The triggers for depression, however, can be complex, because an initial loss for seniors can manifest additional, unrecognized losses. “It can be like layers in an onion,” says Cheryl Thrasher, executive director at Lakeview Estates, a specialty care assisted-living facility. “Many times, a senior may have lost a loved one, and, because of that loss, she has also lost her driver, her caretaker, or even her home.”
Craig Greer, bereavement coordinator and chaplain at Comfort Care Hospice, says these are often not clinical depressions, but rather situational depressions. “Even grief itself is a situational depression,” he says. In those cases, counseling and support may enhance or replace prescriptions.
“The solution may be in the relationships we can stimulate in their life that they’ve been missing,” Greer says. For instance, they may have come to terms with the loss of their spouse, but that caused them to lose their transportation to church. “We may just need to get them in contact with their church or with a group that can help replace that socialization.”
“The biggest thing we can do for their depression is to not dismiss the loss,” Thrasher says. “Recognize that whatever the loss is, it’s real to them. If their loss is that they can’t figure out how to find the bathroom anymore, then that’s real to them, and those fears can cause depression.”
To better pinpoint depression, physicians need to look beyond the external symptoms for answers. “Physicians rarely ask seniors about their emotions surrounding life changes, including when a patient learns he has a disease or disability,” Greer says. “A friend who had a stroke told me, ‘The doctors all told me what I can and can’t do, but no one has asked me how I feel about all these things I can no longer do.’
“But that’s the heart of depression,” Greer says. “How do you feel now that this disease or diagnosis is part of your life? That’s a good assessment question for physicians to ask.”
Depression is almost a certainty when seniors transition into assisted living according to Paulina Gilliland, RN, ALA, director of assisted living and specialty care at Kirkwood by the River. “We do a geriatric depression screen for everyone who moves in, and nearly 80 percent have at least mild depression,” she says.
“All residents sense some loss of security with that move into assisted living,” Thrasher says. “They may feel they don’t know where their money is anymore or they feel that everybody has left them.”
Because the likelihood is so high, physicians doing admission physicals may want to focus on diagnosing depression. “Talk about how they feel about the move and what that means to their way of life. Ask if they feel depressed, and if you can give them something to help ease them over the hump,” Gilliland says. “Or write an order to be seen by the psychiatrist, which many facilities have on staff.”
The diagnosis of dementia also tends to trigger depression in seniors. “They may be thinking that just three days ago they could find their way to the store and now they don’t know how to get there. It takes a lot to admit that,” Cowfer says. “Whether they can admit that cognitive loss or not, this new disability can trigger depression.”
Dementia can also intensify and prolong grief in seniors. “They relive that loss over and over because, in my experience, dementia pulls them back into the past again and again,” Thrasher says.
“Loss doesn’t mean just death. It can be loss of the ability to drive, ability to walk, some health condition or treatment,” Greer says. For instance, a senior might have a valve replaced successfully, yet they’re depressed. “It’s because they may not be aware of the depression related to a realization of mortality after that experience,” he says.
“Many seniors may have gone into work one day and been told, ‘you can’t do this anymore’,” Thrasher says. “Whether they noticed their disability themselves and retired or were made to quit, that’s a huge depression trigger.”
Experts differ when it comes to succumbing to and handling depression, but all agree that it escalates during the holiday months. “For any seniors coming into the office during this period of time, physicians should maybe tack on a discussion about depression and give everyone information about support groups,” Cowfer says.