Mr. Z is a 75-year-old, widowed man who suffers from macular degeneration and diabetes, which resulted in above-the-knee amputation. He lives on the second floor of a walk-up building and has difficulty leaving his apartment because of his poor eyesight, and because his prosthesis no longer fits his leg since Mr. Z's weight loss of 15 pounds in the past year. His only income is social security, with which he barely makes ends meet. Since his eyesight began to fail and his disability increased, Mr. Z has difficulty sleeping, has little energy, has trouble gaining pleasure from activities that he once enjoyed, has trouble concentrating, and feels that life is not worth living. In addition, his eldest son needed temporarily a place to stay and asked persistently to move in with Mr. Z, a situation, which in the past has led to friction. The San Francisco based Home-Delivered Meals Program referred Mr. Z to the University of California-San Francisco (UCSF) Over-60 Clinic program for assessment of depression and treatment.
Depression in older adults can vary considerably across persons in terms of presentation and etiology. Between 1 and 4% of older adults experience major depression (Waraich, Goldner, Somers, & Hsu, 2004), with 40% of depression in older adults representing a recurrent episode, with the first episode having occurred in young adulthood, and 30% being the very first episode of depression ever (late-onset depression; Blazer, 2003). For many years, researchers felt that depression was an understandable consequence of aging, because older adults are exposed to so many risk factors associated with the onset of depression. It is not uncommon for older adults to complain about sadness related to bereavement, social isolation, caregiver strain, and financial problems—all salient psychosocial risk factors for depression
(Arean & Reynolds, 2005). Furthermore, older adults are exposed to many medical conditions that can influence depression directly by their effect on brain chemistry, and indirectly through the onset of disability (Bruce, 2002). Finally, studies have shown that depression in late life may also be influenced by certain cognitive risk factors, such as vascular disease and age-related changes in executive functions (Rapp et al., 2005). Despite their increased exposure to depression risk factors, the fact remains that depression is a relatively uncommon condition in older adults (Charney et al., 2003), and according to the Successful Aging Studies (Rowe & Khan, 1997), not all older people who face these stressors become depressed.
The degree to which these negative life events become salient risk factors for late-life depression depends on how undesirable, disruptive, and uncontrollable these events are. What puts people at risk for depression is not age or exposure to the risk factors discussed earlier, but the predisposing vulnerabilities associated with depression. According to this line of research, the chance of becoming depressed when confronted with the negative life events described earlier is a function of resilience, which has been found to moderate the negative effects of stress in older adults (Wagnild & Young, 1993). Similar to cognitive theory of depression, late-life resilience is seen as a function of having a balanced view of life, a sense of purpose in life, the ability to function even in the face of failures, acceptance of one's life, and self-efficacy (Wagnild, 2003). Considerable research indicates that in addition to resilience, behavioral coping moderates the effect of negative life events in older adults. Older adults who take a more active stance in solving everyday problems tend to be less vulnerable to depression than those who use passive coping strategies, such as avoidance, leaving problem solving to others, and rumination (Denney, 1995; Heidrich & Denney, 1994). Denney and Pearce (1989) found that use of problem-solving skills to deal with life strain is related to better psychological adjustment in late life, and Koenig, George, Titus, and Meador (2004) found that spirituality and active involvement in spiritual endeavors are also related to better psychological well-being in later life.
Based on these findings, late-life depression is a multifaceted problem. Therapists who work with older adults must think multidimensionally about their older patients' problems. Although older adults are faced with a number of potentially adverse events that could each contribute to depression, the fact remains that few older adults suffer from major depression even in the face of these negative events. The research on coping skills and resilience suggests that late-life depression is not solely a function of exposure to negative events but a combination of these life events, cognitive vulnerabili-
ties, and skills deficits. As depicted in Figure 18.1, CT addresses late-life depression by targeting the older person's psychological resilience and coping skills, so that negative life events do not adversely affect his/her mood. How CT works in older adults is discussed in more detail in the section on CT adaptations for late-life depression.
