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KFP Final: Depressive Symptoms, Chronic Conditions, & the Aging Population

Heidi Treser, Keishan Scott, & Nick Zammuto

University of South Carolina-Columbia

SOWK 352: Social Work and Scientific Inquiry

Dr. Woo

April 27, 2022

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Problem Statement and Question

Our study aims to understand what intervention strategies can assist in the mitigation of

social determinants which cause many chronic illnesses within the older population, sixty years

and up. Chronic disease is any illness that lasts 1 or more years and requires ongoing medical

treatment or puts limitations on daily activities (CDC, 2021). The older population of citizens in

the United States has consistently been more vulnerable to chronic disease and deadly illnesses

than most other age groups. This population, sixty years and older, are marginalized and

discriminated against by society often leading to social isolation and increased risk of health

problems. These issues have always persisted, and when the world entered an international

pandemic, this vulnerable population became infinitely more vulnerable. With increases in

isolation and decreases in physical activity the necessity of research involving methods to decrease

health risk among the older population is urgent.

The older population is growing exponentially. According to the CDC, as of 2019 this

group made up 19% of the US population and by 2040, they will make up 25% of the total US

population. Making up one fifth of the US population, this group's health is of immense

importance. Around 85% of the older population has one chronic health condition and 60% have

two or more (NIA, 2017). Chronic disease is the leading cause of death among the older population

and makes up the nations $3.8 trillion in health care costs (CDC, 2021). For reference, if that

amount of money was distributed equally to every US citizen, they would each receive $12,000.

These diseases are often caused by detrimental lifestyle habits that may be encouraged and

reinforced by depressive symptoms.

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Many practices used with the aging population may decrease mental health resiliency.

When individuals age, being placed in a long-term care facility, such as that of a retirement home,

has become a new norm at the expense of the aging population's mental and thus physical health.

Issues such as hypertension, chronic heart disease, and discrimination even before the COVID-19

pandemic had a consistent effect due to the lack of mental health support, except now they are

exacerbated in these uncertain times due to the virality of COVID-19. Mortality in ages seventy-

five and up in 2020 had an increase of forty-four individuals, and ages eighty-five and up saw an

increase of 138 individuals per 100,000 people in comparison to all of 2015 to 2019 (Shiels et al.).

The pandemic has increased social isolation particularly among the older population causing

increased nationwide mental health diagnoses. The importance of noting the effect of the pandemic

allows us to highlight different forms of intervention and compare them to each other to find an

outcome that considers protective and risk factors, and their pros and cons.

If rates previously mentioned continue, we could see spikes in mortality and chronic

illnesses among our aging population, sixty and older. In the longer term, not studying the current

and past effects towards our population could cause unknown health outcomes. Investigation of

this problem is needed so we can find better practices to intervene and or provide intervention

where social determinants of these health outcomes are before serious medical services are

required. Finding the causes of these effects can assist in the health outcomes of our older

populations.

If we, as future social workers, and practitioners, can understand what is needed in our

focal population we can effect social change, creating greater life satisfaction, less medical need,

more intervention, and as a side cause, more money for this population to retain ultimately. Which
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is why we ask the question, what intervention and prevention strategies can be utilized to address

the relationship between depressive symptoms and chronic illness in the aging population?

Background

Chronic illness is extremely prevalent in older adults, more so than any other age group.

Chronic illness is the leading cause of death among the older population. Each group member took

a different path in research using different browsers and search terms, though the focus of all our

articles was always centered around the social determinants of health which impact the older

population as posed by our EBP question. As we discussed as a group, we have all come to the

general understanding that there are various aspects that we could have focused our question but

for us to hone in on the social determinants of health, it allows us to centralize our findings and we

have discovered that all of our findings have intertwined and present the present data that we have

formulated.

Search Term Strategies

All three of us either used different search terms or different search engines to find our

research articles. Heidi found articles authored by Cockerham, et. Al, and Karakus, et. Al through

google scholar by searching “social determinants of chronic illness in older adults.” She began

with this search term and altered it several times to try and find more diverse results as the articles

that were coming up were not as closely related to the research question as she would have liked.

All or most of the articles were linking depression to chronic illness which was not part of the

original research question. Even after altering her search terms several times, the results were still

all relating chronic illness to depression. We decided to go with what the research was pointing to
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and changed our focus to social determinants of chronic illness and its cyclical relationship with

depression.

Keishan researched articles by Genderson et al. (2017) which discussed the onset of

various chronic health conditions that afflict many older and aging adults in the ladder years of life.

The search terms that were used were “chronic conditions” and “aging population.” He began with

these original search terms to find the most relevant information possible that related closely with

the study. For the second article, Bazargan (2019), this article places great emphasis on the

relationship between chronic illness and depression specifically among the African American older

and aging population. The search terms used were “African American,” “chronic illness,” and

“older and aging population.” The results shown were linking chronic illness as a leading factor to

the onset of depressive symptoms.

