Elderly in nursing homes suffer from depression

Among older adults in nursing homes, depression is very common and symptoms are often being overlooked, accepted as a normal part of becoming older, leaving many depressions to go untreated.

By Peter Skovbjerg Jensen and Nadja Dam Jensen

“It’s hard to say how it feels. It can’t really be explained. Anyone who hasn’t tries it can’t understand how it feels,” says Elly about her depression. She spends most of her time in an apartment full of warm carpets and wooden furniture, where the shelves and walls are filled with pictures that shows memories from a long life. Her apartment is part of a nursing home in Randers, a city in Denmark. A place where she can interact with other older adults when she feels like it and get help from caregivers when needed.

Around the time when she moved into the nursing home, was when she got her first depression, says Elly. It was not really until her doctor suggested it that she realised she actually was depressed. Until then she had accepted the sadness as a normal part of life.

According to the World Health Organization, WHO,  7 percent of older adults, age 65 and up, will at some point get a depression. However, research from several other countries suggest a much higher percentage, especially among older adults living in nursing homes or other care facilities. Research from several countries around the world shows a big amount of nursing homes residents suffer from depression. Some places they even suggest that around half of the residents have a depression.

Often overlooked and underdiagnosed

Depression in older adults often goes without being recognised. Accepting symptoms of depression as a normal part of getting older is making elderly and their relatives believe that their sadness can not be treated, leading depression to be underdiagnosed. WHO recognises this as a big problem which they are hoping to be able to solve.

According to Dr. Shekhar Saxena, Director of the Department of Mental Health and Substance Abuse at WHO, the organization is working on guiding countries to recognize depression as an illness that should be treated. He says many believe that it is just common sadness.

“Many older people and their families are not aware that it is an illness. In some cases it might be true, but in many cases it is a depression that must be treated. So health care providers must be fully equipped to identify such issues and treat them,” says Dr. Saxena.

If there is no permanent person in the elderly’s life to watch for changes in mood and personality it is even harder to discover a depression in that person. According to Lissie la Cour, head of development at Kløvervangen nursing home in Aarhus, Denmark, you need to be close to the resident to be able to see that something is wrong.

“We work closely with a couple of local doctors. They know the patients well and that makes it easier to unravel the depression. If we see changes in a resident’s behaviour that could point towards depression, we talk to their family and hear if they have noticed changes, and then we can take it to the doctors and give the residents the right treatment,” she says.

Dr. Shekhar Saxena from WHO explains what the organisation is doing to solve the problem.


Depression or just sadness of loss

Elly does not have much family left. But she believes that is common when you are as old as she is. All of her sibling are gone, so is her husband and the family that is left lives far away and only comes for visits every now and then.

Losing people that are close to you is a normal part of getting older. According to psychologist, Kim Oskar Carlson, who specialises in working with older adults, it can also be part of what leads an older adult to depression.

“Elderly experience a big amount of losses. Not only people they have cared about, but also in how their body functions and letting go of their career. But especially saying goodbye to family and friends is making them vulnerable to sadness,” say Kim Oskar Carlsen.

Nothing is helping

Elly is still not sure about what triggered her depression. She says it might just come from thinking too much. Since she was diagnosed with depression she has been served a daily dose of antidepressants. She has also been to therapy a couple of times. However, she doesn’t feel any difference. Nothing helps, she says.

“I don’t think it has really helped. Sometimes I even feel like therapy is making it worse, ripping up in everything. I don’t think that helps,” Elly says.

Isolation is clear warning sign

WHO stresses that it is important that depression in older adults is identified early so it can be treated quickly. So it is critical when people overlook the signs of depression.

“People can get better and have a much better life,” says Dr. Saxena from WHO.

There are certain behavioural changes that are clear warning signs of depression, according to Lissie la Cour from Kløvervangen nursing home. Warning signs that are easily noticed when you are close to someone.

“When they start to withdraw. When they no longer want to have dinner with the others. If they do not want to get up in the morning. Older adults often have so many regular routines in their everyday life that it is clear when they start to change,” she says. But there is another thing that for Lissie la Cour is very distinct about depressed elderly.

“There is a slightly tortured look in their expression. It is very obvious to me.”

