Assessment Data:

• Verbalization of suicidal thoughts
• Feelings of hopelessness and worthlessness
• Social isolation
• Previous suicide attempt
• Family history of suicide
• Recent significant loss

Expected Outcomes:

• Client will remain free from self-harm during hospitalization
• Client will verbalize decrease in suicidal ideation prior to discharge
• Client will identify at least three coping strategies to manage suicidal thoughts
• Client will demonstrate ability to contact appropriate resources when experiencing suicidal thoughts

Nursing Interventions:

1. Assess suicide risk using standardized tool at admission and regularly throughout treatment
2. Implement appropriate level of observation based on risk assessment
3. Remove potentially harmful objects from client’s environment
4. Administer prescribed medications and monitor for effectiveness and side effects
5. Establish therapeutic relationship to encourage expression of feelings
6. Develop safety plan with client that includes:
   • Recognition of warning signs
   • Internal coping strategies
   • Social contacts for distraction
   • Professional resources to contact
   • Steps to create safe environment
7. Provide education about relationship between depression and suicidal thoughts
8. Include family/support persons in treatment planning with client’s consent
9. Document suicide assessments, interventions, and client responses

Evaluation:

• Has client remained free from self-harm?
• Has suicidal ideation decreased in frequency and intensity?
• Can client identify and demonstrate use of coping strategies?
• Has client verbalized understanding of safety plan?
• Can client identify resources to contact when experiencing suicidal thoughts?

Assessment Data:

• Neglected personal hygiene and appearance
• Unwashed hair, body odor, unchanged clothing
• Reported lack of energy to perform self-care
• Difficulty initiating and completing tasks
• Expressions of worthlessness

Expected Outcomes:

• Client will demonstrate improved self-care within [timeframe]
• Client will perform hygiene and grooming activities with decreasing levels of assistance
• Client will verbalize increased motivation for self-care prior to discharge

Nursing Interventions:

1. Assess current level of functioning and ability to perform self-care activities
2. Establish a daily schedule that includes self-care activities
3. Provide assistance with hygiene and grooming as needed, gradually decreasing assistance as client improves
4. Break tasks into small, manageable steps
5. Allow adequate time for completion of activities
6. Provide positive reinforcement for efforts and accomplishments
7. Encourage participation in therapeutic activities to increase energy and motivation
8. Monitor for medication side effects that may impact self-care abilities
9. Involve client in setting incremental self-care goals

Evaluation:

• Is client demonstrating improved hygiene and grooming?
• Has client’s independence in self-care activities increased?
• Does client report increased motivation for self-care?
• Is client able to maintain a schedule for self-care activities?

Assessment Data:

• Increased psychomotor activity
• Impulsive behavior
• Poor judgment
• Intrusive behavior with others
• Decreased need for sleep
• Involvement in potentially harmful activities

Expected Outcomes:

• Client will remain free from injury during hospitalization
• Client will demonstrate decreased hyperactivity and impulsivity
• Client will participate in therapeutic activities in a safe manner

Nursing Interventions:

1. Assess level of hyperactivity, impulsivity, and judgment at each shift
2. Create a safe environment by removing potential hazards
3. Implement appropriate level of observation based on risk assessment
4. Redirect excessive energy into safe, structured activities
5. Set clear, consistent limits on unsafe behavior
6. Administer mood stabilizers and antipsychotics as prescribed
7. Monitor for medication effectiveness and side effects
8. Reduce environmental stimulation:
   • Quiet environment
   • Limited number of people in client’s space
   • Reduced noise and lighting if agitated
9. Provide regular opportunities for physical activity in a controlled environment
10. Offer PRN medications for extreme agitation per orders
11. Monitor for signs of physical exhaustion

Evaluation:

• Has client remained free from injury?
• Has hyperactivity decreased?
• Is client able to participate in activities without unsafe behavior?
• Is client responding to redirection and limit-setting?
• Is medication effectively managing manic symptoms?

