Depression: Older Adult Patients (Home Health Care) - CE/NCPD

The content in Clinical Skills is evidence based and intended to be a guide to clinical practice. Always follow your organization’s practice.

ALERT

Older adults are among those at the highest risk for committing suicide.

OVERVIEW

All depressive disorders (e.g., major depressive disorder [MDD], persistent depressive disorder, mood dysregulation disorder) share certain characteristics, such as the presence of sad, empty, or irritable mood accompanied by related changes that significantly affect the individual’s capacity to function (Box 1).^{undefined#ref2">2} Risk factors include a combination of genetic, biologic, and environmental factors, such as a family history of depression, traumatic childhood events, polypharmacy, stressful life events, and certain acute or chronic medical and psychiatric conditions (including substance use disorders) (Box 2).^2,7

Screening is recommended for all adults older than age 18 years, regardless of risk factors.⁷ Annual screenings are recommended for patients who do not have a known history of depression.⁴ Opportunistic screenings should be completed for adults who have not been screened previously, and clinical judgment should be used to determine if additional screening is warranted based on risk factors, comorbid conditions, and life events.⁷ Commonly used depression screening instruments include the Patient Health Questionnaire (PHQ)-2 and PHQ-9 (for all ages), the Center for Epidemiologic Studies Depression Scale (CES-D) (for adults), and the Geriatric Depression Scale (GDS) (for older adults).⁷

Treatment of conditions that can present similar to depression, such as substance use (prescribed or illicit) or medical conditions (e.g., vitamin B-12 deficiency, hypothyroidism) (Box 1),⁴ may decrease or resolve depressive symptoms.⁶ Therefore, a positive screening result indicates the need for a comprehensive patient assessment, which should include a psychiatric diagnostic evaluation and laboratory testing (Box 3), along with a referral to a specialized licensed independent practitioner (LIP) (e.g., endocrinologist, cardiologist) as needed or appropriate.⁶

Individualized treatment recommendations (e.g., psychotherapy, medication, electroconvulsive therapy [Table 1]) should be based on a variety of factors, such as coexisting conditions, current depressive symptoms, the patient’s age and history of treatment response, and potential drug-drug interactions.⁶ However, collaboration with the patient through shared decision-making with consideration for the patient’s values and preferences is crucial; even the most efficacious, evidence-supported treatment may have no therapeutic benefit if the patient is unable or unwilling to adhere to the treatment plan.³

Experiencing periods of sadness is an inherent part of being human.² In contrast, depression is a serious condition, which, with timely identification and treatment (including treatment of contributing or causative factors), allows for the opportunity to prevent progression of the condition along with the associated effects on overall well-being (e.g., decreased quality of life).⁷

SUPPLIES

See Supplies tab at the top of the page.

EDUCATION

• Provide education that is up to date, evidence informed, and culturally appropriate based on the desire for knowledge, readiness to learn, learning style or preferred learning method, developmental stage, and overall neurologic and psychosocial state.
• Discuss potential manifestations of depression, including signs and symptoms of increased risk for suicide (Box 4).
• Provide education on the importance of monitoring for and reporting emotional, affective, and physiologic changes or dysregulation.
• Discuss crisis management and steps to take if relapse or symptom exacerbation occurs (e.g., verbalizing statements indicating suicidal ideation or feelings of worthlessness), including information about local, regional, and national supports (e.g., self-help groups, peer support groups) and emergency resources.
• Encourage questions and answer them as they arise.

PROCEDURE

1. Prior to patient interaction, determine if the patient requires tools or assistance to effectively communicate and ensure that the patient’s needs are met, as applicable and appropriate.
2. Perform hand hygiene. Don appropriate personal protective equipment (PPE) based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
3. Using simple and concise language, introduce yourself and explain your role and the objective of the current interaction.
4. Verify the correct patient using two identifiers.
5. If the patient is willing and able, provide opportunities for the patient to participate in assessments privately (e.g., without family or caregivers present).

