Why is recognising depression important in working with older people in hospitals?

Depression is not a normal part of ageing.

Depression is under-recognised and inadequately treated in many older people.

Misdiagnosis of depression delays treatment, increases the risk of functional decline and slows the rate of recovery [54].

Depression is a serious condition that can be life threatening. During a hospital admission, depression is associated with:

• increased risk of death
• loss of independent function
• poor response to rehabilitation and diminished recovery
• poor post-operative recovery
• increased length of stay
• increased health care use after discharge
• increased re-admission rates
• cognitive impairment [54].

Major depression occurs in one to three per cent of the general older population, with a further eight to 16 per cent having clinically-significant depressive symptoms. The incidence of depression in long-term care settings is three to four times higher than in the general population. Sleep disturbances can result in cognitive impairment and depression, with prevalence rates of insomnia in people over 65 years of age reaching 12 to 30 per cent.

Depression can be effectively treated in older people resulting in improved mood, improved function and an increased quality of life [54].

What is depression?

Clinical depression is characterised by at least two weeks of depressed mood or loss of interest or pleasure, accompanied by at least four additional symptoms of depression: Disturbed sleep.

Psychomotor agitation/retardation (Psychomotor agitation refers to a series of unintentional and purposeless movements due to an individual's mental tension, such as pacing or hand wringing. Psychomotor retardation refers to a slowing of thought, coordination and speech, and presents as sluggishness or confusion in speech).

Feelings of worthlessness.

Recurrent thoughts of death or suicidal ideation.

Depression presents as a complex combination of behaviours, thoughts, feelings and physical symptoms that are severe and lasting (such as withdrawing from people and activities, neglecting personal appearance and commitments, moodiness, indecisiveness, lack of energy).

In the most severe form (psychotic) a person has delusions (false beliefs, typically of being a bad person, deserving punishment or that bad things will happen) and hallucinations that may involve hearing voices, smelling bad smells or other physical sensations [54].

Depression can be an acute or chronic condition. It can occur for the first time in an older person, or could be a recurrence or relapse of a previous episode of depression.

Further information

Can I help prevent depression?

Early identification and treatment of depression is critical in minimising functional decline and can contribute to a quicker recovery.

To prevent a recurrence of depression or to keep symptoms from getting worse, individuals should:

Seek treatment immediately at the first sign of symptoms of depression.

Continue with cognitive-behaviour therapy or interpersonal therapy, even after medications have been stopped.

Avoid drugs and alcohol.

Maintain strong connections with family and friends.

Others (for example, family, clinicians) should:

Increase awareness of depression.

Provide realistic hope.

Promote gradual re-engagement.

Facilitate a sense of achievement (for example, provide a role or responsibility within the person's capacity).

Avoid isolation (for example, a single room in hospital).

Make time to listen, encourage recall of positive memories.

Although research on preventing the onset of depression in older people is limited, the main focus has been on public education and regular physical activity.

How can I recognise depression?

It is important to be alert to the following risk factors:

• A past history of depression.
• Chronic and acute stress.
• Cardiovascular disease. There is now strong evidence of an association between heart disease and depression [56].
• Drug and alcohol abuse.
• Lack of material support or emotional support from others.
• Physical disability (for example, associated with a stroke).
• Chronic medical illness (for example, chronic pain).
• Cognitive decline.
• Grief in response to the loss of a loved one, especially the death of a wife, husband or life partner, or loss of opportunities or abilities.
• People caring for a family member with chronic illness - particularly dementia.

Families or carers are often best placed to recognise a change in the older person's normal ways of thinking and reacting to situations.

Depression screening tools

Screening is a rapid and simple process that can be undertaken by staff other than mental health specialists. The choice of tool should be made based on the health care setting, who will be conducting the screening, training requirements, likely compliance and follow-up care available.

Differential diagnosis

In order to provide appropriate care to an older person, clinicians must be able to differentiate between changes in mental status due to dementia and those due to an acute health condition.

