Evidence-Based Content - Updated August 2012
The information in this "Want to know more" section is organized according to the following major components of the NURSING PROCESS:
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.
A. Identify risk factors/high risk groups
1. Current alcohol /substance-use disorder (Ref 1)
2. Specific comorbid conditions: dementia, stroke, cancer, arthritis, hip fracture, myocardial infarction, chronic obstructive pulmonary disease, and Parkinson’s disease (Ref 2; 3)
3. Functional disability (especially new functional loss) (Ref 4; 5)
4. Widow/widowers (Ref 6)
5. Caregivers (Ref 7)
6. Social isolation/absence of social support (Ref 8)
7. Diminished perception of light in one's environment (Ref 9)
B. Assess all at-risk groups using a standardized depression screening tool and documentation score. The GDS-SF 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. (Ref 10; 11)
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 (Ref 12)
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. (Ref 13)
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 (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 ability.
A. For severe depression (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. (Ref 14; 15)
B. For less severe depression (GDS 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. (Ref 14; 15)
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:
a. Avoid/remove/change depressogenic medications.
b. Correct/treat metabolic/systemic disturbances.
3. Monitor and promote nutrition, elimination, sleep/rest patterns, physical comfort (especially pain control).
4. Enhance physical function (i.e., structure regular exercise/activity; refer to physical, occupational, recreational therapies); develop a daily activity schedule.
5. 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.
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), 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, 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).
13. 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.
14. Ensure mental health community link-up; consider psychiatric, nursing home care intervention.
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.
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
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 processes.
From Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th Edition. © Springer Publishing Company, LLC.
3. 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.
5. 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.
6. 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.
7. 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.
8. 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.
10. 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.
13. Alexpoulos, G.S., Katz, I.R., Reynolds, C.F., 3rd, Carpenter, D., & Docherty, J.P. (2001). The expert consensus guidelines series: Pharmacotherapy of depressive disorders in older patients (Special report). Postgraduate Medicine, 1-86. Evidence Level VI.
15. 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.
Last updated - August 2012
These protocols were revised and tested in NICHE hospitals.