Want to know more

DEPRESSION
Nursing Standard of Practice Protocol: Depression

Lenore H. Kurlowicz, PhD, RN, CS, Theresa A. Harvath, PhD, RN, CNS

 

Evidence-Based Content - Updated January 2008

The information in this "Want to know more" section is organized according to the following major components of the NURSING PROCESS:

 

Background

A. Depression, both major depressive disorders and minor depression, is highly prevalent in community-dwelling, medically-ill, 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, subnutrition, and increased suicide- and nonsuicide-related death.

D. Depression tends to be long lasting and recurrent. Therefore, a wait-and-see approach is undesirable, and immediate clinical attention is necessary. If recognized, treatment response is good.

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 and social and economic problems common in late life. Early recognition, intervention, and referral by nurses can reduce the negative effects of depression.


*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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Assessment Parameters

Several studies support the use of an interdisciplinary geriatric assessment team for late-life depression 1, 2, 3, 4 with the following being specific parameters of assessment:

A. Identify risk factors/high-risk groups:

1. Current alcohol /substance-use disorder 5

2. Medical comorbidity: 6 Specific comorbid conditions include dementia, stroke, cancer, arthritis, hip fracture, myocardial infarction, chronic obstructive pulmonary disease, and Parkinson’s disease. 6, 7

3. Functional disability (especially new functional loss). Disability, older age, new medical diagnosis, and poor health status. 8, 9

4. Widow/widowers 10

5. Older family caregivers, especially those caring for persons with dementia 11

6. Social isolation/absence of social support 10, 12

7. Psychosocial causes for depression in older adults include cognitive distortions, stressful life events (especially loss), chronic stress, low self-efficacy expectations. 11, 12, 13, 14, 15

B. Assess all at-risk groups using a standardized depression screening tool and documentation score. The Geriatric Depression Scale-Short Form (GDS-SF)16 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. 17, 18

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); change from normal mood, behavior, and functioning: 19

1. Depressive symptoms

2. Depressed or irritable mood, frequent crying

3. Loss of interest, 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. 6

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

F. 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, kidney failure. 6

G. Assess for cognitive dysfunction.

H. Assess level of functional ability.

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Care Parameters

A. 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 co-morbid 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. 20, 21

B. 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 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 co-morbid substance abuse is present, a referral for a comprehensive psychiatric evaluation should always be made. 20, 21

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

1. Provide an approach to depression management. 3, 4, 22, 23

2. 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).

3. Remove or control etiologic agents:

a. Avoid/remove/change depressogenic medications.

b. Correct/treat metabolic/systemic disturbances.

4. Monitor and promote nutrition, elimination, sleep/rest patterns, physical comfort (especially pain control).

5. Enhance physical function (i.e., structure regular exercise/activity; refer to physical, occupational, recreational therapies); develop a daily activity schedule.

6. 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.

7. Maximize autonomy/personal control/self-efficacy (e.g., include patient in active participation in making daily schedules, short-term goals).

8. Identify and reinforce strengths and capabilities.

9. Structure and encourage daily participation in relaxation therapies, pleasant activities (conduct a pleasant-activity inventory), music therapy.

10. Monitor and document response to medication and other therapies; re-administer depression-screening tool.

11. Provide practical assistance; assist with problem-solving.

12. Provide emotional support (i.e., empathic, supportive listening, encourage expression of feelings, hope instillation), support adaptive coping, encourage pleasant reminiscences.

13. 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).

14. 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.

15. Ensure mental-health community link-up; consider psychiatric, nursing-home-care intervention.

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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. Health care provider:

1. Early recognition of patient at risk, referral, and interventions for depression, and documentation of outcomes will be improved.

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

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Other Clinical Practice Guidelines

A. Practice guideline for the treatment of patients with major depressive disorder. American Psychiatric Association—Medical Specialty Society, 1993 (revised 2000; reviewed 2005). 45 pages. NGC: 001831. Retrieved on June 6, 2007, from http://www.guideline.org/summary/summary.aspx?doc_id=2605&nbr=001831&string=depression.

B. Detection of depression in the cognitively intact older adult. University of Iowa Gerontological Nursing Interventions Research Center, Research Translation and Dissemination Core—Academic Institution, 1998 (revised 2005 May). 33 pages. NGC: 004519. Retrieved on June 6, 2007, from http://www.guideline.org/summary/summary.aspx?doc_id=8112&nbr=004519&string=depression

C. Depression. American Medical Directors Association—Professional Association, 2003. 36 pages. NGC: 003520 AMDA. Retrieved on June 6, 2007, from http://www.guideline.org/summary/summary.aspx?doc_id=4952&nbr=003520&string=depression

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For Definition of Levels of Quantitative Evidence Click Here

Reprinted with permission from Springer Publishing Company. Kurlowicz, L. H. & Harvath, T. A. (2008). Depression. In E. Capezuti, D. Zwicker, M. Mezey, & T. Fulmer (Eds.) Evidence-Based Geriatric Nursing Protocols for Best Practice (3rd ed.), New York: Springer Publishing Company, Inc.

References

1. Boult, C., Boult, L. B., Morishita, L., Dowd, B., Kane, R. L., & Urdangarin, C. F. (2001). A randomized clinical trial of outpatient geriatric evaluation and management. Journal of the American Geriatrics Society, 49, 351–359. Evidence Level II: Single Experimental Study.

