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Jul.15.2020View related content

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

ALERT

Older adults are among those at the highest risk for committing suicide.2 Assess for suicidal ideation in all older adult patients suspected of being depressed and obtain an order for a psychiatric practitioner consult if suicidal ideation is present.

OVERVIEW

Depression interferes with a person’s ability to function daily and in many cases requires treatment to manage symptoms. Depression is the most predominant mood disorder among older adults worldwide.2 It is a serious public health concern and is associated with significant functional disability. Many older adults face significant life changes and stressors that put them at risk for depression. There is also evidence that many physical illnesses affecting older adults are associated with depression; these include cardiovascular disease, diabetes, Parkinson disease, and illnesses associated with chronic pain.9

Depression is frequently unrecognized and untreated in the home setting because it is thought to be a normal part of the aging process. Because depression can impact the patient’s response to care and quality of life, assessing for and addressing its signs and symptoms is important. Differentiating between depression and normal grief also is important.5

Forms of depression include minor depression, psychotic depression, and seasonal affective disorder.1 Depression involves symptoms of depressed mood, diminished interest or pleasure in almost all activities, changes in sleep and appetite, increased fatigue, social withdrawal, feelings of worthlessness, poor memory and concentration, and suicidal ideation.1

Depression is not a normal part of aging and when diagnosed can be successfully treated in most people.2 Older adults have more expected losses, so grieving and sadness are common; if sadness persists, depression should be considered. The onset of depression later in life may contribute to dementia and cardiovascular problems.10 In addition, older adults may have substance use issues, which complicate and worsen the depression.7

Depression increases suicide risk. Specific risk factors for older adults include:11

  • Chronic illness, including those that cause severe or chronic pain
  • Family history of depression
  • Living alone, social isolation
  • Polypharmacy
  • Substance abuse or dependence
  • Reduced sense of purpose

EDUCATION

  • Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
  • Instruct the patient, family and caregivers regarding all treatments.
  • Instruct the patient, family and caregivers on the signs and symptoms of depression.
  • Instruct the patient, family and caregivers to report any change or worsening in the patient’s normal mood or behavior.
  • Instruct the patient, family and caregivers to report any suicidal ideation.
  • Instruct the family and caregivers on the steps to take if the patient verbalizes statements indicating suicidal ideation or feelings of worthlessness.
  • Instruct the patient, family and caregivers on the effects, potential adverse reactions, and drug-drug interactions of all prescribed medications.
  • Instruct the patient, family and caregivers on how to maintain adequate nutrition and hydration.
  • Encourage questions and answer them as they arise.

PROCEDURE

  1. Perform hand hygiene.
  2. Introduce yourself to the patient, family, and caregivers.
  3. Verify the correct patient using two identifiers.
  4. Explain the procedure to the patient, family, and caregivers, and ensure that the patient agrees to treatment.
  5. Verify the practitioner’s order and assess the patient for pain.
  6. Complete a comprehensive admission assessment, including psychiatric–mental health history and depression screening.8
  7. Assess the patient for symptoms of depression.
  8. Assess the patient for suicidal or homicidal ideation or thoughts of self-harm. Use an organization-approved standardized tool for suicide assessment.6 Assess for a specific suicide plan or history of suicide attempts.
    Rationale: A history of suicide attempts places the patient at a higher risk for another attempt.
  9. After obtaining the patient’s consent, obtain additional assessment information from the family and caregivers and any other involved persons without the patient present.
  10. Obtain a complete list of medications, as provided by the patient, family, or caregivers, or all, during the admission visit.
    Rationale: Assess the medications that the patient is taking, including over-the-counter medications, vitamins, and herbal supplements. 4 Polypharmacy is a risk factor for depression in older adults. 3
  11. Assess the patient for current or past substance use.
  12. Assess the patient for possible signs of abuse or neglect, such as bruising or dehydration.
  13. Assess the patient’s nutrition and hydration status.
  14. Use direct, matter-of-fact communication techniques with the patient.
    Rationale: Direct questioning with a matter-of-fact attitude provides clear communication regarding what is being assessed.
  15. Assess the patient for signs of grieving.
    Rationale: Determining if a patient is exhibiting symptoms of grief or depression is important. When experiencing grief, a patient’s feelings, emotions, and behaviors typically come as a result of a loss. These feelings typically come in waves and diminish in intensity over time.
  16. Contact the practitioner to obtain an order for a psychiatric practitioner consult if the patient exhibits worsening signs and symptoms of depression or suicidality.
    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.
    Determine if the patient is a danger to others. If safety is at risk, contact local law enforcement for assistance.
    Follow the organization’s practice for mental health emergencies.
  17. Assess the patient for behavior and mood changes during each home visit.
  18. Assess the patient for changes in cognition at each interaction.
  19. Instruct the patient, family, and caregivers regarding prescribed antidepressant medication and possible interactions with other drugs.
    Rationale: Patients should be instructed on the effects and possible adverse reactions associated with their medications and potential drug-to-drug interactions.
    Rationale: Antidepressant therapy may not take effect for 4 to 6 weeks, 2 so the patient will need encouragement to continue with the prescribed medications.
  20. Assess the patient’s living situation and address issues of social isolation and increased loneliness in the plan of care.
  21. Perform ongoing assessments for signs and symptoms of depression and suicidal ideations.
  22. Assess the patient’s response to the medication regimen, including adverse reactions.
  23. Assess pain, treat if necessary, and reassess.
    Rationale: Chronic pain is a risk factor for depression. 2
  24. Perform hand hygiene.
  25. Document the procedure in the patient’s record.