Mr. Z was seen by one of the 0ver-60 clinicians for an assessment of depression. In addition to a comprehensive health and mental health history, the clinician also spoke with Mr. Z's doctor to obtain results from a recent physical exam. The clinician administered the 9-item Patient Health Questionnaire (PHQ-9) and the Folstein Mini-Mental Status Exam (MMSE). Based on his symptom count and his score on the PHQ-9, Mr. Z met criteria for major depression. His MMSE was a 26. Mr. Z had lived in the United States for over 30 years, but English was not his first language. Mr. Z reported that he had had symptoms of depression for a year, which coincided with his son's request to move in with him and a recent move to publicly funded senior housing. These symptoms also coincided with an increase in his hemoglobin A1c (a measure of blood glucose). The clinician was left with several issues to consider in managing Mr. Z's depression. First, his hemoglobin A1c could have accounted for several of his symptoms, particularly lack of energy and lack of interest in activities. However, he also had two stressful life events that seemed to contribute to his depression. Although his MMSE was within normal limits, it was on the low side, which could indicate early-stage dementia. Was Mr. Z's depression a result of uncontrolled diabetes, early dementia, or psychosocial stress?
Diagnosing depression in older people can be tricky given the cluster of symptoms that defines the disorder. For instance, research has shown that symptoms of fatigue, trouble concentrating, and lack of enjoyment can be the result of illness or early stages of dementia (Karel, Ogland-Hand, & Gatz, 2002). Some researchers on the assessment of late-life depression has found that somatic symptoms overidentify depression in older community-dwelling adults (Yesavage et al., 1982-1983). Others have found that affective symptoms, particularly feeling sad and depressed, are underreported in older people, particularly older medical patients; thus, late-life depression goes unrecognized (Gallo & Rabins, 1999). This mixed body of research suggests that assessment in older adults must take into consideration physical and cognitive explanations for depressive symptoms. As illustrated with Mr. Z, determining the causes of depressive symptoms in older adults is not a straightforward task. Although Mr. Z presented with several symptoms of depression, many of them could be explained by an exacerbation of his diabetes and potential cognitive impairment.
When assessing an older person's depression, the therapist should keep in mind the following: the biological, psychological, and social risk factors that are contributing to the depression; the degree to which depression is influenced by medical conditions, and in turn the degree to which the management of illness is affected by depression; how cognitively intact the patient is (whether he/she can participate in CT); the patient's ability to take part in activities of daily living (managing self-care, finances, cooking); the extent of the patient's social support; and finally, the patient's past history with regard to previous strengths and weaknesses in handling adversity (Scogin, 2000).
This information is easily obtained by making sure the patient comes to his/her first session with some basic information. At the 0ver-60 clinic at UCSF, we typically ask patients to bring with them a recent medical report from their primary care physician to rule-out other causes of depression
(malnutrition, anemia, thyroid disease, diabetes, hepatitis, cancer). If patients have chronic medical conditions, we ask to have recent lab reports sent to us. In addition, we also ask patients to bring all their medications with them, so that we can investigate issues of polypharmacy (which can contribute to some symptoms of depression; e.g., trouble concentrating, fatigue, and sleeplessness) and to make sure patients are not on medications that can exacerbate depression, such as prednisone, beta-blockers, medications for Parkinson's disease, and interferon (Rodin, Crave, & Littlefield, 1991). When we are concerned that an illness or medication may be contributing to depression, we contact the patient's physician to discuss the possibility of either treating the condition or changing medications.