2. Callahan, C. M., Kroenke, K., Counsell, S. R., Hendrie, H. C., Perkins, A. J., Katon, W. et al. (2005). Treatment of depression improves physical functioning in older adults. Journal of the American Geriatrics Society, 53(3), 367–373. Evidence Level III: Quasi-experimental Study.

3. Harpole, L. H., Williams, J. W. J., Olsen, M. K., Stechuchak, K. M., Oddone, E., Callahan, C. M., et al. (2005). Improving depression outcomes in older adults with co-morbid medical illness. General Hospital Psychiatry, 27(1), 4–12. Evidence Level II: Single Experimental Study.

4. Unutzer, J., Katon, W., Callahan, C. M., Williams, J. W. J., Hunkeler, E., Harpole, L., et al. (2002). Collaborative care management of late-life depression in the primary care setting: A randomized controlled trial. Journal of the American Medical Association, 288(22), 2836–2845. Evidence Level II: Single Experimental Study.

5. Hasin, D. S., & Grant, B. F. (2002). Major depression in 6,050 former drinkers: Association with past alcohol dependence. Archives of General Psychiatry, 59, 794–800. Evidence Level III: Quasi-experimental Study.

6. Alexopoulos, G. S., Schultz, S. K., & Lebowitz, B. D. (2005). Late-life depression: A model for medical classification. Biological Psychiatry, 58, 283–289. Evidence Level VI: Expert Opinion.

7. Butters, M. A., Sweet, R. A., Mulsant, B. H., Kamboh, M. I., Pollock, B. G., Begley, A. E., et al. (2003). APOE is associated with age-of-onset, but not cognitive functioning, in late-life depression. International Journal of Geriatric Psychiatry, 18, 1075–1081. Evidence Level IV: Nonexperimental Study.

8. Cole, M. G. (2005). Evidence-based review of risk factors for geriatric depression and brief preventive interventions. Psychiatric Clinics of North America, 28(4), 785–803. Evidence Level I: Systematic Review.

9. Cole, M. G., & Dendukuuri, N. (2003). Risk factors for depression among elderly community subjects: A systematic review and meta-analysis. American Journal of Psychiatry, 160(6), 1147–1156. Evidence Level I: Meta-analysis.

10. National Institute of Health (NIH) Consensus Development Panel (1992). Diagnosis and treatment of depression in late life. Journal of the American Medical Association, 268, 1018–1024. Evidence Level I: Systematic Review.

11. Pinquart, M., & Sorensen, S. (2004). Associations of caregiver stressors and uplifts with subjective well-being and depressive mood: A meta-analytic comparison. Aging & Mental Health, 8(5), 438–449. Evidence Level I: Systematic Review.

12. Kraaij, V., Arensman, E., & Spinhoven, P. (2002). Negative life events and depression in elderly persons: A meta-analysis. Journals of Gerontology: Series B: Psychological Sciences and Social Sciences, 57B(1), P87–P94. Evidence Level I: Meta-analysis.

13. Blazer, D. G. (2002). Depression in Late Life. Mosby Year Book (3rd ed.). Level of Evidence VI: Expert Opinion.

14. Blazer, D. G. (2003). Depression in late life: Review and commentary. Journals of Gerontology: Series A: Biological Sciences and Medical Sciences, 58A(3), 249–265. Evidence Level VI: Expert Opinion.

15. Blazer, D. G., & Hybels, C. F. (2005). Origins of depression in late life. Psychological Medicine, 35(9), 1241–1252. Evidence Level VI: Expert Opinion.

16. Sheikh, J. I., & Yesavage, J. A. (1986). Geriatric depression scale (GDS) recent evidence and development of a shorter version. Clinical Gerontologist, 5, 165–173.

17. Pfaff, J. J., & Almeida, O. P. (2005). Detecting suicidal ideation in older patients: Identifying risk factors within the general practice setting. British Journal of General Practice, 55(513), 261–262. Level of Evidence IV: Nonexperimental Study.

18. Watson, L. C., & Pignone, M. P. (2003). Screening accuracy for late-life depression in primary care: A systematic review. Journal of Family Practice, 52(12), 956–964. Evidence Level I: Systematic Review.

19. American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th ed., TR). Washington, DC: American Psychiatric Association. Evidence Level VI: Expert Opinion.

20. Arean, P. A., & Cook, B. L. (2002). Psychotherapy and combined psychotherapy/pharmacotherapy for late-life depression. Biological Psychiatry, 52(3), 293–303. Evidence Level VI: Expert Opinion.

21. Hollon, S. D., Jarrett, R. B., Nierenberg, A. A., Thase, M. E., Trivedi, M., & Rush, A. J. (2005). Psychotherapy and medication in the treatment of adult and geriatric depression: Which monotherapy or combined treatment? Journal of Clinical Psychiatry, 66(4), 455–468. Evidence Level VI: Expert Opinion.

22. Arean, P. A., Ayalon, L., Hunkeler, E., Lin, E. H. B., Tang, L., & Harpole, L. (2005). Improving depression care for older minority patients in primary care. Medical Care, 43(4), 381–390. Evidence Level VI: Expert Opinion.

23. Hegel, M. T., Unutzer, J., Tang, L., Arean, P. A., Katon, W., Noel, P. H., et al. (2005). Impact of co-morbid panic and post-traumatic stress disorder on outcomes of collaborative care for late-life depression in primary care. American Journal of Geriatric Psychiatry, 13(1), 48–58. Evidence Level II: Single Experimental Study.

Last updated - January 2008

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