EXPECTED OUTCOMES

  • Patient’s depression is managed or resolved.
  • Patient adheres to treatment regimen.
  • Patient does not cause harm to self or others.

UNEXPECTED OUTCOMES

  • Patient’s depression does not resolve.
  • Depression worsens.
  • Patient attempts to hurt self or others.
  • Patient does not adhere to treatment.
  • Death results from suicide.

DOCUMENTATION

  • All assessment findings
  • Information from family and caregivers regarding the patient’s usual mood and behavior compared with the current mood and behavior
  • Patient’s participation level
  • Any verbalization of depression or suicidal ideation
  • Pertinent responses made by the patient
  • Interdisciplinary communication
  • Changes made to the plan of care
  • Risk factors related to home health staff safety
  • All interventions
  • Patient’s response to interventions
  • Patient’s response to medication, including any adverse reactions
  • Any referrals or consults
  • Education
  • Contact with the practitioner
  • Orders received
  • Unexpected outcomes and related interventions
  • Patient’s progress toward goals
  • Assessment of pain, treatment if necessary, and reassessment

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 Psychiatric Association. (2013). Depressive disorders. In DSM-5: Diagnostic and statistical manual of mental disorders (5th ed., pp. 155-188). Washington, DC: Author. (classic reference)* (Level VII)
  2. Casey, D.A. (2017). Depression in older adults: A treatable medical condition. Primary Care: Clinics in Office Practice, 44(3), 499-510. doi:10.1016/j.pop.2017.04.007
  3. Davies, L.E. and others. (2020). Adverse outcomes of polypharmacy in older people: Systematic review of reviews. Journal of the American Medical Directors Association, 21(2), 181-187. doi:10.1016/j.jamda.2019.10.022 (Level I)
  4. Fick, D.M. and others. (2019). American Geriatrics Society 2019 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 67(4), 674-694. doi:10.1111/jgs.15767 (Level VII)
  5. Hale, D., Marshall, K. (2019). Depression and loss in older adults. Home Healthcare Now, 37(6), 353-354. doi:10.1097/NHH.0000000000000828
  6. Joint Commission, The. (2020). National patient safety goals. Hospital accreditation program. Retrieved June 24, 2020, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/npsg_chapter_hap_jan2020.pdf (Level VII)
  7. Lehmann, S.W., Fingerhood, M. (2018). Substance-use disorders in later life. The New England Journal of Medicine, 379(24), 2351-2360. doi:10.1056/NEJMra1805981
  8. Pilotto, A. and others. (2017). Three decades of comprehensive geriatric assessment: Evidence coming from different healthcare settings and specific clinical conditions. Journal of the American Medical Directors Association, 18(2), 192-e1-192e11. doi:10.1016/j.jamda.2016.11.004 (Level I)
  9. Puyat, J.H. and others. (2017). Comorbid chronic general health conditions and depression care: A population-based analysis. Psychiatric Services, 68(9), 907-915. doi:10.1176/appi.ps.201600309 (Level VI)
  10. Van Damme, A. and others. (2018). Late-life depression: Issues for the general practitioner. International Journal of General Medicine, 11, 113-120. doi:10.2147/IJGM.S154876
  11. Westefeld, J.S. and others. (2015). Suicide and older adults: Risk factors and recommendations. Journal of Loss & Trauma, 20(6), 491-508. doi:10.1080/15325024.2014.949154.

ADDITIONAL READINGS

Haigh, E. and others. (2018). Depression among older adults: A 20-year update on five common myths and misconceptions. The American Journal of Geriatric Psychiatry, 26(1), 107-122. doi:10.1016/j.jagp.2017.06.011

*In these skills, a “classic” reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice.

Elsevier Skills Levels of Evidence

  • Level I - Systematic review of all relevant randomized controlled trials
  • Level II - At least one well-designed randomized controlled trial
  • Level III - Well-designed controlled trials without randomization
  • Level IV - Well-designed case-controlled or cohort studies
  • Level V - Descriptive or qualitative studies
  • Level VI - Single descriptive or qualitative study
  • Level VII - Authority opinion or expert committee reports

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