Brief cognitive screening is typically helpful in determining if an older patient is mentally intact enough to engage in a learning-based therapy such as CT, and if depression is a precursor to an illness that causes dementia. Because some dementias are reversible if caught early, and depression has been identified as a prodrome for dementias (Lyketsos, Rosenblatt, & Rabins, 2004), this assessment is particularly important. The most widely used cognitive screening test, the Folstein MMSE (Folstein, Folstein, & McHugh, 1975), is popular because it covers several areas of cognitive function, such as fund of information, immediate and delayed recall, verbal functioning, visual-spatial functions, and, to some degree, executive functions; it is also easy to administer, taking 5-10 minutes in a cognitively intact patient. It has its limitations, however, in that it is influenced by education (Jones & Gallo, 2001) and must be administered exactly as intended; variations in administration can change the score by as much as 5 points. Most researchers consider an MMSE score of 24 or better to be within the range of normal cognitive functioning for depressed older patients (Scogin, 2000). It is important to note here that mild cognitive impairment is common in late-life depression; 60% of older adults with depression have some form of cognitive impairment; the most common impairment is executive dysfunction (Alexopoulos et al., 2005).
Although physical and cognitive exams give the clinician information about how the patient's body is functioning, it is still important to determine whether the older patient feels that he/she is functioning physically and cognitively as well as before. The Medical Outcomes Study 36-item Short-Form Health Survey (SF-36; Gandek, Sinclair, Kosinski, & Ware, 2004) provides useful information with regard to the degree to which the older patient can complete his/her activities of daily living. This scale provides information about the older patient's ability to complete basic activities, and the degree to which he/she feels that his/her disability is attributed to depression or physical illness.
The cognitive therapist should also ask about older patients' social networks. Although formal assessments of social support do exist, these instruments can be too long and cumbersome for clinical settings. The clinician can assess social support informally by asking patients whether they have friends and family who they feel have been helpful and supportive of them in the past. Social support is an important moderator for treatment outcome in older adults, in that persons with low social support do not respond as well to treatment as those who have good social support (Karel et al., 2002); older adults with good social networks can call upon others in the event that they need help in participating in therapy. As an example, Mr. Z reported that he could not get the news regularly, which contributed to feelings of isolation. In discussing several alternatives for getting up-to-date news, the therapist discovered that Mr. Z's nephew passed his apartment every day on the way to work, and he was able to stop by in the morning and drop off the morning paper. This small gesture on the part of a supportive family member helped Mr. Z to feel more connected with his community and improved his mood considerably.
Therapists should not overlook the possibility of comorbid substance abuse in older patients. Heavy use of alcohol, by far the most common substance of abuse in older populations, is associated with increased morbidity, impaired social functioning, isolation, and poor mental health, including increased suicidality (Finlayson, Hurt, Davis, & Morse, 1998). In assessing alcohol or drug abuse, it is important that the therapist ask directly about the patient's alcohol intake and be very clear about what he/she means by one drink (3 ounces of wine, 12 ounce of beer, or 1 ounce of hard liquor). Many older adults who drink are unaware of the amount that constitutes one alcoholic drink. When assessing for drug abuse, it is also important to ask about prescription drugs, the second most common form of substance abuse among older adults (Blow, Cook, Booth, Falcon, & Friedman, 1992).
In asking about an older patient's experience with mental health care, it is important to note the type of treatment received, when he/she was in treatment, and his/her expectations for this treatment. More often than not, older patients have not had experience with CT and it is important to socialize them about cognitive theory and the process of care. Some people have been exposed only to mental health treatment as it was 30 or 40 years ago, largely inpatient based, and relying on long-term, intensive therapies. Thus, education about the current mental health system is necessary and should be conducted early on in the therapy. Laidlaw, Thompson, Dick-Siskin, and Gallagher-Thompson (2003) suggest that if this education does not occur early on, patients may prematurely terminate therapy.
Finally, older patients should be allowed the opportunity to tell their story. At the UCSF Over-60 Clinic program, we have found that allowing patients the time to talk about their past, previous employment and education history, and family issues contributes to the development of a good therapeutic alliance. Older people have little opportunity to talk about their pasts, despite the fact that this type of narrative is a common developmental process in late life. At the UCSF Over-60 Clinic, we typically guide this narrative by asking the patient to tell us about specific events in their lives. For example, Mr. Z was first asked to talk about his upbringing as a child, the people he looked up to most, the important events in his life, what regrets, as well as successes, he might have had.
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