   Rationale: Providing opportunities for private assessments promotes patient confidentiality and can increase the likelihood of the patient sharing in a more open and honest manner.

6. Confirm the patient’s desire for the family or caregivers to be involved in treatment. Consider the family’s or caregivers’ ability to support the patient during treatment.
   1. If available, verify applicable patient documentation regarding permission to release information. Check releases of information prior to disclosure of any patient information to ensure that the release has not expired or been rescinded by the patient.
   2. Be aware of and understand laws and regulations regarding situations in which the patient’s expressed consent or refusal for others to be aware of or involved in the patient’s care may be superseded (e.g., if the patient has a legal guardian).
7. Perform a thorough patient assessment, using a trauma-informed care approach. Maintain an open, engaging, and nonjudgmental demeanor.
   1. Evaluate the patient’s overall mental status (e.g., level of orientation, mood, affect, cognitive function, presence of hallucinations), including the patient’s insight into the situation and ability to make rational responses and decisions in the context of the current presentation and symptoms.
   2. Privately, ask if the patient feels safe or is being harmed in any way (e.g., psychological or physical harm, financial exploitation, not having access to or receiving appropriate nutrition).

      Rationale: Asking about the patient’s safety privately promotes patient confidentiality and can increase the likelihood of the patient sharing in a more open and honest manner.

      As a mandated reporter, report abuse in accordance with elder abuse laws, which may vary from state to state.¹

   3. Use a standardized tool or process to screen for depressive symptoms.
   4. Based on the results of the screening, complete a more in-depth depression assessment, including assessing symptoms and effect on the patient’s functioning.
      1. Determine if the patient has a history of similar presentations of depression. If so, determine the suspected or confirmed etiology (e.g., medical or psychiatric condition) and effectiveness of the interventions used.
      2. Ascertain details regarding potential patterns or triggers that may be associated with the patient’s current and historical presentations.
   5. Use validated screening and assessment tools to assess the patient for suicidal ideation,^5,6 thoughts of self-harm, and thoughts of harming others.⁶
      1. Ask about the frequency and intensity of recent and past suicidal, self-harm, and homicidal thoughts or behaviors.
      2. Determine if the patient has a history of self-harm (including suicidal and nonsuicidal acts), marked or prolonged agitation, or aggression towards others.
      3. Determine if the patient is able to recognize the onset of suicidal, self-harm, or homicidal thoughts or urges and is able and willing to report when or if thoughts or urges occur.⁶

         Follow the organization’s practice for mental health emergencies, such as contacting local law enforcement for assistance if the patient is demonstrating a risk for harming the self or others.

   6. Review the patient’s medical and mental health history. Determine if the patient has medical or psychiatric conditions that could cause or contribute to the current presentation and reported symptoms (Box 2).
   7. Complete a physical assessment.
      1. Assess for physical injuries, including possible signs of abuse or neglect, such as bruising or dehydration.
      2. Assess the patient’s nutrition status (e.g., weight changes).
      3. Assess for signs and symptoms of conditions associated with an increased risk for experiencing depressive symptoms or depression (e.g., cardiovascular, metabolic, neurologic, or inflammatory diseases) (Box 2).²
      4. Review any recent diagnostic testing results (Box 3), if available, and perform additional testing as indicated, per LIP orders or the organization’s practice.

         Rationale: Assessing for comorbid conditions (e.g., medical, psychiatric, or both) and potential medical etiologies assists with determining the most appropriate treatment and care.

