Depression

Contrary to popular belief, depression is not a normal part of aging.  Rather, depression is a medical disorder that causes suffering for patients and their families, interferes with a person's ability to function, exacerbates coexisting medical illnesses, and increases use of health services (Lebowitz, 1996).  Despite the efficacious treatments available for late-life depression, many older adults lack access to adequate resources; barriers in the health care reimbursement system are particular challenges for low income and ethnic minority older adults (Charney et al., 2003).  In a comprehensive review of research on the prevalence of depression in later life, Hybels and Blazer (2003) found that although major depressive disorders are not prevalent in late life (1%-5%), the prevalence of clincially significant depressive symptoms is high (3%-30%).  What is more, these depressive symptoms are associated with higher morbidity and mortality rates in older adults than in younger adults (Bagulho, 2002; Lyness et al., 2007). 

Late-life depression often occurs within a context of medical illnesses, disability, cognitive dysfunction, and psychosocial adversity, frequently impeding timely recognition and treatment of depression, with subsequent unnecessary morbidity and death (Bagulho, 2002; Lyness et al., 2007).  A substantial number of older patients encountered by nurses will have clinically relevant depressive symptoms.  Nurses remain at the frontline in the early recognition of depression and the facilitation of older patient's access to mental health care.  

 

BACKGROUNDa

A.  Depression—both major and minor depressive disorders—is highly prevalent in medically ill, functionally impaired, and institutionalized older adults.

B.  Depression is not a natural part of aging or a normal reaction to acute illness hospitalization.

C.  Consequences of depression include amplification of pain and disability, delayed recovery from illness and surgery, worsening of drug side effects, excess use of health services, cognitive impairment, poor nutrition, and increased suicide and nonsuicide-related death.

D.  Depression (major and minor) tends to be long lasting and recurrent. Therefore, comprehensive and timely approaches are necessary.

E.  Somatic symptoms may be more prominent than depressed mood in late-life depression.

F.   Mixed depression and anxiety features may be evident among many older adults.

G.  Recognition of depression is hindered by the coexistence of physical illness, cognitive decline, and social and economic problems common in late life. Early recognition, intervention, and referral by nurses can reduce the negative effects of depression.

ASSESSMENT PARAMETERS

Identify risk factors/high-risk groups (APA, 2013; Aziz & Steffens, 2013; Melrose, 2018; Smith et al., 2015; Taylor, 2014).

A.  Biological contributors

  1. Vascular disease (MI, CAD, CVA)
  2. General health (new medical illness, pain, insomnia, prior depression, history of suicide attempt, concomitant substance abuse)
  3. Dementia (vascular and Alzheimer’s disease)
  4. Other chronic or disabling medical conditions (diabetes, Parkinson’s disease, arthritis, low vision, COPD)
  5. Psychosocial contributors
  6. Personality attributes (personality disorder, low self-efficacy)
  7. Life stressors (trauma, low income, impaired function, disability)
  8. Social stressors (bereavement, loneliness, impaired social support, caregiving)

B.  Screen all at-risk groups using a standardized depression screening tool and document score

1.  The GDS-SF is recommended for its brevity, validity, and extensive use with medically ill older adults, and inclusion of few somatic items that may be confounded with physical illness.

2.  The PHQ-9 and PHQ-2 are recommended for their brevity, validity with older as well as younger adults, and availability in hospital and primary care settings.

C.  Perform a focused depression assessment on all at-risk groups and document results. Note the number of symptoms; onset; frequency/patterns; duration (especially 2 weeks); and change from normal mood, behavior, and functioning.

  1. Depressive symptoms
  2. Depressed or irritable mood, frequent crying
  3. Loss of interest or pleasure (in family, friends, hobbies, sex)
  4. Weight loss or gain (especially loss)
  5. Sleep disturbance (especially insomnia)
  6. Fatigue/loss of energy
  7. Psychomotor slowing/agitation
  8. Diminished concentration
  9. Feelings of worthlessness/guilt
  10. Suicidal thoughts or attempts, hopelessness
  11. Psychosis (i.e., delusional/paranoid thoughts, hallucinations)
  12. History of depression, current substance abuse (especially alcohol), previous coping style
  13. Recent losses or crises (e.g., death of spouse, friend, pet; retirement; anniversary dates; move to another residence, nursing home); change in physical health status, relationships, roles

D.  Obtain/review medical history and physical/neurological examination.

E.  Assess for depressogenic medications (e.g., steroids, narcotics, sedative/hypnotics, benzodiazepines, antihypertensive, H2 antagonists, beta-blockers, antipsychotics, immunosuppressive, cytotoxic agents).

F.   Assess for related systematic and metabolic processes (e.g., infection, anemia, hypothyroidism or hyperthyroidism, hyponatremia, hypercalcemia, hypoglycemia, congestive heart failure, kidney failure).

G.  Assess for cognitive dysfunction.

H.  Assess level of functional disability and quality of life.

CARE PARAMETERS

Based on guidelines and reviews (APA, 2010; Melrose, 2018; Pinquart et al., 2006; Taylor, 2014)

A.  For severe depression (GDS-SF score of 11 or greater, five to nine depressive symptoms [must include depressed mood or loss of pleasure] plus other positive responses on individualized assessment [especially suicidal thoughts or psychosis and comorbid substance abuse]), refer for psychiatric evaluation. Treatment options may include medication or cognitive behavioral, interpersonal, or brief psychodynamic psychotherapy/counseling (individual, group, family); hospitalization; or ECT.

