Biopsychosocial Factors And Nursing Management Of Depression In Older Adults

Biopsychosocial Factors of Depression in Older Adults

Depression is a common phenomenon occurring the older adults especially in the aged residential facility settings. This is often recognized a slate-life depression. Depression impacts the older adults differently from the younger adults. This depression leads to increase in the risk factors of these older adults. It has been estimated that about 13.5% of older adults who are in need of home healthcare experience major signs of depression (Edwards, McDonnell & Merl, 2013). A wide variety of factors are associated which are seen as the signs of depression such as medical illness, disability along with the side effects from medication. In addition to the progressive sensory loss, sleep disturbances, a history of falls, social isolation, and personal losses, contribute to the increase in the risk of depression in older adults (Brownie & Nancarrow, 2013). Often these patients fail to identify the symptoms of depression. The nurses play a predominate role in most of the care settings. The nurses are trained to identify as well as care for depression in these older adults. This paper aims to identify the bio psychological factors of depression presented in the given case study. In addition, the paper discusses the nursing care management and the interventions that are required to provide effective care to these aged individuals suffering from depression. The paper also illustrates the ethical implications associated with the treatment of depression in such individuals.

Several studies have shown that depression is quite common in the aged especially in then one belonging to the residential aged care settings (Van Malderen, Mets & Gorus, 2013). This is often seen to be late-life depression, where more than 14 to 26 % of the individuals suffer from it (Schure, Odden & Goins, 2013)). In this case study, a similar setting is found where the patient Amy, is a 75 years old woman and currently lives in a retirement village, after the death of her husband. As evident from some of the papers that depression often begins in these older adults after being diagnosed from at two of the serious physical illnesses. Similarly Amy was first diagnosed with depression 10 years ago, after she was came to know that she was suffering from diabetes and hypertension. This is due to the fact that composites measures of the physical illnesses are often associated with the increase of the risk of the symptomatology of depression (Steptoe, Deaton & Stone, 2015). A study by Jeste et al., (2013), suggested that depression was strongly associated with the declines of disability and function in the late life of an older adult, and this disability often is directly proportional to depression. The case study informs that after the loss of her husband, the patient has suffered from heightened amount of depression. She lacked sleep and urge to eat anything along with feeling socially isolated as she felt she had no one to talk to. This bio psychological factor is quite prominent in such cases of depression as after the physical death of someone who had a very close relationship with the individual, it results in elevated levels of depression score in such aged individuals. After Amy was transferred to the retirement village, she managed her daily tasks on her own which included managing her medication however sometimes she forgot to take them. This is also a bio psychological factor associated with ageing, which needs to be understood. The older people receive a sense of competence when they are able to master their day-to-day environment in terms of self-acceptance, purpose in life, autonomy or self-reliance (Beerens et al., 2013). However in this case Amy lacked such competence as she was unable to manage her medications on her own. This sense of failure was one of the bio psychological factors that added to her depressive state. Many theorists are of the view that depression is associated with a lower level of mastery and that older adults in residential facilities settings often possess lowered levels of autonomy and self-acceptance along with no purpose in life or perceived personal growth (Tiong et al., 2013).

Nursing Management and Interventions

Social relationships too plays a prominent part in such cases. Amy has two daughters who try to visit her every month. However Amy feels that she is a burden for them and believes that of she died, it would be easier for her daughters. This is another bio psychological factor that is adds to depression due to the lack of a social support group. Marital status also plays a big role as a factor, where researchers suggested that depression is often high in the older adults if they are widowed or are separated and divorced (Butcher, Mineka & Hooley, 2013). Apart from this the feeling of hopelessness adds up to the complexity of the situation in such patients. Amy too faced these problems. She expressed feelings of worthlessness, not wanting to get out of bed. Due to these problems she lacked sleep and resulted in an appetite loss, ending up losing six kilograms of weight. Thus the key bio psychological factors identified from the case study were self-rated depressive symptomatology along with established chronic illness (Ryff, 2014). Additionally factors like self-acceptance, autonomy, environmental mastery, perceptions of social support, purpose in life, and personal growth played a major role. Lastly another factor cannot be overlooked which was the hereditary factor. Amy’s mother too had suffered from depression, which eventually led to her death.

As already mentioned, depression is common in patients in the older homes, which often increases their risk of adverse outcomes. For such cases the nurses play a pivotal role in order to manage depression effectively in the older patients. With the use of the Collaborative Care models, the nurses are able to play the role of the Depression Care Manager. This enables them to work with the primary care clinicians along with the psychiatric specialists so that the patients receive both guideline-based treatment and ongoing management (Aziz & Steffens, 2013). The patient’s primary care provider (PCP) tends to authorize the Care Plan and is made responsible for treatment decisions that are made. The home health nurse are involved in supporting the patient by providing them with in-home patient care. They also consult with the PCP and the other specialists as is clinically indicated, both during the ongoing care and during the discharge (Baranyi et al., 2013).