Further information

What can I do if I recognise that an older person has depression?

Refer the older person to a mental health specialist (for example, a psychiatrist, clinical psychologist, psychiatric nurse) for a diagnostic assessment. In rural and regional centres, where specialists are not available or access is limited, an assessment can typically be conducted by a general practitioner.

If an older person is diagnosed with depression, ensure appropriate treatment starts quickly.

What are the care or management principles I should follow if an older person has depression?

When an older person is diagnosed with depression and treatment has commenced, focus on the following areas of care: Use gentle but persistent encouragement to engage the person in tasks. Have the whole health care team adopt a consistent approach.

Emphasise even small progress and avoid criticism.

Encourage achievable tasks to enhance self-esteem and avoid failure.

Encourage regular contact with family, friends and carers, by telephone if they are unable to visit.

Provide a level of stimulation and interaction appropriate to the person's abilities [54].

Assist patients to:

Mobilise for personal care activities as much as possible.

Practice mobilisation (under prescription, direction or instruction by physiotherapist).

Undertake theraband strengthening exercises (under prescription, direction or instruction by physiotherapist).

In different settings of care

Emergency Department (ED)

Identification is a priority and screening is recommended.

If depression is likely, contact their usual general practitioner (GP) and assist with making an appointment, as necessary.

Refer to a mental health specialist for risk assessment if suicidal ideas are expressed.

Acute

If not conducted in ED, an admission screen is recommended in general medical wards.

If possible, liaise with Consultant Liaison Psychiatry if a diagnostic assessment is required or an older person's condition deteriorates.

Mood should be observed and monitored daily.

Medication and psychological treatment may be commenced.

A patient's usual GP should be contacted prior to discharge.

Sub-acute (in-patient)

Admission and discharge screening is recommended.

If possible, refer to Consultant Liaison Psychiatry and/or Clinical Psychology for a diagnostic assessment if required.

A treatment plan of medication and psychological intervention is usually recommended.

Every person is different and has different needs for their specific treatment plan to address.

Consider day, overnight or weekend leave to promote the patient's engagement in their usual activities and social supports. This may be contraindicated if the patient is suicidal, unless a careful risk management plan with supervision is available.

Sub-acute (ambulatory)

Screen on admission.

Contact GP and assist the patient with making a GP appointment, as necessary.

At night

Night time can be particularly challenging for older people with depression. Difficulty getting to sleep, restlessness, nightmares or waking early are common. Night time and darkness is lonely and the lack of distractions can lead to pondering over fears or feelings of hopelessness.

If the older person's suicidal risk is high, an additional nurse may need to be allocated to observe and monitor the patient. Removing any means to act on suicidal ideas is critical.

An evening shower, clean sheets and a warm drink at night may be helpful. The reassurance of a familiar staff member who is willing to listen, can be comforting. It may also be easier for some people to express their thoughts and feelings when the ward is quieter [54].

What needs to be considered when planning discharge for an older person with depression?

The main emphasis of the discharge plan is promoting continued improvement in mental health through:

Psychological intervention.

Social connectedness.

Regular contact with the patient's GP.

What can patients, families or carers do to help someone with depression in hospital and at home?

In hospital

Bring familiar and comforting items from home (for example, photos, favourite doona).

Match the depressed older person's pace in conversation (in other words, speak slower) and activities (anticipate that it will take longer to finish a task).

Talk about usual family events and activities and reminisce about positive memories.

If a depressed person has a large number of family and friends, develop a schedule for visiting that is evenly spread throughout the week.

At home

Assist with maintenance of daily routine and weekly activities.

Engage them in low demand tasks (for example, wiping the dishes).

Reinforce hope. The likelihood of improvement is high.

Support treatment, including medication adherence and attending appointments with GP, psychiatrist or psychologist.

Encourage participation in previously enjoyed activities.