Assessment Data:

• Reports feeling “no need for sleep”
• Observed to be awake for extended periods
• Excessive energy

  Geriatric Considerations for Mood Disorders

  Follow-up Care and Rehabilitation

  Comprehensive Nursing Notes

  Mood disorders in older adults present unique challenges and require specific considerations for assessment, treatment, and follow-up care. These notes provide evidence-based information on the geriatric aspects of mood disorders with practical guidance for nursing care and rehabilitation strategies.

  1. Overview of Mood Disorders in the Elderly

  Definition: Mood disorders represent the most common source of psychiatric morbidity in older adults, including unipolar (depressive disorder) and bipolar (manic-depressive) subtypes, with varying degrees of severity.

  1.1 Epidemiology

  Depression in Older Adults

  • Affects 10-38% of the elderly population
  • 35.3% of cases are mild, 51.9% moderate, and 12.7% severe
  • Significantly underdiagnosed (40-60% of cases go unrecognized)
  • Treatment-resistant depression occurs in 26-41% of cases

  Bipolar Disorder in Older Adults

  • 12-month prevalence: 0.1-0.5% in adults 65+
  • Lifetime prevalence: 1% in adults 60+
  • Despite low community prevalence, represents 4-8% of geriatric psychiatric hospital admissions
  • Mean age of onset in late-onset BD: 49 years

  Characteristic	Bipolar Disorder	Major Depression
  Prevalence	0.1-0.5%	10-38%
  Female predominance	66%	52%
  Cognitive deficits	Yes	Yes
  Treatment-resistance	Common	Common
  Under-recognized	Yes	40-60%

  2. Clinical Presentation in Older Adults

  Geriatric Depression

  • More sleep disturbance, fatigue, and psychomotor retardation
  • Greater feelings of hopelessness about the future
  • Often presents with cognitive complaints (“pseudodementia”)
  • May present with irritability rather than sadness
  • Somatic complaints may mask emotional symptoms
  • Higher risk of suicide, especially in older white males

  Geriatric Bipolar Disorder

  • Late-onset cases (8% of cases) show different patterns
  • More cognitive impairment in late-onset cases
  • Early-onset cases show more mixed episodes
  • Irritability and dysphoria more common than euphoria during mania
  • Higher rates of comorbid medical conditions
  • Greater risk of medication side effects

  MNEMONIC: “DEPRESSION” in Older Adults

  D – Disturbance in sleep (more pronounced)

  E – Energy loss and fatigue (prominent)

  P – Psychomotor changes (more retardation)

  R – Reduced interest or pleasure

  E – Executive function deficits (common)

  S – Somatic complaints (may mask mood symptoms)

  S – Suicidal thoughts (higher completion rate)

  I – Irritability (may replace sadness)

  O – Overwhelming hopelessness

  N – Neurocognitive complaints

  Important Nursing Alert: Older adults with depression have a higher risk of completed suicide compared to younger adults. White men over 85 have suicide rates 5 times higher than the general population. Always assess suicide risk thoroughly, especially when firearms are accessible.

  3. Neurobiological Correlates in Geriatric Mood Disorders

  Understanding the neurobiological basis of late-life mood disorders helps explain their presentations and guides treatment approaches.

  Geriatric Depression

  • Neuroendocrine changes: HPA axis dysregulation with increased cortisol
  • Neuroimaging findings: Volume loss in frontal-subcortical pathways
  • Vascular depression: White matter lesions in prefrontal regions
  • Neurotrophic factors: Reduced BDNF and NGF levels
  • Inflammatory processes: Increased pro-inflammatory cytokines (TNF-α, IL-6)

  Geriatric Bipolar Disorder

  • Structural changes: Cortical thinning in frontal regions
  • Functional abnormalities: Hypoactivation of prefrontal cortex
  • Microstructural changes: Reduced connectivity between prefrontal and limbic regions
  • Inflammatory mechanisms: HPA axis dysfunction with increased inflammation
  • Oxidative stress: Mitochondrial dysfunction and increased reactive oxygen species

  Vascular Depression Hypothesis

  The “vascular depression” hypothesis proposes that cerebrovascular disease disrupts frontal-subcortical circuits, leading to a distinct presentation of late-life depression characterized by:

  • Executive dysfunction
  • Psychomotor retardation
  • Apathy and reduced motivation
  • Limited insight
  • Poor response to antidepressants
  • Increased risk of vascular dementia

  Pathways Between Depression and Dementia

  Chronic depression throughout life

  ↓

  Increased risk of dementia in later life

  OR

  Late-life depression

  ↓

  Prodromal stage of dementia

  Note: Patients with concomitant major depression and mild cognitive impairment have impaired performance on instrumental activities of daily living.