   8. Review current and historical medications to determine these items:
      1. Patient’s knowledge and understanding of prescription indications and viewpoint on each medication’s efficacy
      2. Adherence (i.e., taking as prescribed)
      3. Potential interactions (e.g., drug-drug, drug-food)
      4. Adverse effects, such as effects on the patient’s activity level or movements (e.g., akathisia, sedation), toxicity risk, and risk for emotional or behavioral manifestations, such as depressive symptoms or agitation

         Rationale: Polypharmacy is a risk factor for depression in older adults.⁶

8. If the patient provides consent, obtain additional assessment information (e.g., recent changes in mental status, depressive symptoms, medical and psychiatric history) from collateral informants (e.g., family, caregivers, any other involved persons).
9. Notify the designated LIP of assessment findings and concerns, as appropriate.
10. Obtain specialist referrals (e.g., psychiatric practitioner, occupational therapist, nutritionist, neurologist, endocrinologist), as indicated.
11. Engage the patient in collaborative treatment planning. Incorporate the patient’s feelings, questions, concerns, and perspective along with coexisting physical, medical, or psychiatric health conditions and previous treatment history.
    1. Explore factors that may be contributing to the current situation (e.g., psychological stressors, comorbid psychiatric and medical conditions).⁶
    2. Consider social, cultural, and situational factors that may help to identify relevant stressors, precipitants, or other situational variables that may affect patient functioning. Assist with guiding treatment recommendations.
    3. Assess the patient’s living situation (e.g., risk for social isolation and increased loneliness).
    4. Determine the patient’s goals for treatment.
    5. Review factors that may affect the patient’s ability or willingness to fully engage in treatment (e.g., patient preferences, patient’s experiences with previous treatments [positive and negative]).^3,6
    6. Discuss and address any barriers to treatments (perceived and actual).⁶
12. Review the determined treatment plan, including discussion of goals, benefits, and risks.
    1. If the patient poses a risk to self or others, initiate interventions immediately to promote and maintain safety.

       Ensure that a patient who has a specific suicide plan is not left alone. If weapons, medications, or any other lethal means are in the home, arrange for their immediate removal.

    2. If psychotherapy is a part of the patient’s ongoing treatment plan, encourage the patient’s participation in therapy sessions and provide any additional support, as needed or appropriate to the situation.
    3. If pharmacologic methods are implemented as part of the patient’s treatment plan, discuss and provide information about these items:
       1. Reason for the medication (e.g., expected benefits)
       2. Dose and administration information (e.g., how often and when the medication should be taken)
       3. Potential harms (e.g., side effects and adverse effects, such as serotonin syndrome and an increased risk of suicide towards the initiation of the antidepressant)
       4. How long it may take to see a medication effect (e.g., effects of antidepressant medications may take up to 4 weeks to notice)⁶
       5. The importance of following the prescribed regimen
13. Ensure that team members who may be involved in caring for the patient are aware of the patient’s relevant medical or psychiatric conditions, history of trauma, behavioral issues, and related triggers.
14. At each home visit, perform these steps:
    1. Assess the patient for behavior and mood changes. Continually assess for signs and symptoms of depression and suicidal ideations.
    2. Assess the patient for changes in cognition.
    3. Assess for physical injuries (e.g., wounds from self-harm, signs of physical trauma).
    4. Assess for signs and symptoms of conditions associated with an increased risk for experiencing depressive symptoms or depression (e.g., cardiovascular, metabolic, neurologic, or inflammatory diseases).²
    5. Assess the patient’s response to the medication regimen, including adverse reactions.
15. If the patient is unwilling or unable to participate in care (e.g., follow directions, uphold safety measures, participate in assessments), be prepared to:
    1. Complete assessments as thoroughly as possible. Information obtained from observation can yield valuable information (Box 5).
    2. Notify the LIP of the patient’s inability or refusal to participate in care and any observed behaviors, as appropriate.
    3. Consider contacting support services (e.g., emergency medical services) if the patient or situation does not appear to be safe.
16. Remove PPE and perform hand hygiene.
17. Document the procedure in the patient’s record.

