Note from the National Guideline Clearinghouse (NGC): In this update of the guideline, the process previously used to develop the geriatric nursing protocols has been enhanced.
Levels of evidence (I –VI) are defined at the end of the "Major Recommendations" field.
Assessment Parameters
Several studies support the use of an interdisciplinary geriatric assessment team for late-life depression (Boult et al., 2005 [Level II]; Callahan et al., 2005 [Level III]; Harpole et al., 2005; Unutzer et al., 2002 [Level II]) with the following being specific parameters of assessment:
- Identify risk factors/high risk groups:
- Current alcohol/substance use disorder (Hasin & Grant, 2002 [Level III]).
- Medical comorbidity (Alexopoulos, Schulz, & Lebowitz, 2005 [Level VI]). Specific comorbid conditions: dementia, stroke, cancer, arthritis, hip fracture, myocardial infarction, chronic obstructive pulmonary disease, and Parkinson's disease (Alexopoulos, Schulz, & Lebowitz, 2005; Butters et al., 2003 [Level VI]).
- Functional disability (especially new functional loss). Disability, older age, new medical diagnosis, and poor health status (Cole, 2005; Cole & Dendukuuri, 2003 [Level I]).
- Widows/widowers (National Institute of Health [NIH], 1992 [Level I])
- Older family caregivers, especially those caring for persons with dementia (Pinquart & Sorensen, 2004 [Level I]).
- Social isolation/absence of social support (Kraaij, Arensman, & Spinhoven, 2002; NIH, 1992 [Level I]).
- Psychosocial causes for depression in older adults include cognitive distortions, stressful life events (especially loss), chronic stress, low self-efficacy expectations (Blazer, 2002 [Level VI]; Blazer, 2003 [Level VI]; Blazer & Hybels, 2005 [Level VI]; Kraaij, Arensman, & Spinhoven, (2002) [Level I]).
- Assess all at-risk groups using a standardized depression screening tool and documentation score. The Geriatric Depression Scale-Short Form (GDS-SF) (Sheikh & Yesavage, 1986) is recommended because it takes approximately 5 minutes to administer, has been validated and extensively used with medically ill older adults, and includes few somatic items that may be confounded with physical illness (Pfaff & Almeida, 2005 [Level IV]; Watson & Pignone, 2003 [Level I]).
- 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); changes in normal mood, behavior and functioning (American Psychiatric Association, 2000 [Level VI]):
- Depressive symptoms:
- Depressed or irritable mood, frequent crying
- Loss of interest, pleasure (in family, friends, hobbies, sex)
- Weight loss or gain (especially loss)
- Sleep disturbance (especially insomnia)
- Fatigue/loss of energy
- Psychomotor slowing/agitation
- Diminished concentration
- Feelings of worthlessness/guilt
- Suicidal thoughts or attempts; hopelessness
- Psychosis (i.e., delusional/paranoid thoughts, hallucinations)
- History of depression; current substance abuse (especially alcohol); previous coping style
- Recent losses or crises (e.g., death of spouse, friend, pet; retirement; anniversary dates; move to another residence, nursing home); changes in physical health status, relationships, roles
- Obtain/review medical history and physical/neurological examination (Alexopoulos, Schulz, & Lebowitz, 2005 [Level VI]).
- Assess for depressogenic medications (e.g., steroids, narcotics, sedatives/hypnotics, benzodiazepines, antihypertensives, histamine-2 antagonists, beta-blockers, antipsychotics, immunosuppressives, cytotoxic agents).
- Assess for related systematic and metabolic processes that may contribute to depression or might complicate treatment of the depression (e.g., infection, anemia, hypothyroidism or hyperthyroidism, hyponatremia, hypercalcemia, hypoglycemia, congestive heart failure, and kidney failure) (Alexopoulos, Schulz, & Lebowitz, 2001 [Level VI]).
- Assess for cognitive dysfunction.
- Assess level of functional ability.
Care Parameters
- For severe depression (i.e., GDS score 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 electroconvulsive therapy (Arean & Cook, 2002; Hollon et al., 2005 [Level VI]).
- For less severe depression (i.e., GDS score 6 or greater, fewer than five depressive symptoms, plus other positive responses on individualized assessment), refer to mental-health services for psychotherapy/counseling (see above 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 (Arean & Cook, 2002; Hollon et al., 2005 [Level VI]).
- For all levels of depression, develop an individualized plan integrating the following nursing interventions:
- Provide an approach to depression management (Arean et al., 2005 [Level VI]; Harpole et al., 2005 [Level II]; Hegel et al., 2005 [Level II]; Unutzer et al., 2002 [Level II]).
- 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).
- Remove or control etiologic agents:
- Avoid/remove/change depressogenic medications.
- Correct/treat metabolic/systemic disturbances.
- Monitor and promote nutrition, elimination, sleep/rest patterns, and physical comfort (especially pain control).
- Enhance physical function (i.e., structure regular exercise/activity; refer to physical, occupational, recreational therapies); develop a daily activity schedule.
- Enhance social support (i.e., identify/mobilize a support person(s) [e.g., family, confidant, friends, hospital resources, support groups, patient visitors]); ascertain need for spiritual support and contact appropriate clergy.
- Maximize autonomy/personal control/self-efficacy (e.g., include patient in active participation in making daily schedules and setting short-term goals).
- Identify and reinforce strengths and capabilities.
- Structure and encourage daily participation in relaxation therapies, pleasant activities (conduct a pleasant activity inventory), and music therapy.
- Monitor and document response to medication and other therapies; readminister depression- screening tool.
- Provide practical assistance; assist with problem-solving.
- Provide emotional support (i.e., empathic, supportive listening; encourage expression of feelings and hope instillation), support adaptive coping, and encourage pleasant reminiscences.
- 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).
- Educate about the importance of adherence to prescribed treatment regimen for depression (especially medication) to prevent recurrence; educate about specific antidepressant side effects due to personal inadequacies.
- Ensure mental-health community linkup; consider psychiatric, nursing home care intervention.
Definitions:
Levels of Evidence
Level I: Systematic reviews (integrative/meta-analyses/clinical practice guidelines based on systematic reviews)
Level II: Single experimental study (randomized controlled trials [RCTs])
Level III: Quasi-experimental studies
Level IV: Non-experimental studies
Level V: Care report/program evaluation/narrative literature reviews
Level VI: Opinions of respected authorities/Consensus panels
Reprinted with permission from Springer Publishing Company: Capezuti, E., Zwicker, D., Mezey, M. & Fulmer, T. (Eds). (2008) Evidence Based Geriatric Nursing Protocols for Best Practice, (3rd ed). New York: Springer Publishing Company.