B.  For less severe depression (GDS-SF score 6 or greater, less than five depressive symptoms, plus other positive responses on individualized assessment), refer to mental health services for psychotherapy/counseling (see previous types), especially for specific issues identified in individualized assessment and to determine whether medication therapy may be warranted. Consider resources such as psychiatric liaison nurses, geropsychiatric advanced practice nurses, social workers, psychologists, and other community and institution-specific mental health services. If suicidal thoughts, psychosis, or comorbid substance abuse are present, a referral for a comprehensive psychiatric evaluation should always be made.

C.  For all levels of depression, develop an individualized plan integrating the following nursing interventions:

  1. Institute safety precautions for suicide risk as per institutional policy (in outpatient settings, ensure continuous surveillance of the patient while obtaining an emergency psychiatric evaluation and disposition).
  2. Remove or control etiologic agents.
    • Avoid/remove/change depressogenic medications.
    • Correct/treat metabolic/systemic disturbances.
  3. Monitor and promote symptom management of depression and anxiety (e.g., supporting individuals to improve nutrition, elimination, sleep/rest patterns, physical comfort [especially pain control], mindfulness interventions; routine aerobic and strength exercise programs).
  4. Monitor and enhance physical function (i.e., structure regular exercise/activity; refer to physical, occupational, or recreational therapies); develop a daily activity schedule.
  5. Enhance social support and reduce isolation (i.e., identify/mobilize a support person(s) [e.g., family, confidant, friends, hospital resources, support groups]); ascertain need for spiritual support and contact appropriate clergy.
  6. Maximize autonomy/personal control/self-efficacy (e.g., include patient in active participation in making daily schedules, short-term goals).
  7. Identify and reinforce strengths and capabilities.
  8. Structure and encourage daily participation in relaxation therapies, pleasant activities (conduct a pleasant activity inventory), and music therapy.
  9. Monitor and document response to medication and other therapies; readminister depression screening tool.
  10. Provide practical assistance; assist with problem-solving.
  11. Provide emotional support (i.e., empathic, supportive listening, encourage expression of feelings, hope instillation), support adaptive coping, and encourage pleasant reminiscences.
  12. Provide information about the physical illness and treatment(s) and about depression (i.e., that depression is common, treatable, and not the person’s fault). Include attention to addressing potential fear and stigma associated with depression.
  13. Educate about the importance of adherence to prescribed treatment regimen for depression (especially medication) to prevent recurrence; educate about specific antidepressant side effects.
  14. Ensure mental health community link-up; consider collaborative care programs.

EVALUATION OF EXPECTED OUTCOMES

A.  Patient

  1. Patient safety will be maintained.
  2. Patients with severe depression will be evaluated by psychiatric services.
  3. Patients will report a reduction of symptoms that are indicative of depression. A reduction in the GDS score will be evident, and suicidal thoughts or psychosis will resolve.
  4. Patient’s daily functioning will improve.

B.  Healthcare provider

  1. Document risk assessment, interventions initiated for depression, progress of patients with depressive symptoms, and referrals.
  2. Provide support and depression-specific education to patients and their families (and other caregivers) via written and verbal information on depression and its management, including how families or carers can support the person.
  3. Conduct medication review for potential drug–drug interactions.
  4. Evaluate physiological findings necessitating adjustment (e.g., liver and renal function).

C.  Institution

  1. The number of patients identified with depression will increase.
  2. The number of in-hospital suicide attempts will not increase.
  3. The number of referrals to mental health services will increase.
  4. The number of referrals to psychiatric nursing home care services will increase.
  5. Staff will receive ongoing education on depression recognition, assessment, and interventions.
  6. Develop collaborative depression care management programs.

FOLLOW-UP TO MONITOR CONDITION

A.  Continue to track prevalence and documentation of depression in at-risk groups.

B.  Show evidence of transfer of information to postdischarge mental health service delivery system.

C.  Educate caregivers to continue assessment and management strategies.

ABBREVIATIONS

APA            American Psychiatric Association

CAD            Coronary artery disease

COP            Chronic obstructive pulmonary disease

CVA            Cerebrovascular accident

GDS-SF      Geriatric Depression Scale–Short Form

MI               Myocardial infarction

PHQ            Patient Health Questionnaire

__________________

a Somatic symptoms, also seen in many physical illnesses, are frequently associated with A and B; therefore, the full range of depressive symptoms should be assessed.

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Updated: November 2020

Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti PhD, RN, FAAN, E., Zwicker DrNP, APRN, BC, D., & Fulmer PhD, RN, FAAN, T. T. (2020). Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed.). Springer Publishing. Retrieved November 4, 2020, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826188144.html#description

REFERENCES

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Press. Evidence Level IV.

Aziz, R., & Steffens, D. C. (2013). What are the causes of late-life depression? Psychiatric Clinics of North America, 36(4), 497–516. doi:10.1016/j.psc.2013.08.001. Evidence Level V.

Melrose, S. (2018). Late life depression: Nursing actions that can help. Perspectives in Psychiatric Care, 2018, 1–6. doi:10.1111/ppc.12341. Evidence Level VI.

Pinquart, M., Duberstein, P. R., & Lyness, J. M. (2006). Treatments for later-life depressive conditions: A meta-analytic comparison of pharmacotherapy and psychotherapy. American Journal of Psychiatry, 163(9), 1493–1501. doi:10.1176/ajp.2006.163.9.1493. Evidence Level I.

Smith, M., Haedtke, C., & Shibley, B. (2015). Late-life depression detection. Journal of Gerontological Nursing, 41(2), 18–25. doi:10.3928/00989134-20150115-01. Evidence Level V.

Taylor, W. D. (2014). Depression in the elderly. New England Journal of Medicine, 371(13), 1228–1236. doi:10.1056/NEJMcp1402180. Evidence Level IV.