  4. Cognitive Impairment in Geriatric Mood Disorders

  Affected Cognitive Domain	Major Depression	Bipolar Disorder
  Executive functions	✓	✓
  Abstract thinking		✓
  Cognitive set-shifting		✓
  Inhibitory control		✓
  Decision-making ability		✓
  Working memory	✓
  Sustained attention	✓	✓
  Verbal fluency	✓
  Episodic memory	✓
  Processing speed	✓	✓
  Psychomotor skills		✓

  Important Clinical Note: Cognitive deficits may persist even after remission of mood symptoms, particularly in processing speed, executive function, and memory domains. This impacts functional recovery and quality of life.

  5. Treatment Considerations for Special Populations

  MNEMONIC: “SPECIAL” Considerations for Geriatric Mood Disorders

  S – Slower metabolism requiring lower medication doses

  P – Polypharmacy and drug interactions

  E – Evaluate for medical comorbidities

  C – Cognitive effects of medications

  I – Increased sensitivity to side effects

  A – Adherence challenges (due to cognitive/sensory limitations)

  L – Longer response time to medications

  5.1 Pharmacological Approaches

  Geriatric Depression Treatment

  • First-line: SSRIs (sertraline, citalopram, escitalopram)
  • Alternative: SNRIs (venlafaxine, duloxetine)
  • Special cases:
    • Bupropion – for apathy, low energy (avoid with seizure risk)
    • Mirtazapine – for insomnia, poor appetite
  • Augmentation strategies:
    • Lithium (careful monitoring of levels and renal function)
    • Thyroid hormone (T3) with caution in cardiac patients
    • Aripiprazole (has FDA indication for adjunctive use)

  Geriatric Bipolar Disorder Treatment

  • Mood stabilizers:
    • Lithium (reduced doses, monitor levels, renal and cognitive effects)
    • Valproate (alternative for acute mania)
    • Lamotrigine (particularly for depressive symptoms)
  • Antipsychotics:
    • Quetiapine (effective for acute mania in older adults)
    • Olanzapine (monitor metabolic effects)
    • Aripiprazole (less metabolic effects)
  • Special considerations: Lithium may reduce dementia risk and has neuroprotective properties

  Medication Concerns in Older Adults:

  • SSRIs may cause hyponatremia and bleeding
  • Antipsychotics increase risk of stroke and mortality
  • Lithium requires careful monitoring (narrow therapeutic window)
  • TCAs have significant anticholinergic and cardiac effects (avoid if possible)
  • Benzodiazepines increase fall risk and cognitive impairment

  5.2 Non-Pharmacological Approaches

  Psychotherapy

  • Evidence-based approaches:
    • Cognitive Behavioral Therapy (CBT)
    • Problem-Solving Therapy
    • Interpersonal Therapy
    • Life Review Therapy
    • Brief Psychodynamic Therapy
  • Benefits: Addresses psychosocial stressors, improves coping, reduces isolation

  Brain Stimulation Therapies

  • Electroconvulsive Therapy (ECT):
    • Highly effective for severe/psychotic depression
    • Response rate >80% in most trials
    • Consider cardiac risks and cognitive effects
    • Newer approaches reduce cognitive impact
  • Transcranial Magnetic Stimulation (TMS):
    • Well-tolerated in older adults
    • Mixed evidence for efficacy in late-life depression

  Physical Exercise as Treatment: Exercise has demonstrated moderate to large effect sizes for improving depressive symptoms, with efficacy comparable to antidepressants in some studies. Both anaerobic and aerobic forms can be beneficial, with evidence supporting even light to moderate intensity activity.

