Depression and older adults

AORN Journal,  Feb, 2007  by Nancy R. Cyr

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Perioperative nurses often are faced with complex, clinical presentations when assessing patients who may have comorbid mental disorders. For example, depression in a patient is one condition that frequently goes undetected and untreated. (1) Factors that contribute to this problem include a patient's reluctance to discuss emotional issues, societal stigmatization of depression, a clinician being too hurried to spend time with the patient, or a health care worker's lack of knowledge or skill in recognizing depression.

Nearly one-third of all older adults may have symptoms of depression and five million are known to be clinically depressed. (2) Perioperative nurses may have a unique opportunity to address the issue of depression with their older patients.

DEPRESSION AND HEALTH

The importance of assessing patients for depressive symptoms cannot be overemphasized. To illustrate, in the 10 years after a cerebral vascular accident, patients diagnosed with depression were 3.5 times more likely to die than patients who were not depressed. (3) In patients who have undergone coronary artery bypass grafting, there is evidence to suggest an association between depressive symptoms and infections, impaired wound healing, and adverse outcomes. (4) In addition, depression has been associated with higher mortality and morbidity rates after acute myocardial infarction (MI). (4)

Growing evidence suggests that the immune system can become compromised by chronic stress, such as is found in patients with depression. (5) This can result in disease or changes in the course of pre-existing diseases. Depression has been identified as a risk factor for cardiovascular disease and contributes to poorer outcomes after an MI. (5) Depression also may contribute to the progression of breast cancer and has been shown to delay wound healing time. (5)

A meta-analysis of 10 recent studies that examined the contribution of depression to the onset of cardiovascular disease revealed that depression is an independent risk factor for the development of cardiovascular disease. This reinforces the need for nurses to assess psychosocial issues when taking patient histories, particularly in patients with coronary heart disease. (6) These data, coupled with the aging population of America, illustrate the importance of accurate and thorough nursing assessments.

DEPRESSION AND THE OLDER ADULT

In the United States today, 35 million people are 65 years of age or older, comprising 13% of the population. (7) Heisel (8) reports that by the year 2030, older adults will comprise 20% of the population (ie, 70 million people based on the aging Baby Boomer segment of the population). The diagnosis of depression in older adults frequently is missed, and these individuals subsequently do not receive treatment for their depression.

Raj (3) notes that only one-quarter of older adults will self-report having symptoms of depression. They may resist reporting their symptoms because they view mental illness as a stigma. Older adults are of a generation and perhaps a culture in which attitudes toward psychiatric illness are based on media sensationalism, cultural beliefs or values, or an extremely poor prognosis. (7)

Another factor influencing underdiagnosis of depression is that many in society and many health care providers view depression as a normal part of growing old. (3) This perception frequently leads to a lack of recognition by family members and clinicians of the symptoms associated with depression. Health care providers, including nurses, may view depression as a normal part of aging or as a logical response to the effects of reduced functioning or chronic disease. Individuals who are not depressed, however, are much better able to deal with the losses associated with aging and to accept the limitations of their physical conditions. (1)

During a nurse's assessment of an older adult patient, he or she should consider that depression can

* precede medical problems (eg, Alzheimer's disease, Parkinson's disease);

* occur at the same time as other medical conditions (eg, MI); and

* appear after other conditions (eg, cerebral vascular accidents). (3)

Additionally, a diagnosis of cancer often results in patient depression, and 80% of all cancers occur in people 60 years of age or older. (3) Interpreting the patient's symptoms of depression as "normal" rather than a separate condition that should be treated is a mistake that too many health professionals make because of the serious nature of a patient's treatment for cancer.

IDENTIFYING DEPRESSION

During the preoperative assessment of a patient, the following conditions should alert the nurse to the possible presence of depression:

* central nervous system disorders (eg, Alzheimer's dementia, Parkinson's disease, multiple sclerosis, Huntington's disease, cerebral vascular accident);

* diabetes;

* hypothyroidism;

* macular degeneration;

* MI; and

* use of specific medications (eg, beta blockers, many medications used to treat cancer). (3)