EXPECTED OUTCOMES

• Health care team members employ therapeutic communication and a trauma-informed care approach during interactions.
• Health care team members respond safely and in a timely manner to unsafe or crisis situations, concerning behavior, or behavioral issues.
• Based on the patient’s desire for knowledge, readiness to learn, learning style or preferred learning method, and overall neurologic and psychosocial state:
  • Patient is able to identify symptoms of depression.
  • Patient is able to identify how to access assistance if needed (e.g., increase in depressive symptoms).
  • Patient is able to identify goals for treatment.
• Patient and health care team members collaborate to develop a treatment plan.
• Patient, health care team members, other patients, and visitors do not sustain injury.

UNEXPECTED OUTCOMES

• Therapeutic communication and a trauma-informed care approach are not utilized or not used during interactions.
• Health care team members do not respond safely or in a timely manner to crisis situations, concerning behavior, or behavioral issues.
• Health care team members do not communicate with or educate the patient effectively.
  • Patient is not able to identify symptoms of depression.
  • Patient is not able to identify how to access or when to request additional assistance.
  • Patient is not able to identify goals for treatment.
• Patient and health care team members are unable to collaborate to develop a treatment plan.
• Patient, health care team members, other patients, or visitors sustain injury.

DOCUMENTATION

• Details of assessments (e.g., neurologic, mental status, physical), including objective observations, findings, patient reports, and the patient’s level of participation
• Objective description of observed signs of depression, including standardized tools used for assessments
• Patient’s progress toward goals, as applicable
• Patient’s views and preferences regarding treatment and treatment goals
• Results of laboratory or other diagnostic testing results, as applicable
• Strategies and interventions used and their associated effectiveness, including the patient’s response to medications and related adverse effects
• Family’s or caregivers’ involvement in the patient’s assessment and care, as applicable
• Information obtained from collateral informants relevant to the patient’s care
• Consultation requests and referrals, including interdisciplinary communication
• Changes made to the plan of care
• Risk factors related to home health staff safety
• Practitioner communication or notifications, including receipt of orders
• Education
• Unexpected outcomes and related interventions

OLDER ADULT CONSIDERATIONS

• Older adults should be given realistic prognoses so that they may develop realistic expectations regarding their physical status.
• Older adults should be encouraged to use coping mechanisms that they have used successfully in the past.
• Depressive symptoms in older adults may be exhibited differently and be less obvious than in younger adults.

REFERENCES

1. American Bar Association (ABA) Commission on Law and Aging. (2022). Adult Protective Services reporting laws. Retrieved January 31, 2024, from https://www.americanbar.org/content/dam/aba/administrative/law_aging/2020-elder-abuse-reporting-chart.pdf
2. American Psychiatric Association. (2013, revised 2022). Depressive disorders. In DSM-5-TR: Diagnostic and statistical manual of mental disorders (5th ed., text rev., pp. 177-214). Washington, DC: Author.
3. American Psychological Association (APA). (2019). APA Clinical practice guideline for the treatment of depression across three age cohorts. Retrieved January 31, 2024, from https://www.apa.org/depression-guideline/guideline.pdf
4. Department of Veterans Affairs (VA), Department of Defense (DoD). (2022). VA/DoD Clinical practice guideline for the management of major depressive disorder. Retrieved January 31, 2024, from https://www.healthquality.va.gov/guidelines/MH/mdd/VADoDMDDCPGFinal508.pdf
5. Joint Commission, The. (2024). National Patient Safety Goals for the hospital program. Retrieved January 31, 2024, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2024/npsg_chapter_hap_jan2024.pdf
6. National Institute for Health and Care Excellence (NICE). (2022). NICE guideline: Depression in adults: Treatment and management (NG222). Retrieved January 31, 2024, from https://www.nice.org.uk/guidance/ng222/resources/depression-in-adults-treatment-and-management-pdf-66143832307909
7. U.S. Preventive Services Task Force (USPSTF) and others. (2023). Screening for depression and suicide risk in adults: U.S. Preventive Services Task Force recommendation statement. JAMA, 329(23), 2057-2067. doi:10.1001/jama.2023.9297

Clinical Review: Kristin Bursey, MSN, PMHNP-BC, RN-BC, PHN, RDH

Published: March 2024