Nick researched the articles by Hughes et al. (2010) and Hale et al. (2018) through the

database Academic Search Complete. The search terms were “intervention,”, “chronic illness” and

“aging population”, “intervention strategies and chronic disease”, and “chronic conditions” and

“intervention”, which all yielded many results which we had to filter are search further by year

between 2010 and present, language in English, assuring a peer reviewed filter, and making sure it

was an academic journal. Of these remaining options, the first about ten articles reviewed by Nick

on our target population, however, he was able to refine his search by noting “aging population” as

a search term in addition to “chronic illness” and “intervention.” The two articles found homed in

on intervention strategies related to our target population.

Notable Social Determinants of Chronic Illness

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To accurately measure treatable causes of chronic illness in the older population, the social

determinants of chronic illness must be known. Income, accumulated wealth, education,

occupational characteristics, and social inequality based on race and ethnic group membership play

a significant role in determining if an individual will develop a chronic illness, and their likelihood

of survival (Cockerham, 2016). Often these determinants influence behavior which causes a

chronic illness to develop over time (Cockerham, 2016). These social determinants will influence

the individuals' access to resources or the way they are treated by others, which eventually will

determine whether a chronic illness will develop (Cockerham, 2016). With these determinants in

mind, universally applicable intervention strategies may be developed and applied to decrease the

likelihood of chronic illness and mortality in the older population, particularly those suffering from

depressive disorders.

Links between depression and chronic illness

A direct correlation has been found between older adults with depressive disorders and a

higher likelihood of experiencing chronic diabetes, heart problems, and arthritis (Karakus, 2011).

This problem is urgent due to the increased likelihood of depression amongst people ages 40-59

years old as 7.3% of this population has a diagnosed depressive disorder (Karakus, 2011). A study

done by Karakus, et. Al. follows a large group of aging individuals for 12 years and found core

evidence that links depression with increased likelihood of chronic illness, as well as decreased

self-reported physical health (Karakus, 2011). This study has measured for the social determinants

of the above section to exclusively study the effects of depression on chronic illnesses (Karakus,

2011). The links between depression and aging are known and measurable, but the link between

depression and chronic illness is not yet known (Karakus, 2011).

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This study has shown that there is a greater risk relationship between older and aging adults

and depressive symptoms among those who are experiencing multiple chronic diseases

simultaneously at the same time. Between 2006 and 2014, controlling for age, gender, income,

race, and a lifetime diagnosis of depression, people who transitioned to having a diagnosis of

multiple chronic conditions had significantly higher levels of depressive symptoms than people

who did not make this transition (Bazargan,2019). These studies relate to the onset of depressive

symptoms because although these are social determinants of health, the symptoms lead to higher

rates of depressive symptoms because of chronic illnesses. Both articles found further provided

research that added to the understanding that chronic illnesses such as cancer, heart disease,

diabetes, and arthritis are leading factors of depressive symptoms among older and aging adults.

Intervention Strategy

One intervention mentioned by Hale et al. (2018) is a strategically planned

interprofessional care team rounding, which is a group of professional medical staff who all go day

by day with a client’s plan for care, called a Chronic Care Management team (CCM). The study

focused on a group of six pharmacists from Nova Southeastern University College of Pharmacy,

two paramedics, medical assistants, a mental health counselor, and a palliative care and hospice

physician (Hale et al., 2018). The study was conducted as outpatient rounds once weekly for two

hours each time with the client and CCM team to discuss goals of rounding, treatment, and what

will happen in each future visit (Hale et al., 2018). This type of chronic care keeps all staff and the

patient in the same loop regarding the information, communication, and preventing barriers to each

(Hale et al., 2018). Regarding eligibility for this treatment, clients must have two or more

conditions which can last at least another year, until death, or are at a larger risk for death (Hale et

al., 2018). Additionally, this intervention strategy aimed towards prevention of services, so
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preventing the client needing to go to the hospital or receive certain medical attention (Hale et al.,

2018). The team of differing experts discusses next steps for the client in real time offering

different perspectives as to what is the best evaluation of the client’s needs.

In relation to the link between depressive symptoms and chronic illness and conditions in

the previously mentioned studies, the CCM team addresses the high number of prescriptions

correlating to a client’s illness(es), the negative outcome of mental illness while on medication and

maintaining a lifestyle (Hale et al., 2018). A strategy this team utilizes as Hale et al. mentioned

involves giving patients self-determination which gives the client control rather than feeling like

their chronic condition controls them (2018). Via a social work lens this intervention method could

be a form of motivational interviewing to promote client’s maintenance of their lifestyle.

