The Most Wonderful Time?

It’s the most wonderful time of the year for many of us.  For others, Christmas is to be endured like plantar warts.  One out of five of the elderly suffer from Depression on a good day.  For a person suffering depression, the holidays along with a demand for forced merriment can be the season of dread.  In addition to the holidays themselves, the days are shorter and the weather is getting colder and even brief outings to see family can be more than a person with depression can tolerate.  According to the CDC,

• 7 million adults aged 65 years and older are affected by depression (Steinman, 2007).
• Chronically ill Medicare beneficiaries with accompanying depression have significantly higher health care costs than those with chronic diseases alone (Unützer, 2009).
• People aged 65 years and older accounted for 16 percent of suicide deaths in 2004 (Centers for Disease Control and Prevention, 2007).

Perhaps, even more alarming is the high rate of suicide in the elderly.  According to the American Society of Suicidology, a suicide occurs in the elderly population about every 18 minutes.  White males have the highest rate in the elderly population with 32 suicides per 100,000 every year.

There is an upside to this cheery little post.  The holidays offer home care workers opportunities to talk about depression and possibly intervene.  It may be easier to assess for depression in some elderly patients as they step back from the festivities, preferring to stay in their rooms in stark contrast to the rest of the world.

Know the Signs of Depression

• Irritability
• Slower movements and speech
• Difficulty concentrating
• Sleeping more or less than usual
• Feelings of worthlessness
• Lack of interest – apathy
• Thoughts of death and suicide

Visiting nurses have an opportunity that most healthcare providers do not have.  The changes in a patient from week to week are more evident to those who know the patient and there may be family members or home health aides who can contribute to your assessment.

During the next week or so, pay special attention to your elderly patients who are at risk for depression which is pretty much all of them.  Mover to the top of the list those that have a history of depression, have recently lost a friend or loved one, are completely alone or have had significant medication changes.

If a patient tells you no family will be visiting for Christmas, there’s your chance to ask if that makes them depressed.  Listen to his answer – what he says as well as how he says it.

Is the house any messier than normal?  Is it because they were making cookies with the grandchildren or because they couldn’t be bothered to clean up?

Weigh your patients.  Depressed people may not eat well or they may eat too much.

If the patient complains of more pain than usual, tell your patient that not sleeping, anxiety and depression make pain worse.  Invite comments.

If you have a patient who is showing signs of depression, perhaps the best gift you can give them is a little extra time.  Plan your week so that you can sit and visit for a few minutes longer.   Slow down and really listen to them.

If your patient is an elderly gentleman, consider that their high suicide rate may be related to their reluctance to admit that they are ‘weak’ or ‘crazy’.  They may blow off questions about depression saying things, ‘Life isn’t supposed to be about fun,’ or ‘Nobody is happy all the time’.  That’s your opportunity to agree with the patient and to point out that your concern is more about their inability to enjoy anything or get a good night’s sleep.  You can explain that some medications can cause them to feel this way and there are medications the doc can order to offset the side effects.

Remember that in the elderly population, their first experience with antidepressants was in the pre-SSRI days.  Prior to SSRI’s, medications for depression caused dreadful side effects and were reserved for only the very ill.  Teach about the newer medications, the comparable lack of side effects and the prevalence of their use.  Explain that millions of people take these medications and they work.  They are a completely different class of medication and if he wanted to try them, he would probably start to feel better very soon – unlike the older meds that took weeks to relieve depression.  Maybe you can get him to try an SSRI for a week or so.  It is especially important to some elderly patients to know that they won’t get ‘hooked’ or high.

Non-pharmaceutical approaches are simple but may take some time.  Sunlight can brighten moods and may help regulate sleep cycles by preventing afternoon lethargy and napping.  Exercise is also useful depending on the tolerance of the patient.

Nobody gets better from anything if they do not eat well.  Remind your patient to eat and drink sufficiently.

Encourage the patient to be social; tell him you are going to check with him on your next visit to see if he has called two friends.  If he will let you, call a family member to take him out for dinner or lunch.

If your patient truly is all alone, make sure he has something special to eat on Christmas day.  If you can’t arrange to visit him, call him on the phone.  If your patient wants to practice his religion, call the church or temple or mosque and see if any of the congregation would provide transportation.

It’s a lot of trouble and people who are depressed have a way of sucking the life out of the room stealing your joy.  Most people who are depressed are not exactly grateful. Still, it is your job as a nurse to recognize the signs and symptoms of depression and report them.  It is your job as a human to give your patient opportunities to feel connected to the rest of the community and a reason to work hard at controlling his depression.