For About and By Caregivers
Today's Rural Cargiving: Managing Mood Without Medication
by Linda Lindsey Davis, RN, PhD 

Gemma Reilly is a 72 year-old woman who, with her 74 year-old husband Bob, divided her time between visiting four adult children and 10 grandchildren, worked in the family garden, and maintained a busy schedule of church activities. After Bob’s death three years ago, Gemma tried to cope, but the recent death of her childhood best friend seemed to be the final blow. She began to lose interest in her previous activities, missing church services, letting the garden go to seed and attending fewer and fewer family functions. She also has become reluctant to take her arthritis and blood pressure medications, saying: “I have to expect some aches and pains in old age”. More recently, she has begun wearing the same dress and sweater every day. Gemma’s oldest daughter tells the other brothers and sister that she is afraid “Momma is getting senile”. 
Recognizing and distinguishing depression from other illnesses in an elder can be challenging because elders and their family members often attribute any new symptoms to the aging process. While some depressive symptoms in the elderly are similar to those in younger adults, others may remain unnoted because they are often mistaken for age-related decline. Apathy and withdrawal from the world, changes in grooming and hygiene, changes in sleep, appetite, elimination and activity patterns, negative mood, slower thinking and responding, and increased complaints of physical ailments are common signs of depression in elders. 

When depression is suspected, the physician or health professional can more easily sort out suspected medication problems when provided with: (1) an accurate list of the elder’s daily medication regimen, including OTC medications (over-the-counter cold medications that include antihistamines and/or alcohol can be major factors in an elder’s level of alertness); (2) information on the elder’s current nutrition, exercise and sleep patterns; and (3) observations and concerns of the family/caregiver (Hint: take a written diary of key symptoms and the date and time they occurred, to aid in sorting out possible medication side effects). 

Medication and Mood 
Non-compliance with a medication regimen should also be suspected if an elder’s symptoms change over time. Since older adults metabolize drugs more slowly than younger adults, their medication programs are often more difficult to monitor and manage. It’s important for family caregivers to understand the elder’s medications and their side effects. Drugs currently used to treat memory loss can have troublesome gastrointestinal side effects including nausea, vomiting and diarrhea; antidepressants can cause side effects ranging from dry mouth and constipation to lowered blood pressure and mental confusion. Some elders conclude these types of side effects and/or the costs of some drugs are worse than the symptoms, and often discontinue those medications without consulting their family or health care provider.

Dementia and Mood
When changes in an elder’s functional status and abilities become apparent, families are frequently challenged to sort out a wide variety of symptoms that may be reflective of normal aging or a more serious health problem. While mild depression may herald the early onset of dementia or be mistaken for dementia, there are differences. The initial signs of dementia are memory loss for recent events that gradually develop over a period of years with the afflicted person unaware and often unconcerned about the memory deficits. In contrast, depression has a more abrupt onset, often occurring after a ‘single life event’ such as serious illness or death of a loved one, a move out of a long-standing living situation or the onset of a chronic disease. The depressed person complains of memory loss, both for recent and distant events and frequently admits to sleep and appetite disturbances and may even verbalize negative thoughts (“I am such a burden to you; I wish I had never …”) or sometimes, suicidal thoughts (“It would be better for everyone if I wasn’t around anymore”). 

Blue Mood Thinking 
Mrs. Reilly’s situation has a number of contributory factors for the development of depressive symptoms, including her experience of the loss of her spouse and close friend, a chronic illness that causes functional limitations and a medication program that may have serious side effects. However, the ways Mrs. Reilly thinks about her situation may also play a significant role in the development and control of her depressive symptoms. David Burns, the author of “Feeling Good: A Guide to the New Mood Therapy”, and a well-known depression researcher from the University of Pennsylvania, notes that it is not what happens to us, but rather, how we think about what happens to us, that governs our emotional responses. According to Burns, persons are likely to become depressed if they think in certain ways. The depressed person uses one or more of these thinking styles. (See Table Above)

Improving mood without drugs
When medications cause undesirable side effects or an elder refuses to take medications, family caregivers often find simple mood management strategies can improve emotion and affective response. Psychologists, psychiatrists and other mental health professionals have noted the profound effects that increasing the number of pleasant daily life events can have in reducing depressive responses. Here are 20 pleasant life events that have been demonstrated in various clinical studies to enhance mood and reduce depressive symptoms, even without antidepressant medications: 

Pleasant Life Activities

 Being outside
 Reading or listening to stories
 Listening to music
 Watching TV
 Having meals with friends or family
 Making & eating snacks
 Helping around the house
 Being with family
 Wearing favorite clothes
 Listening to the sounds of nature
 Getting or sending cards, letters
 Going on an outing
 Having coffee or tea with a friend
 Being complimented
 Going for a car ride
 Grooming (make-up, shaving)
 Recalling & discussing pleasant events

Use the list above to help your elder develop their own pleasurable activities that she or he can enjoy alone such as listening to music, taking a favorite walk or a watching familiar TV programs. 

The following five strategies are recommended for family caregivers who want to improve mood in a elder:

Plan and organize additional pleasant activities that the elder and other family members can enjoy together regularly. This might include weekly family dinners and short shopping trips.

Use memory aids to encourage the elder to recall past pleasant events. For example, help him or her to organize photo albums of family pictures. Put together a memory book of photos of family members, vacation trips or other pleasant events for the elder’s purse or wallet. Encourage family members to sit with the elder regularly and review the happy experiences represented in the memory book. Add new photos to the book regularly. 

Utilize reminders to help the elder anticipate upcoming pleasant events. For example, use a large refrigerator calendar to list the schedule of daily events for the next week (e.g., family viewing of favorite TV shows, a plan for a walk or trip to the store, anticipated visits from children and grandchildren). Refer the elder to the schedule frequently so he/she can anticipate upcoming pleasant events each day.

Set realistic goals for mood management. Encourage the elder to assume some planning responsibility but do only those activities that can be accomplished without causing you and the elder stress or frustration.

Finally, become an expert on the elder’s thinking style. Listen and look for signs of blue mood thinking. Observe the elder’s behavior in stressful situations and try to avoid or reduce the occurrence of situations that cause blue mood thinking. 

Caregiving and Mood
Caring for an increasingly frail elder can be challenging and family caregivers should be encouraged not to neglect their own need for pleasant events. As many as 50% of those family members involved in long-term care for an elder will themselves become depressed. Successful respite services for stressed-out and discouraged caregivers are those that increase opportunities for their increasing pleasant events. When families must function as caregivers, the first major step is to become expert in recognizing health problems early and developing practical strategies for managing the day-to-day occurrence of those problems. This often means identifying and building in opportunities for pleasant events. 


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