It is difficult to measure this intervention strategy regarding patient health outcomes, as

there needs to be more research regarding the mitigation of chronic illnesses, and thus the patients’

feelings before, during, and after services are rendered. However, this strategy does promote

strengthened care services, which in turn can be argued that with better practices comes better

patient health outcomes regarding their chronic conditions (Hale et al., 2018). This intervention

strategy can be applicable to all ages, not specifically, or only the older population 65 years and up,

however, we can see increases in preventative services usage from this population (Hughes et al.,

2010). From this we can infer these services are preventative to the onset of serious chronic

conditions and illnesses.

Prevention Strategy

In this study by Hughes et al. (2010), they discussed how chronic conditions are a

fundamental problem for morbidity and death based on a large test population answer to different
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questions regarding illness, conditions, activities, and services they have, participate in, or do not

have or participate in. The prevention research studied the responses of individuals from all fifty

states, District of Columbia, Puerto Rico, Guam, and the US Virgin Islands (Hughes et al., 2010).

It was centered around consistent checkups, which decreases risk for chronic illness, gives early

notice of chronic conditions, and can help detect points for further intervention when a client is

more at-risk (Hughes et al., 2010). From the findings of the study, pneumonia, the flu, and cancer

lead the older and aging population, 65 years and up, for their morbidity and death (Hughes et al.,

2010).

The prevention strategies resulting from the data were routine check-ups, flu and

pneumococcal vaccinations, and cancer screenings were the reported preventative practices used

by the study group (Hughes et al., 2010). However, these practices can be influenced heavily by

decreasing health risk behaviors like smoking, binge drinking, not being active, and obesity

(Hughes et al., 2010) as determinants of chronic conditions. The methods used in this study for

collecting data via phone calls (Hughes et al., 2010), can be used as accessible data to that of a

CCM team (Hale et al., 2018) to inform their practice of new patients seeking intervention

services. Hughes et al. (2010) study does lack however in gaining information about that of

individuals who are currently institutionalized, or currently receiving care at a facility. With regard

to our original EBP question, this study does reflect on a numerous amount social determinants of

health and the outcomes of those determinants if left untreated and provides some preventative

services to individuals based on the idea that most individuals have equal access to these resources

at all times, which in is not the case most of the time.

Recommendations for Future Practice

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In relation to our original EBP question, our findings were a little off kilter in that what we

found was cyclical. The relationship between depressive symptoms and chronic illness in the aging

population was found to be a constant, where depressive symptoms can lead to further chronic

conditions, and chronic conditions can lead to the onset of depressive symptoms. To address the

issue of chronic illness amongst the older population, both depressive symptoms and chronic

conditions must be addressed as separate issues, then together, to promote a holistic balance within

the aging individual. Backed by the understanding of physical health status being highly predicated

upon emotional distress and depressive symptoms (Bazargan, 2019). Those with existing mental

health diagnoses, particularly depressive disorders, are also more likely to engage in behaviors that

will later lead to chronic diseases (Karakus, 2011). It can be concluded that early prevention of

depressive symptoms and emotional distress can lead to better health outcomes regarding chronic

illness. On the back end of this, seeing that depression and chronic illness maintain a cyclical

relationship, intervention in chronic illnesses will lead to improvements in mental health,

preventing further damage of physical health.

We recommend that the preventative strategies, vaccinations, cancer screenings, and

decreasing risky behavior (Hughes et al., 2010) can inform future practitioners on how chronic

conditions could arise, or how depressive symptoms could arise. Risky behavior smoking, binge

drinking, obesity (Hughes et al., 2010) can lead to more negative health outcomes and may be

influenced by depressive symptoms. However, this preventative strategy is that, and not an

intervention strategy, which is why it would be best to have this strategy inform future intervention

strategies such as Interprofessional Care Team Rounding which should be paired with regular

mental health screening and appropriate treatment of symptoms (Hale et al., 2018).
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A CCM team would be the ideal intervention strategy for future practice because it is a

carefully orchestrated team focusing on a weekly basis on the client's needs and goals to promote

the dignity and worth of the individual with chronic conditions. Even though this recommendation

is the ideal, it could be limited by the financial situation of the individual needing to receive care.

These strategies can be used in any setting with the older population, including hospice care, at-

home visits, and assisted living facilities to name a few. Regardless, this type of intervention would

allow for medical staff and social workers to behave in an ethical manner falling in line with the

code of ethics. As the most important goal for practitioners is to help people in need and with their

social problems (NASW, 2022), we recommend care team rounding (Hale et al., 2018), informed

by preventative practices (Hughes et al., 2010) as an effective intervention strategy can be used to

help in mitigating depressive symptoms and chronic conditions in the aging population.
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References

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Centers for Disease Control and Prevention. (2021, February 11). How much physical activity do

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Cockerham, W. Hamby, B. Oates, G. (2016). The social determinates of chronic disease. American

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