Not something you talk about

The lights are dimmed in Elly’s small apartment as she fiddles with her fingers, somehow finding it hard to explain it all. Elly says she has accepted the depression as a somewhat permanent part of her life. She does not believe it will ever change or go away.

Elly has sometimes been able to spend an entire day in her apartment, just looking into the air. But she tries to go out and interact with other people. Every Tuesday she tries to take part of the weekly quiz night at the nursing home. Though she does not understand why more people aren’t participating. Everyday she also talks and drinks coffee with the others in the common room, but she never brings up her depression.

“We haven’t talked about it. I don’t know why. I guess it’s not something you talk about. You just keep it to yourself,” says Elly.

Social activity fights loneliness

At nursing home Kløvervangen head of development, Lissie la Cour has focused a lot on finding social activities for the residents to prevent them feeling lonely or unmotivated. This can be cardgames, people meeting over common interests or bus trips out of the house.

Head of development at nursing home Kløvervangen explains how they try to create a better life for the elderly.

“It is important that someone can talk to them. Just for them to be heard. That someone takes an interest in them can make a big difference,” says psychologist Kim Oskar Carlsen.

Recently nursing home Kløvervangen arranged a bus trip for five of the residents. They all grew up on farms and spend an entire day visiting their old homes where they had lots of stories to tell.

“It probably won’t cure them, but can maybe prevent a depression by making them feel less alone. It can make their lives more bearable despite their illnesses. Then they’re not just sitting around, waiting for their medication. There’s more to life,” says Lissie la Cour.

Antidepressants used too much in treatment of elderly

Treatment of depression in older adults, especially with dementia, should be done much more carefully according to a professor in psychology.

By Peter Skovbjerg Jensen and Nadja Dam Jensen

Many nursing homes mainly or exclusively use anti depressive medication to fight depression among residents. Medication can cause severe side effects among elderly such as nausea, weight gain, insomnia, drowsiness and anxiety.

Lissie la Cour, head of development at Kløvervangen nursing home, thinks that antidepressants are a good solution for treating depression in nursing home residents. She has experienced many people that have gotten out of their depression completely by using medication. However, she believes that many are on the medication for way too long.

“I think they are often overmedicated. It needs to be supervised more frequently, so as soon as the medication is no longer necessary, they will be taken off of it,” says Lissie la Cour.

Kim Oskar Carlsen is a psychologist specialising in gerontopsychology, psychology with focus on older adults. He agrees that medication in general is used too heavily to treat depression. It is especially problematic among elderly, as they are more easily affected by the side effects than younger adults. Also because they often take several other types of medication at the same time, which can interfere with one another.

Instead he believes that there should be a bigger focus on therapy and that residents should not be given medication to treat the depression as the first measure.

“By talking about it in therapy you can get down to the core of the problem. Medication is just treating the symptoms, but you are not solving whatever started it. As a general rule I would say that talking to them is really good,” says Kim Oskar Carlsen.

Antidepressants effects doubtful in dementia patients

“The reason we don’t offer our resident therapy is that most of the ones who are on antidepressants have some form of dementia symptoms or other mental illnesses. Most people in nursing homes today are not just people, who have gotten 50 years older physically, but mostly people with other mental impairments as well. In these cases you won’t benefit much from therapy” says Lissie La Cour.

Antidepressant medication like sertraline and mirtazapine are commonly used to treat depression in people with dementia. However, recent research shows a lack of efficacy in use of these drugs in dementia patients.

Kim Oskar Carlsen believes that antidepressant should be used less when it comes to treatment of depression in elderly.

“The less the better. It should be used where it is relevant, but it should be reconsidered as it is not working as intended among elderly with dementia,” says Kim Oskar Carlsen.

A large research project was done in 2011 to investigate the efficacy and safety of treating depressed dementia patients with antidepressants. It showed no effect in the dementia patients with depression, who were treated with antidepressants compared to a similar group treated with a placebo.

“The problems is that such drugs are often developed and tested on healthy young men. Of course they will not have the same effect on weaker and older people,” says Kim Oskar Carlsen.

Even though research is showing doubtful results from using antidepressants on dementia patients, Lissie la Cour believes that it has made a big change for many patients at nursing home Kløvervangen.

“Many patients are slowly tapered down in their doses until they are off the medication completely – and then that’s it.”