Promote manageable social contact (for example, arrange dinner with one or two friends).

Case study

Scenario 1

During a six day admission in an acute stroke unit, Mrs Phillips does not initiate showering or dressing and is very slow. She prefers to remain in bed during the day and sleeps often throughout the day. She is very quiet and tearful and does not speak to staff. She refuses to participate in physiotherapy. Her balance has not improved and she has made minimal progress in her mobility. She has developed a Stage 2 pressure ulcer on her heel. She is transferred to a sub-acute stroke rehabilitation unit.

A morning rehabilitation program, which includes physiotherapy and occupational therapy, is provided to Mrs Phillips. During the first week, she attends physiotherapy twice but does not participate. For the next two weeks, she does not attend her program despite encouragement from therapists. It is noted that she is not sleeping well at night and wakes early. After a three week admission, she has not improved and has experienced further functional decline. A discharge plan to residential accommodation is discussed with her.

Three days later, it is noted that Mrs Phillips has not eaten since the discussion about discharge, and referrals to Dietetics and Speech Pathology are made. Respectively, the assessments indicate a low body mass index (BMI) and no swallowing difficulties. A social worker rings Mrs Phillips' daughter and discusses her condition. Her daughter suggests that her mother may be depressed. She indicates that Mrs Phillips' husband died 15 months ago and she has become socially isolated. A medical mood screen indicates features consistent with a depressive illness and medication is commenced. Food intake is encouraged by all staff, and after four days Mrs Phillips begins eating again. Three days later, due to her poor mobility and de-conditioning, she is discharged to a residential care facility.

Scenario 2

Utilising the following strategies from The toolkit:

Early identification of possible factors contributing to presentation.

Use of validated depression screening tool to identify risk of depression in first 24 hours of admission.

Activity participation is maximised by teams during acute and sub-acute admission through a structured daily activity program.

Persistent and consistent encouragement by team members to engage in tasks, and enhancing self-esteem through adapting program to be achievable (for example, morning only).

Assessment by a mental health specialist.

A treatment plan of medication and psychological intervention.

Comprehensive discharge planning for ongoing treatment of depression. The multidisciplinary team, in discussion with Mrs Phillips, sets up a structured daily (written) program that includes: physiotherapy, occupational therapy, music therapy, clinical psychology, reminiscence group, indoor walking group and afternoon bingo (run by an allied heath assistant and volunteer). In addition to monitoring pressure areas, nursing staff in particular focus on encouraging progress, listening to her concerns, and being present at night when sleeping is a problem. The ward social worker contacts her daughter and, with Mrs Phillips' permission, also provides information on depression and suicide. She arranges a meeting with Mrs Phillips and her daughter to explore discharge options.

Initially Mrs Phillips does not attend her program. The team conduct a treatment planning meeting with Mrs Phillips. She is provided with verbal and written information about her potential progress and, after significant encouragement from the team, agrees to attend the morning program. After three weeks, Mrs Phillips' depressive symptoms are improving and she agrees to participate in her entire program. Her balance has improved and she is attending an outdoor walking group. Her food intake and hydration have improved and she is not as tearful. She is still slow with showering and dressing, but does not require assistance. She does, however, require reminders about her daily program.

After another three weeks, Mrs Phillips is attending her program independently, has gained weight, and is sleeping better. She smiles and engages in social conversation. Her discharge is arranged for later in the week and she is moving interstate to live with her daughter. Her daughter has discussed a role for Mrs Phillips in minding her grandchildren one afternoon a week, when she is feeling very well. She is not as concerned about being a burden and is looking forward to living with her family. Two of Mrs Phillips' old friends live close to her daughter and she is looking forward to this social contact. Her daughter is aware that she will need to assist her mother with establishing a routine and weekly activity program, based on her interests. A treatment program will be set up with the assistance of a GP and both Mrs Phillips and her daughter are aware that full recovery could take approximately six months.

Further reading

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