● What brings you joy? Treatments and recommendations for depression depend on the health status of the older adult and their living situation. Treatment may be necessary for older adults experiencing symptoms of depression that have a sustained impact on positive mental health: physical exertion, proper nutritional intake, regular restful sleep, social connection, and engagement in activities that bring satisfaction (NIA, 2021b). These recommendations can be individualized to fit the needs of the older adult and their circumstances. Case management and community engagement can be useful additions for support. The APA has published treatment recommendations specific to age ranges. For initial treatment of the older adult with MDD, the APA (2019) recommends group-based cognitive- behavioral therapy (CBT) or interpersonal psychotherapy (IPT) in combination with pharmacotherapy. The APA recognizes that treatment options are dependent on social determinants. The following are recommended treatments for MDD if group CBT or IPT are unavailable for initial treatment: individual CBT with or without pharmacotherapy and problem-solving group therapy (APA, 2019). If the healthcare provider is considering psychopharmacological interventions, a review of the AGS list of potentially unsafe medications for the older adults is needed. The AGS (2019) lists two tricyclic antidepressants, amitriptyline (Elavil) and imipramine (Tofranil), as potentially inappropriate and encourages considering prescribing selective serotonin reuptake inhibitors (SSRIs) citalopram (Celexa) and sertraline (Zoloft) as well as bupropion (Wellbutrin) if possible. Treating depressive symptoms of MDD with medication can be accomplished but must be reviewed for the safest option that meets the needs of the older adult. Protective factors that apply to the older adult are cultural views, spiritual beliefs, coping skills, personality traits, social support systems, and past responses to stress/loss/bereavement (APA, 2010). Assessment can be completed during the psychiatric interview. The healthcare worker can use an informal format or systematic questioning to elicit safety responses. No formal training is needed to administer the brief suicide screener called the Columbia Suicide Severity Rating Scale (C-SSRS) (SAMHSA, 2022a). All healthcare workers can administer the C-SSRS. The tool probes the older adult about their intent, plan, and preparation for death. If the questions are answered honestly, it can indicate older adults who are at high risk of suicide completion (The Columbia Lighthouse Project, 2016). To garner the greatest gains, the healthcare worker must utilize empathy to nurture an environment of trust within the therapeutic alliance with the older adult during this part of the assessment. The APA (2010) recognizes the use of a suicide contract commonly called a no harm contract between a mental healthcare provider and a patient. There is no evidence to prove its effectiveness in prevention and it is cautioned against as a replacement for a thorough suicide risk assessment. But it can be a useful method for discussing protective factors and a safety plan of action. The healthcare worker has decisions to make based on the level of risk verbalized by the older adult. The approach for intervention will depend on the severity of risk, workplace policy, and state legalities—especially related to breaching confidentiality. The healthcare worker will abide by the individualized plan of action for suicide prevention according to protocol and treatment setting. that can include change, transition, loss, and death. Upon assessment, loss, grief, and bereavement can look like anxiety. When assessing anxiety, it’s necessary to establish the underlying etiology, length of symptom interference, and cultural considerations. A thorough psychiatric history is needed for clarity of diagnosis. Degrees of clinical anxiety are mild, moderate, severe, and panic (Boyd, 2017). Anxiety often accompanies depression.
Caregivers should also receive this intervention so that they can request early intervention when possible. Symptoms of depression include sad mood, persistent feelings of hopeless/ worthless/helplessness, an inability to find pleasure in regular activities (including sex), a low energy level, markedly slow speech (noticed by others), cognitive struggles (difficulty concentrating/remembering/making decisions), problems sleeping (more or less than usual), changes in appetite (increased or decreased), and thoughts of death or suicide (NIA, 2021b). If multiple symptoms are found and last more than two weeks, the healthcare worker (if allowed within scope of practice) can consider a clinical diagnosis of major depressive disorder (MDD) in line with the DSM-5 (APA, 2013). Recent loss, grief, bereavement, and culture must be taken into consideration prior to diagnosing. Untreated depression can lead to physical detriment for the older adult. Coping inappropriately with food can lead to obesity or geriatric anorexia (APA, 2022f). Depression can also alter cognitive clarity. Depressed older adults have a slower reaction time to stimuli, increasing the risk and dangers of driving, cooking, and self-care activities such as medicating (APA, 2022f). The healthcare worker can use a self-reporting scale when assessing. Geriatric-specific depression scales are available, but documentation and scope of practice should be discussed with your place of employment. A strength assessment can help the healthcare worker find the older adult’s historical methods of coping and resilience. It can also highlight unhealthy coping mechanisms that can be discussed. Questions for assessing an older adult’s strength include the following (Boyd, 2017): ● How have you coped with depression or depressive symptoms in the past? ● What do you find relaxing? Suicidal risk The older adult population has a particularly high rate of suicide. White men over the age of 65 have a risk that is five times higher than the general population, and older adult men account for 60% of all completed suicides (Sadock et al., 2015). The safety of the older adult is paramount for all healthcare workers in all settings. The recognition of risk factors coupled with appropriate intervention can save lives. Risk factors can be modifiable or nonmodifiable. The APA clinical practice guideline (2010) notes genetics, family history, and demographics as nonmodifiable risk factors. Knowing the older adult’s risk factors can aid the healthcare worker in risk calculation but does not precisely predict attempts. The National Council on Aging (NCA) (2021) notes loneliness as the top reason for suicidal ideations, followed by suicidal intent caused by feelings of deep grief over a loved one, mourning the loss of autonomy and self-sufficiency, chronic illness and pain that decrease the quality of life, cognitive impairment and dementias, and financial stress that causes an inability to pay bills. The older adult’s increased suicide risk is also consistent with a mental health diagnosis of depression, schizophrenia, posttraumatic stress disorder, substance use disorders, an inclusion of trauma, an experience of discrimination based on sexual identity, access to lethal means, and sleep disturbances (LeFevre & Force, 2014). The suicidal older adult with access to lethal means should trigger the healthcare worker to immediately assess for safety. Statistics show that older adults plan more thoroughly for suicidal completion and are most likely to use lethal means (firearms) than younger populations (NCA, 2021). Reasons stopping or preventing the older adult from following through on suicidal thoughts, intent, and plans are called protective factors. Anxiety Anxiety is commonly found in early or middle adulthood but can be seen after 60 years of age, although initial panic disorders are very rare (Sadock et al., 2015). The symptom profile for older adults experiencing anxiety is different than younger populations. Older adults tend to be less symptomatic, yet they are equally as troubled. The decreased symptoms have been attributed to a decreased autonomic nervous system (Sadock et al., 2015). Older adults have a vast life experience
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