  6. Follow-up Care and Home Management

  Clinical Follow-up Recommendations

  • More frequent initial visits (every 1-2 weeks) then tapering
  • Monitoring for treatment response and side effects
  • Ongoing suicide risk assessment
  • Regular assessment of cognitive function
  • Medication adherence evaluation
  • Laboratory monitoring as indicated (e.g., lithium levels, electrolytes)
  • Collaborative care with primary care providers

  Home Care Management

  • Medication management assistance
  • Home safety evaluation (fall risks, suicide means)
  • Regular social contact and activity scheduling
  • Support for activities of daily living as needed
  • Caregiver education and support
  • Connection to community resources
  • Integration of telehealth when appropriate

  MNEMONIC: “HOME CARE” for Mood Disorders

  H – Help with medications and adherence

  O – Observe for warning signs of relapse

  M – Maintain social connections

  E – Encourage physical activity

  C – Create structured daily routines

  A – Address safety concerns

  R – Regular follow-up appointments

  E – Educate patient and caregivers

  Follow-up Care Pathway

  Initial Stabilization (Acute Phase)

  ↓

  Continuation Phase (4-9 months)

  ↓

  Maintenance Phase (1+ years)

  Acute Phase

  – Weekly visits
  – Symptom monitoring
  – Adjusting treatments
  – Safety planning

  Continuation Phase

  – Biweekly to monthly visits
  – Preventing relapse
  – Functionality focus
  – Psychosocial support

  Maintenance Phase

  – Monthly to quarterly visits
  – Preventing recurrence
  – Quality of life focus
  – Long-term monitoring

  Collaborative Care Models: Integrating mental health care within primary care settings (as demonstrated by PROSPECT, IMPACT, and PRISM-E studies) has shown effectiveness for older adults with mood disorders. This approach improves access, reduces stigma, and addresses both physical and mental health needs.

  7. Rehabilitation Strategies

  Exercise-Based Rehabilitation

  • Benefits of exercise:
    • Antidepressant effects comparable to medications
    • Improves cardiovascular health and reduces stroke risk
    • Enhances cognitive function and may prevent cognitive decline
    • Reduces inflammation and oxidative stress
    • Increases BDNF levels (brain-derived neurotrophic factor)
    • Improves sleep quality
  • Recommended protocols:
    • Start with light activity and gradually increase
    • Aim for 30 minutes, 3-5 times per week
    • Combine aerobic and strength training
    • Group-based activities enhance social benefits

  Functional Rehabilitation

  • Cognitive rehabilitation:
    • Cognitive remediation exercises
    • Compensatory strategies for deficits
    • Memory and organizational aids
  • Social rehabilitation:
    • Structured social activities
    • Group therapy and support groups
    • Community engagement programs
  • Occupational therapy:
    • Assessment of functional abilities
    • Environmental modifications
    • Skills training for ADLs and IADLs

  Benefits of Exercise for Comorbid Conditions: Exercise has been shown to improve outcomes in conditions frequently comorbid with mood disorders in older adults, including:

  • Anxiety: Exercise is comparable to CBT and nearly as effective as medication
  • Sleep disturbance: Reduces night awakenings and improves sleep quality
  • Pain: Reduces perception of pain and improves physical functioning

  7.1 Potential Mechanisms of Exercise in Mood Disorders

  BDNF Upregulation

  Enhances neuroplasticity and neurogenesis in hippocampus

  Reduction in Oxidative Stress

  Decreases cellular damage and mitochondrial dysfunction

  Epigenetic Changes

  Modifies gene expression related to stress response

  Comprehensive Rehabilitation Program Elements

  • Structured physical activity program
  • Cognitive-behavioral therapy
  • Social skills training
  • Nutritional counseling
  • Sleep hygiene education

  • Stress management techniques
  • Medication adherence support
  • Family/caregiver education
  • Community reintegration activities
  • Relapse prevention planning

