November 16, 2004 Feature

Depression in Older Adults With Hearing Loss

All people feel sad or unhappy at times during their lives, but persistent sadness may be depression, a serious illness affecting 15 out of every 100 adults over age 65 in the United States, according to the Geriatric Mental Health Foundation. The American Psychological Association estimates that 20% of older adults living independently and as many as 50% living in nursing homes suffer from depression.

Depressive symptoms are not a normal part of aging. Unlike normal sadness, clinical depression doesn't go away by itself and lasts for months. In contrast to the normal emotional experiences of sadness, grief, loss, or passing mood states, depression in older adults can lead to impairment in physical, mental, and social functioning, and must be treated professionally.

Serious depression may lead to disability; it may worsen symptoms of other illnesses or may result in premature death or suicide. Unresolved depression can affect the immune system, which makes the depressed individual more susceptible to other illnesses, a complication often found in older adults. Symptoms in older persons may differ somewhat from symptoms in other populations. Clinical depression is often undiagnosed and under treated in elderly adults because symptoms go unrecognized in the context of multiple physical problems.

Impact of Hearing Loss

Research indicates that as health problems increase, the risk of depression increases. Individuals who are depressed often experience a more rapid deterioration in health. Hearing loss is not included in the wide range of health problems that may be associated with depression, but this is because adequate data in research studies do not exist.

In 1999, however, the National Council on the Aging reported that hearing loss in older persons can have a significant negative impact on quality of life. In their survey of 2,300 hearing impaired adults age 50 or older, those with untreated hearing loss were more likely to report depression, anxiety, and paranoia and less likely to participate in organized activities, compared to those who wore hearing aids. In addition, although hearing aids can reduce depression, the remaining communication struggles can be depressing in themselves. In a further complication, hearing loss may be only one of several "co-occurring" bases for depression.

Older adults are saddened by the deaths of friends and family members and the limitations on once-routine activities that added to the social enjoyment of life. It is common for older adults to spend a lot of time alone. Many are divorced or widowed. And their circle of friends narrows. It is important that solitude for elder Americans does not turn into isolation, and ultimately depression. We know that hearing loss has the potential to drive some people into isolation, and older adults are particularly vulnerable due to coexisting health conditions.

Symptoms

Awareness of a variety of clinical and behavioral clues is useful in the identification of depression in your patients. Persistent complaints such as pain, headaches, fatigue, insomnia, GI symptoms, arthritis, multiple diffuse symptoms, and weight loss are well-known primary presentations of depression in the elderly. However, they may be particularly confusing in the elderly because co-existing medical disorders may also cause some of these symptoms. In addition, depression in older people is often characterized by memory problems, confusion, social withdrawal, loss of appetite, inability to sleep, irritability, and in some cases, delusions and hallucinations. Depression in older adults may be mistaken for dementia, or the symptoms are so disabling that individuals cannot articulate their distress and reach out for help. The clinician should watch for signs of depression in older people and these clues should not be ignored.

Older depressed individuals often have severe feelings of sadness but these feelings frequently are not acknowledged or openly shown. Sometimes, when asked if they are "depressed," the answer from persons suffering from depression is "no." Therefore, "depression without sadness" may significantly impede its recognition. Some general clues that someone may be suffering from depression in such cases are persistent and vague complaints and attempts to seek help, along with demanding behavior and frequent phone calls.

Causes

Depression has no single cause; often, it results from a combination of things. Unlike the onset of depression in non-elderly populations, depression in the elderly is thought to be a psychological disorder triggered by specific stressors, such as medical illness. Some particularly important contributing factors are:

  • Personality Factors. Certain personality traits seem to be more common in people who become depressed. For example, people with low self-esteem, greater pessimism, or greater dependency needs, seem to be more vulnerable to depression. Certainly, because of the role of cognitive evaluations and pessimism in depression, some personality traits are likely to be more closely related to the development of depression. However, these factors can be treated by a psychologist.
  • Life Events. The death of a loved one, divorce, moving to a new place, money problems, or any sort of loss have all been linked to depression. People without relatives or friends to help may have even more difficulty coping with their losses. Certain stressors are more common in older people, such as chronic medical problems, financial distress, loss of close friends and family, and loneliness.
  • Medications. The side effects of some medicines cause depressive symptoms. Certain drugs used to treat high blood pressure and arthritis fall into this category. In addition, different drugs can interact in unforeseen ways when taken together.
  • Genetics and Family History. Depression runs in families. Children of depressed parents have a statistically higher risk of depression. Because of these statistics, researchers believe that some people may have a biological make-up that increases their vulnerability.

