleep. ● Observable psychomotor agitation or retardation. ● Tiredness or loss of energy. ● Thoughts of dying or suicide, suicide attempt (APA, 2013). Two of the most common tools used to screen for depression in older adults are the Geriatric Depression Scale (GDS; Yesavage et al., 1983) and the Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961). Both tools are likely to identify depression in older adults (Smarr & Keefer, 2011). The original GDS is a 30-item tool that addresses the following domains: somatic concerns, lowered affect, cognitive impairment, and feelings of discrimination, impaired motivation, lack of future orientation, and lack of self-esteem. The higher the score, the greater the level of depression. ● Feelings of guilt or worthlessness. ● Poor concentration or indecisiveness. The Beck Depression Inventory (BDI-II) is a 21-question multiple-choice self-report inventory and is one of the most widely used instruments for measuring the severity of depression (Beck, Steer, Ball, & Ranieri, 1996). As an assessment tool, it provides a measure of severity of symptoms rather than a diagnosis. The tool measures depression based on two components or sub-scales: the psychological or “cognitive” component (such as mood) and the physical or “somatic” component (such as loss of appetite). All items are added, and the total score is used to determine the depression severity. Higher total scores indicate more severe depressive symptoms. Like all self-report tools, GDS and BDI-II scores can be easily exaggerated or minimized by the person completing the assessment, and as with all questionnaires, the way the test is administered can affect the final score. All practitioners need to address the appearance of depression. Physical therapists must make sure that the referring doctor is made aware of signs of depression and that the apparently depressed older adult is given a referral to a mental health professional. Practitioners must be able to differentiate among delirium, dementia, and depression. As noted in Table 2, the conditions differ by presentation, course, and on many elements of cognitive functioning. Making errors in determining these diagnoses is not uncommon because the snapshot symptoms of delirium and dementia are similar, and many older people with depression present with impaired cognition (Hanyu, Sakurai, & Iwamoto, 2007). Similarly, symptoms of depression are common in people with dementia (Snowdon et al., 2009). For many reasons, recognizing depression is extremely important when assessing patients. It has been shown that depressive symptoms among older adults are common and present in up to 47% of those with hip fracture (Holmes & House, 2000; Morghen et al., 2010). Perioperative depression interferes with functional recovery (Cree et al., 2000) and is associated with higher mortality (Nightingale, Holmes, Mason, & House, 2001). Also, the prevalence of depression increases with advancing age and dementia (Lai, Mughal, Fong, & Fenner, 2013). Moreover, in terms of other chronic conditions, stroke survivors have a greatly increased risk for clinically significant depression even 2 or more years after initial stroke, independent of functional disability, cerebrovascular risk factors, and previous depressive symptoms (Whyte & Mulsant, 2002). In a study of 569 older community-dwelling adults, it was found that depression was a significant contributing factor to ADL and IADL functional limitations of older adults (Song, Meade, Akobundu, & Sahyoun, 2014).
Examples of additional evidence-based tools commonly used by rehabilitation professionals to screen for cognitive functioning include the Short Blessed Test to assess cognitive changes associated with Alzheimer’s disease (Katzman et al., 1983) and the St. Louis University Mental Status Exam (SLUMS) to assess orientation, memory, attention, and executive function (Tariq, Tumosa, Chibnall, Perry, & Morley, 2006). More information on certain evidence-based tools can be found in The concept of well-being is known to reflect the personal, subjective assessment of each individual with regard to his or her own health, participation, and overall quality of life (Kiefer, 2008). The WHO includes the combined consideration of physical well-being, social well-being, and mental well-being in the overall determination of health (WHO, 2001). Collaboration with social workers, psychologists, psychiatrists, occupational therapists, and mental health providers to address mental health needs may be warranted. Appendix A. Psychosocial An array of psychosocial and developmental theories that attempt to explain the relationship between aging and social/ mental well-being exist in the current literature (Cole, 2008). These theories target engagement in life activities to describe health and well-being in older adults. While aging alone does not cause the onset of mental health conditions, many stressors to which people are exposed over the course of time often serve as triggers. Examples of potential stressors include chronic disease, loss of loved ones, and recurrent falls. Depression Depression affects more than 6.5 million older Americans (National Alliance on Mental Illness [NAMI], 2009). Depressive disorders occurring in adults age 65 and older are referred to as late life depression. Major depressive disorder – also known as major depression, unipolar depression, or clinical depression – is characterized by a pervasive low mood, loss of interest in customary activities, and diminished ability to experience pleasure (APA, 2013). Because there are no laboratory tests for major depression, the diagnosis is based on both the person’s subjective experiences and objectively observed behavior. Although there is no one particular characteristic look or behavior for a person with major depression, most people will have a depressed mood or a general loss of interest in activities they once enjoyed. In contrast to younger adults, older adults experiencing depression will be less likely to express feelings of worthlessness or guilt, and may be more likely to experience sleep disturbance, slower cognitive processing, and hopelessness about the future (Fiske, Wetherell, & Gatz, 2009). Depression among older adults is usually difficult to detect, with patterns of depressive symptoms in older people often differing from those in younger people (Cahoon, 2012). Many older people may not complain of symptoms of depression, considering them to be normal aspects of getting older (NAMI, 2009). Depressed older adults commonly present to their medical providers with multiple and vague somatic complaints such as headaches, backaches, memory loss, or fatigue. According to the Centers for Disease Control and Prevention (CDC, 2012a), some healthcare providers may simply discount older adults’ complaints as an expected part of aging. However, late life depression is a serious condition, with suicide risk for older adults exceeding that of all other age cohorts and being highest for white males over the age of 85 (National Institute of Mental Health, 2010; Snowdon, Steinman, Frederick, & Wilson, 2009; National Institute of Mental Health, 2016). Depression in older adults can lead to decreased self-care and poor chronic disease management, decline in the patient-provider relationship, decreasing access to care, and increasing costs of care (Snowdon et al., 2009). Physical risk factors for depression in older adults include chronic disease, organic brain disease (e.g., dementia), and chronic pain or disability (Colasanti, Marianetti, Micacchi, Amabile, & Mina, 2010). Psychosocial risk factors for depression include social isolation, caregiving, bereavement,
EliteLearning.com/Physical-Therapy
Page 48
Powered by FlippingBook