The grades of evidence (A-D) are defined at the end of the "Major Recommendations" field.
Individuals at Risk for Depression
The following characteristics increase the risk for major depression: (American Psychiatric Association [APA], 2000. Evidence Grade = B).
- A prior episode of major depression
- A family history for depressive disorders
- A personal history of prior suicide attempts
- Being female
- Recent loss of a spouse
- Medical co-morbidity (See Table 2 in the original guideline document)
- Lack of social supports
- Stressful life events, such as death of a loved one, divorce
- Current alcohol or substance abuse
Older individuals are at increased risk for depression because they frequently exhibit several of these risk factors simultaneously. In addition, caregivers of persons with dementia are extremely vulnerable to depression secondary to the burden of caregiving. Prevalence rates, ranging from 30 to 83% (Baumgarten et al., 1992; Cohen & Eisdorfer, 1988; Drinka, Smith, & Drinka, 1987; Gallagher et al., 1989; Kiecolt-Glaser et al., 1991; Schulz & Martire, 2004) are consistently reported in the literature. Elderly persons caring for their grandchildren are also at higher risk for depression (Burton, 1992; Fuller-Thomson & Minkler, 2000; Minkler et al., 1997). Major depression is one of the most prevalent conditions occurring concurrently with post-traumatic stress disorder (PTSD) (O'Donnell, Creamer, & Pattison, 2004) and increases the risk for suicidal behavior (Oquendo et al., 2005).
Assessment Criteria
Any individual over age 60, who is identified as at risk according to the factors listed earlier (e.g., caregiver, socially isolated, bereaved, physically ill), should be evaluated for depression (APA, 2000. Evidence Grade = B).
In practice, detection of depression in the older adult is a complex process and there are many factors which may interfere with detection. According to Rouchell and colleagues (Rouchell, Pounds, & Tierney, 2002), reasons for the under-diagnosis and under-treatment of depression in medically ill patients include the following:
- Emphasis on somatic rather than cognitive and mood complaints
- Reluctance to stigmatize patient with psychiatric diagnosis
- Mild or nonspecific symptoms of depression
- Fear of antidepressant side effects
- Mistaken notion that reactive depressions are not pathological (e.g., "She should be depressed; she has cancer.")
- Time limitations in primary care
- Inadequate training in psychiatry among primary care providers
Attitudes are difficult to change and time limitations will continue to be a limiting factor so detection methods must be quick. Training and education of health care staff can improve detection rates and health care outcomes.
Detection of depression is further hampered by the way depressive symptoms are manifested in the elderly. Whereas sad mood is a prominent feature of depression in younger persons, it isn't always a symptom in older adults (Kane, Ouslander, & Abrass, 2004). In contrast to younger persons, presentation of depression in older adults may be characterized by the following:
- Complaints of somatic (physical) symptoms, rather than psychological symptoms
- Denial of feeling sad
- Apathy and withdrawal are common.
- Feelings of guilt are less common.
- Feelings of loss of self-esteem are prominent.
- Inability to concentrate, impairment of memory, and other cognitive function is common.
Description of Practice
The following assessment is a simple, but effective practice that can be widely used to screen for the presence of clinically significant depressive symptoms. This is a screening process, not a diagnostic process. Positive screens should be followed with a diagnostic evaluation by a physician or nurse practitioner.
- Assess for cognitive impairment using the Mini Mental State Exam (MMSE) (See Appendix A-1 in the original guideline document). If the patient scores 23 or above (normal cognitive function), administer the Short form of the Geriatric Depression Scale (SGDS) (See Appendix A-2 in the original guideline document).
If the patient scores below 23 on the MMSE, establish whether this is an acute change in mental status (see Research Translation and Dissemination Core [RTDC] guideline for "Acute Confusion/Delirium" by Rapp, 1998) or typical mental status for this individual (Folstein, Folstein, & McHugh, 1975. Evidence Grade = B). (For non-acute and/or progressive mental status changes and associated agitated behaviors please refer to the RTDC guideline "Non-pharmacologic Management of Agitated Behaviors in Persons with Alzheimer Disease and Other Dementing Conditions" by McGonigal-Kenny & Schutte [2004]). The Cornell Scale for Depression in Dementia (Alexopoulos, Abrams, & Young, 1988) and the Apparent Emotions Rating scale (Ryden et al., 1998) are available to assess depression among cognitively impaired older adults.
- The suggested cutoff score for SGDS is 6 (Eisdorfer, Rovner, & Whitehouse, 2001; Sheikh & Yesavage, 1986; Evidence Grade = B), therefore, if the patient scores 6 or greater on the SGDS, notify the primary health care provider (i.e., physician and/or geriatric/psychiatric mental health nurse practitioner) of the patient's increased risk for major depression and the need for further evaluation, treatment, and referral.
- If the patient scores below 6 on the SGDS, monitor the patient's mood (document decreased speech, irritability, or tearfulness), sleep, (document for difficulty falling asleep, frequent awakenings, and early morning awakening), and appetite (document poor appetite, weight loss, poor wound healing). If symptoms continue, repeat the MMSE and SGDS every week or more frequently if necessary. Patients who score below 6 (subsyndromal) depression are at high risk for developing major depression. If early treatment is not elected, these patients should be followed closely for the development of major depression (Williams et al., 1995). Their discharge plan should include recommendations for monitoring depression levels in the community or other health care settings.
Nursing Interventions
The Nursing Interventions Classification (NIC) is a comprehensive, standardized classification of interventions that nurses perform. The Classification includes the interventions that nurses do on behalf of patients, both independent and collaborative interventions, both direct and indirect care. An intervention is any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes. NIC can be used in all settings (from acute care intensive care units, to home care, to hospice, to primary care) and all specialties (from critical care to ambulatory care and long term care) (Dochterman & Bulecheck, 2004).
Please refer to the original guideline document for the Nursing Interventions Classification.
Priority Interventions
These are the obvious interventions associated with the guideline. They were selected because they provide a good match with the focus of the guideline.
Health Screening -- Detecting health risks or problems by means of history, examination, and other procedures
Suicide Prevention -- Reducing risk of self-inflicted harm with intent to end life
Definitions:
Evidence Grading
- Evidence from well-designed meta-analysis
- Evidence from well-designed controlled trials, both randomized and nonrandomized, with results that consistently support a specific action (e.g., assessment, intervention or treatment)
- Evidence from observational studies (e.g., correlational descriptive studies) or controlled trials with inconsistent results
- Evidence from expert opinion or multiple case reports