When Clients Are Depressed

Audiologists who believe their clients may be depressed about their hearing loss can take steps:

  • Providing a safe climate to allow patients to express their feelings of depression related to hearing loss. Ensure that your patient's adjustment to his or her hearing aid includes the identification of symptoms for depression and to provide appropriate referrals for appropriate diagnosis and treatment
  • Offering emotional support. This involves understanding, patience, and encouragement. Engage the depressed person in conversation and listen carefully. Do not disparage feelings expressed, but point out realities and offer hope. Do not ignore remarks about suicide. Encourage participation in some activities that once gave them pleasure, such as hobbies, sports, religious or cultural activities.
  • Suggesting appropriate activities. Be careful not to push the client to undertake too much too soon in terms of activities. The depressed person needs diversion and company, but too many demands increase feelings of failure. Assure the depressed person that, with time and help, he or she will likely feel better.
  • Displaying consumer brochures on depression. If you observe symptoms, you may want to conduct a screening test (see sidebar on screening tool, page 12). For those who need referrals, you may also want to provide a list of local resources for treatment (page 13).

Depression in the older person is often associated with dependency and disability and causes great suffering for the individual and their families. Loved ones and health care providers may attribute the signs of depression to the normal results of aging, and many older people are reluctant to talk about their symptoms. As a result, older people may not receive treatment. Improved recognition and treatment of depression in later life will make those years more enjoyable and fulfilling for the depressed elderly person, the family and caretakers. 

Tina Mullins, is ASHA's Director of Audiology Adult Practice. She earned her master's degrees in both audiology and social work with a certificate in aging studies. Contact her at tmullins@asha.org.

cite as: Mullins, T. (2004, November 16). Depression in Older Adults With Hearing Loss. The ASHA Leader.

Geriatric Depression Scale

(This is a Geriatric Depression screening tool currently available in the public domain. Answers in parentheses suggest depression, hence the higher the score, the more likely the respondent is experiencing depression.)

Questions: Short Form

  • Are you basically satisfied with your life? (No)
  • Have you dropped many of your activities and interests? (Yes)
  • Do you feel your life is empty? (Yes)
  • Do you often get bored? (Yes)
  • Are you in good spirits most of the time? (No)
  • Are you afraid something bad is going to happen to you? (Yes)
  • Do you feel happy most of the time? (No)
  • Do you often feel helpless? (Yes)
  • Do you prefer to stay at home, rather than going out and doing new things? (Yes)
  • Do you feel you have more problems with memory than most? (Yes)
  • Do you think it is wonderful to be alive now? (No)
  • Do you feel pretty worthless the way you are now? (Yes)
  • Do you feel full of energy? (No)
  • Do you feel that your situation is hopeless? (Yes)
  • Do you think most people are better off than you? (Yes)

Interpretation

  • Normal: 0 to 4
  • Mild depression: 5 to 8
  • Moderate depression: 8 to 11
  • Severe depression: 12 to 15


Where to Get Help

Check the Yellow Pages under "mental health," "health," "social services," "suicide prevention," "crisis intervention services," "hotlines," "hospitals," or "physicians" for phone numbers and addresses. The professionals listed below will refer or provide diagnostic and treatment services.

  • family doctors
  • mental health specialists
  • health maintenance organizations
  • community mental health centers
  • hospital psychiatry departments and outpatient clinics
  • university- or medical school-affiliated programs
  • state hospital outpatient clinics
  • family service, social agencies, or clergy
  • private clinics and facilities
  • employee assistance programs
  • local medical and/or psychiatric societies

More information and assistance about mental health topics can be obtained online from the Center for Mental Health Services and the National Institute of Mental Health



References

American Psychological Association
(http://www.apa.org/ppo/issues/olderdepressfact.html)

Geriatric Mental Health Foundation
(http://www.gmhfonline.org/gmhf/resources/depression.html)

Yesavage J.A., Brink T.L., Rose T.L., Lum O., Huang V., Adey M.B., and Leirer V.O. (1983). Development and validation of a geriatric depression screening scale: A preliminary report. Journal of Psychiatric Research (17) 37-49.



Symptoms of Depression

  • Persistent sad, anxious, or "empty" mood
  • Feelings of hopelessness, pessimism
  • Feelings of guilt, worthlessness, helplessness
  • Loss of interest or pleasure in hobbies and activities that were once enjoyed, including sex
  • Decreased energy, fatigue, being "slowed down"
  • Difficulty concentrating, remembering, making decisions
  • Insomnia, early-morning awakening, or oversleeping
  • Appetite and/or weight loss or overeating and weight gain
  • Thoughts of death or suicide; suicide attempts
  • Restlessness, irritability
  • Persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders, and chronic pain


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