  8. Special Considerations for Unique Populations

  Residents of Long-Term Care Facilities

  • Higher prevalence of depression (up to 40%)
  • Often underdiagnosed and undertreated
  • Requires staff training for recognition
  • Increased risk for medication interactions
  • Limited access to specialized mental health care
  • Benefits from structured activities and social engagement
  • Consider behavioral interventions for agitation/aggression

  Older Adults with Dementia and Mood Disorders

  • Depression may be expressed behaviorally
  • Agitation may represent mood symptoms
  • Antidepressants have mixed evidence in this population
  • Focus on non-pharmacological approaches first
  • Caregiver education and support is crucial
  • Environmental modifications often help
  • Monitor for worsening cognition with medications

  Older Adults with Complex Medical Comorbidities

  • Increased risk of drug-drug interactions
  • Mood disorders may worsen medical outcomes
  • Medical conditions may mask mood symptoms
  • Requires integrated care approach
  • Close monitoring of medication effects
  • Consider impact of medical treatments on mood
  • Address pain management (common comorbidity)

  Older Adults with Late-Life Trauma or Loss

  • Bereavement may progress to complicated grief
  • Trauma symptoms may mimic depression
  • Prior trauma may re-emerge in late life
  • Trauma-informed care approach needed
  • Narrative and life review therapy can be effective
  • Social support is particularly important
  • May benefit from specialized grief counseling

  MNEMONIC: “DIVERSE” Approaches for Special Populations

  D – Develop individualized treatment plans

  I – Involve family members and caregivers

  V – Validate cultural beliefs and preferences

  E – Engage multidisciplinary team

  R – Respect autonomy while ensuring safety

  S – Simplify medication regimens

  E – Emphasize strengths and resilience

  9. Nursing Role in Care and Rehabilitation

  Assessment

  • Conduct comprehensive mental status assessment
  • Assess for suicide risk using standardized tools
  • Monitor for medication side effects
  • Evaluate functional abilities and limitations
  • Screen for physical health comorbidities
  • Assess sleep, nutrition, and activity patterns
  • Evaluate home environment and safety

  Interventions

  • Develop therapeutic relationship and trust
  • Provide psychoeducation about illness and treatment
  • Implement medication management strategies
  • Facilitate engagement in therapeutic activities
  • Support physical activity and exercise programs
  • Encourage healthy sleep and nutrition habits
  • Coordinate care among providers

  The Nurse’s Role in Home Care: Nurses are often the primary coordinators of care for older adults with mood disorders living at home. Key responsibilities include:

  • Regular assessment of mood and functioning
  • Monitoring treatment adherence and effectiveness
  • Education and support for patients and caregivers
  • Crisis prevention and intervention
  • Facilitating communication between providers
  • Supporting implementation of rehabilitation activities

  Caregiver Burnout Alert: Nurses should monitor for signs of caregiver stress and burnout, which is common when caring for older adults with mood disorders. Provide resources, respite options, and support strategies to prevent caregiver health deterioration.

  10. Summary and Key Points

  Geriatric Mood Disorders

  • Common but often underdiagnosed in older adults
  • Present differently than in younger populations
  • Associated with cognitive impairment and functional decline
  • Have neurobiological basis with structural and functional changes
  • Require careful assessment and tailored treatment approaches
  • Increase risk of mortality including suicide

  Follow-up and Rehabilitation

  • Regular follow-up is essential for monitoring and adjusting treatment
  • Home-based care should address medication management and safety
  • Exercise is an effective adjunctive treatment with multiple benefits
  • Multidisciplinary approaches yield the best outcomes
  • Special populations require tailored interventions
  • Collaborative care models show promising results

  Best Practice Recommendations

  Assessment

  • Use age-appropriate screening tools
  • Assess for cognitive impairment
  • Evaluate medical comorbidities
  • Thorough suicide risk assessment

  Treatment

  • Start low, go slow with medications
  • Combine pharmacological and non-pharmacological approaches
  • Include exercise as adjunctive treatment
  • Address comorbid conditions

  Follow-up

  • Frequent initial visits then tapering
  • Involve caregivers in care planning
  • Assess for treatment adherence
  • Monitor for functional improvements