For proper care management, both pharmacological as well as psychotherapeutic treatment is provided to the patients. In case of pharmacological treatment, the patients are generally administered with anti- depressant drugs. These therapies should be continued at least for six months in the patients. In case of psychotherapeutic treatment, it is seen that the structured psychotherapy, is quite effective for older adults with depression. It might be alone or combined with the antidepressant treatment. Cognitive behavioral therapies that are manualized have been shown to be quite effective in depressed older adults. This even includes the elders with comorbid physical illness and disability along with cognitive impairment, or comorbid anxiety. The intervention’s like the Cognitive-Behavioral Therapy (CBT) helps in challenging the pessimistic or self-critical thoughts towards the emphasizing rewarding activities along with the decreasing behavior that adds to depression (Lopresti, Hood & Drummond, 2013). The interventions have also explored the alternative modes of delivery of CBT that including group CBT and telephone or computer self-help formats. Apart of CBT, interventions like the Interpersonal Therapy (IPT) combines elements of psychodynamic-oriented and cognitive therapies in order to address difficulties which are interpersonal, in addition to the role transitions, and the unresolved grief (Robinson et al., 2013). The majority of studies found in literature have shown that older adults undergo combined IPT with medication or pill-placebo. Combination of IPT with antidepressant medication is seen to be quite effective in reducing symptoms in older adults. It may also prevent relapse and is effective as a maintenance treatment for more severely depressed older adults. Other such nursing care interventions include the Problem-solving therapy for mild executive dysfunction (PST-ED). This PST-ED is conducted as a 12-week outpatient treatment program which involves 7 stages of problem solving and helps the individuals suffering to identify their individual problems and helps them to identify the solution that is best suited to them (Ryff, 2014). This is done by learning the stages and then applying them for their individual problems. This program has been found to significant in reduction of depression in such population of individuals. Another such intervention is the Interpersonal psychotherapy for mild cognitive impairment (IPT-CI). PT-CI program has been modified especially for the elderly patients suffering from depression along with mild cognitive impairment. Modifications that are made includes the association of concerned caregivers into the process of treatment in a systematic manner along with conduction of joint patient-caregiver sessions (Tiong et al., & Luo, N. (2013). This helps to promote better understanding of the patients along with better communication and show of respect. Finally, the IPT-IC therapist helps the patient along with their caregiver to adapt to their role change due to the patient’s cognitive deficiencies and their impaired functioning.

Ethical Implications

Ethical decision making is an intricate part of treatment especially in cases if astute and compassionate clinical care. Clinicians who are wise enough about their practise, take steps to identify and reflect on the ethical factors of their practise. They make themselves get involved in care habits without much fuss and often intuitively and try to maintain the therapeutic boundaries. They often seek consultations from other experts while they care for a patient who are difficult to treat and when such patients have high complex conditions (Jeste et al., 2013). In order to safeguard against such high risk situations an expert opinion is often required. These habits and behaviours of the clinical practitioners help them to ensure a rigour ethical aspect in their practise. The field of psychiatry especially touches the big moral questions. The conditions faced by the clinicians while their practise of psychiatry often tends to threaten the qualities are involved in defining the human beings. The conditions are often associated with sufferings, stigma or disability. The individual suffering from such conditions tend to show tremendous adaptation along with strength.

When considering depression, it can be put forward that depression is the second leading cause of disability which in turn affects an individual’s quality of life along with increasing the socio-economic burden of the person. The clinical care for depression is associated with urgency of crisis where the patients experience feelings of hopelessness and sadness. Therefore in this case many ethical questions are raised that are related to the issues of patient safety, in addition to appropriate treatment of the disease and the restoration of self-agency of the individual (Giallo et al., 2013).

The recent developments in the therapies that are innovative, the methods of care raise many ethical questions. Such as in the case of split care model if pharmacology and psychotherapy used for the treatment of depression. The therapeutic boundaries of such care models are being challenged. Treatment procedures like the brain stimulation raises ethical questions, discussions on which are going on for a long time now (Steptoe, Deaton & Stone, 2015). Some researcher also argue that it is imperative in an ethical way to provide psychotherapy to depressed patients as the insights that are received from it promotes autonomy.

Conclusion

From the above discussion it can be concluded that then low levels of environmental mastery, purpose in life and autonomy proved prominent factors in development of late life depression in older adults especially in the aged care facilities in addition to the other factors like such as poor physical health and disability, chronic illness and perceptions of low levels of social support. The marital status of the individual and heretical factors also tend to play a role in adding to the factors of depression. Nursing care interventions like the Cognitive behavioural therapy along with patient’s primary care provider (PCP), Interpersonal Therapy (IPT) and Problem-solving therapy for mild executive dysfunction (PST-ED) are used to effectively treat these individuals.

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