Older adults are at risk for grief and depression. As people age, many losses are experienced, which are painful (and can lead to depression). These may include loss of a loved one, or a loss of independence, mobility, or health (Robinson et al., 2019). Home healthcare clinicians need to consider depression and grief in their patient's assessment, and be able to distinguish between the two.
Grief is a natural response to loss-the emotional suffering one feels when someone or something is taken away (such as loved ones, health, pets, or the family home). Home healthcare clinicians play an important role in assessing a patient's grieving process and helping the patient navigate through it. Some physical symptoms of grief may include fatigue, nausea, lowered immunity, weight loss or weight gain, aches and pains, and insomnia (Smith et al., 2019).
Depression is a long-lasting mood disorder that can interfere with all aspects of daily life. Depression symptoms may include a sad or depressed mood (although many older adults claim not to feel sad but have some of the other symptoms instead); loss of interest or pleasures in things the patient used to like; changes in weight or appetite, sleep problems, restlessness/agitation, or slowing of movements; less energy, feelings of hopelessness, worthlessness, or excessive guilt; decreased ability to think or concentrate; or repeated thoughts of death or suicide (which is an emergency) (American Geriatrics Society [AGS], 2017).
We need to help differentiate between grief and clinical depression, even though these conditions often share symptoms. Grief can be described as a roller coaster of good and bad days and a mix of emotions. Over time, the difficult periods become less intense and shorter, but at special events (such as at a wedding, or the birth of a child in the family), a strong sense of grief may be felt. With depression, however, feelings of emptiness and despair are constant. Some symptoms that may indicate depression and not just grief include: intense sense of guilt; thoughts of suicide or preoccupation with dying; feelings of hopelessness or worthlessness; slow speech and body movements; inability to function; or seeing/hearing things that aren't there. Additionally, if grief does not let up over time or if all signs of joy are extinguished-it may be depression (Robinson et al., 2019).
Educate the patient or caregiver that they need to (1) acknowledge their pain, (2) accept that grief can trigger different and unexpected emotions, (3) understand that each person has their own unique grieving process, (4) seek out face-to-face support from people who care, (5) take care of themselves physically to help their emotional health, and (6) understand the difference between grief and depression (Smith et al., 2019). Those dealing with grief need to be encouraged to acknowledge their feelings in order to heal-unresolved grief can lead to depression, anxiety, substance abuse, and health problems. Some individuals may feel better if they can express their loss in a tangible or creative way, such as writing in a journal, writing a letter to a lost loved one to say the things the patient didn't get to say; making a scrapbook or photo album celebrating the person's life, or getting involved in a cause or organization that was important to the loved one. Encourage the patient to maintain their hobbies and interest, and not to let anyone tell them how to feel-their grief is their own, and they should be encouraged to let themselves feel without embarrassment or judgment. Anniversaries, holidays, and milestones are opportunities for memories and feelings to reawaken grief-the patient should be encouraged to plan ahead for how they will deal. Also, patients need to look after their physical health-proper sleep, eating habits, and exercise are important to their physical and emotional health. Drug or alcohol use should be discouraged.
Treatment for depression is a little different from grief management. Depression treatment usually has three parts (1) immediate treatment, (2) continuing treatment to prevent relapse (includes antidepressant therapy and usually lasts around 6 months), and (3) maintenance therapy (if necessary). Typical treatments for depression, depending on symptoms and history, may include single or combination therapy of: psychotherapy ("talk therapy"); antidepressant medications; electroconvulsive therapy; vagus nerve stimulation; deep brain stimulation, or transcranial magnetic stimulation (AGS, 2017).
Antidepressant medications have a few caveats to keep in mind and monitor for: (1) For older adults, it is best to start with a low dose and slowly titrate up until a desired effect is seen; (2) Patients who have kidney or liver disease will require monitoring to make sure the medication levels are not getting too high or impacting renal or hepatic function; (3) These medications typically take time to work, and about half of adults with major depression respond well to antidepressants within 6 weeks, another 15% to 25% just begin to respond in the first 6 weeks, but continue to improve if therapy is continued for another 4 to 6 weeks; and (4) If a prescribed medicine does not seem to be working, a dosage adjustment, new antidepressant, or additional therapy (such as psychotherapy) may be necessary. Many patients need to take an antidepressant for at least 6 to 12 months for full benefit and to lower the odds of recurring depression. Severe or suicidal depression is best treated with a combination of medications and psychotherapy, with or without hospitalization, which seems to work quickly and keep depression from recurring.
Other support measures for depression are important, and can align with grief treatment measures as well. Ensure that the patient is getting the proper amount of Vitamin B6, B12, and iron levels in their diet to help with depressive symptoms, especially if the patient is a vegetarian (AGS, 2017). Exercise is another way to help the brain release chemicals to feel better-even just 30 minutes a few days a week can have an impact. Ensuring proper sleep hygiene; spending at least 15 minutes in the sunlight; avoiding alcohol (which exacerbates depression); minimizing sugary, starchy foods; being social; and finding activities the patient enjoys and can engage in are all helpful ways to help combat depression as well.
Depression and grief are serious health issues in the older adult that have a tremendous impact on quality of life. The home healthcare clinician plays an important role in the assessment and management of each of these conditions. Patients are at risk for mental health decline and physical health issues without proper treatment for these conditions. Treatment measures will need to be individualized based on the patient's needs and responses, and it may take time for the full benefits of the therapy to be realized.
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