Geriatric Depression Assessment and Plan of Care

It is difficult to imagine approximately 5.6 to 8 million Americans 65 years or older are diagnosed with a mental health or substance-use disorder (Bartels & Naslund, 2013, p. 493). Furthermore, it is estimated by 2030 these numbers will not decrease, rather, increase. It is estimated 10.1 to 14.4 million geriatric patients will be diagnosed with a mental illness by 2030 (Bartels & Naslund, 2013, p.493). Specifically within the geriatric population, mental health providers recognize depression is a common mental health concern worldwide.

Depression has several factors that are disabling. Depression has a significant impact on a patient's physical health, emotional health and general quality of life. For some, just waking up to see a new day of life could be a difficult challenge to overcome. Older adults are normally characterized as happy and satisfied with their quality of life. However, research proves this is not always true.

Depression is common among the geriatric population, however, it is most prevalent among older residents living in nursing homes. In a randomized controlled trial, researchers in the United Kingdom evaluated residents among care homes. The geriatric population assessed were that of those 65 years or older. Researchers excluded all residents who they deemed "too ill" or diagnosed with a terminal illness. Together, historical data shows individuals susceptible to developing depression have other health related co-morbidities of which commonly include macular degeneration and stroke according to researchers Bartels and Naslund (2013). Other related health conditions collected within the historical data assessment includes urinary incontinence, dementia, anxiety, cancer, osteoporosis and chronic lung disease (Underwood et al., 2013). Those who are affected by depression also reported during historical data collection their lack of education, unemployment status and their lack of personal financial stability (Nair, Hiremath, Ramesh, Pooja, & Nair, 2013). In other words, the geriatric population does not actively seek mental health care, as the affordability is an issue. If a patient were required to choose paying for their much needed diabetic supplies, versus seeking medical treatment, they would without hesitation spend their funding on their diabetic supplies. After all, they could die if their diabetic supplies are not refilled adequately.

Assessment data recorded amongst the geriatric population was a major component within depressive research. Collectively, it was important to gather assessment data such as the Geriatric Depression Scale (GDS), Mini Mental State Exam (MMSE), European Qualify of Life-5 Dimensions (EQ-5D), current pain level and the individual's "fear of falling" score (Underwood et al., 2013, p. 43). Demographic data such as the patients' age, race, height, weight, mid-arm circumferences and hip circumferences were also proven to be beneficial for researchers. It was important to assess the level of malnutrition among the geriatric population. When assessed for depression, a 24-hour diet food recall was completed (Ahmadi et al., 2013). It was also found beneficial to gather data including how many years of education the geriatric patient received and how many years were spent living inside of their home (Underwood et al., 2013).

Mental health is often viewed as a forgotten part of healthcare. Unlike physical illnesses, mental health illnesses cannot always be diagnosed and determined by an x-ray or abnormal lab value. Rather, they are often evaluated by questionnaires and surveys. In determining the depressive findings among older adults, researchers must examine the above mentioned tests.

The Geriatric Depression Scale (GDS) ranges from a score of 0 to 15. Furthermore, the scoring of the exam is classified as 0-4 normal, 5-8 mild depression, 9-11 moderate depression and 12-15 severe depression (Greenberg, 2012). If a patient scores greater than 5 points on the Geriatric Depression Scale (GDS), depression is warranted (Greenberg, 2012). If a patient scores greater than 10 on the GDS, this is clearly indicative of depression.

It is statistically proven the Geriatric Depression Scale provides an accurate account of the level of depression amongst the geriatric patient population. The scale consists of series of questions compiled into a questionnaire. Researchers have developed a long form and a short form. The geriatric population is able to simply answer "yes" or "no" to questions such as, "Do you feel that your life is empty?" (Greenberg, 2012, para 8).

Although this tool cannot be replaced by a complete and thorough evaluation by a mental health provider, it can provide a baseline of their mental illness. Nurses and caregivers can easily perform this test in order to assess whether or not further mental health care is indicated. Research demonstrates the scale should be performed regularly amongst older adults in resident care homes and community centers. The short 5-7 minute form could potentially save an older adult's life.

The GDS score is typically the depression diagnostic evaluator for the geriatric population. However, healthcare professionals should also evaluate the Mini Mental State Exam (MMSE) score thoroughly, as it may provide other rationales for the patient's behavioral and/or emotional concerns. Further, the GDS score does not present information on the patient's assessment of suicidal ideation. That crucial piece of information should be meticulously examined at the time of the examination.

Other scales mentioned in assessing depression among geriatric adults are Beck Depression Inventory (BDI) and the Hamilton Rating Scale for Depression (Cooney et al., 2013). The type(s) of scales used are dependent on the healthcare provider's choice of preference.

In evaluating for a physiological reason as to the patient's emotional concerns, labs such as a complete blood count, comprehensive metabolic panel, thyroid stimulating hormone, vitamin C and vitamin D should be drawn, as a part of the assessment procedure. A urine analysis should also be assessed. Depending on the sex of the patient being assessed, testosterone and estrogen levels should also be evaluated. Often, a slight abnormality within the lab workup can cause irrational, abnormal behavior.

If a patient meets the criteria for the diagnosis of depression, it is important to explain to the patient what their diagnosis means. Most patients have heard of the word depression, but have never developed any thought into what it might entail. The word depression for some can be shameful to hear. This can make the patient feel even more saddened, after learning he/she has been diagnosed. After the patient has a grasp on what depression consists of, and how the provider came to their diagnostical decision, options for treatment should be explained.

Antidepressants may be the first intervention implemented by the mental health provider. Antidepressants are known to be an effective type of therapy for those suffering from depression. However, before pharmacological techniques are introduced, a change in the patient's lifestyle could be a simple and effective treatment. Exercise therapy has been suggested by researchers in the past, as being as effective if not more effective than antidepressant medication (Cooney, et al., 2013). Although ultimately an antidepressant medication may be required in order for the patient to live a happy life, exercise therapy can be suggested in conjunction to the medication. If the patient would rather attempt natural remedies for treating his/her depression, proper nutrition, exercise therapy and peer support would be beneficial for their plan of care (Bartels & Naslund, 2013).

A team approach must be taken to initiate the interventions suggested in the patient's plan of care. The patient, their family, nurses, physicians, social workers, physical therapists and pharmacists should work together as a team to strive for one common goal: maintaining a happy and fulfilling life for the patient in need. The team should suggest non-pharmacological interventions such as joining a social club, going on a walk, visiting with friends on a regular basis and eating a balanced diet. These are just a few of the many suggestions the team could suggest the patient attempt, prior to prescribing an antidepressant. If these techniques are unsuccessful, the team should evaluate the medication regimen the patient is currently prescribed and consider the safest antidepressant available to administer.

If the patient is at risk for suicidal ideation, family members and/or staff at the care home should be notified and preventative measures should be taken immediately. The patient should be informed of the serious side effects of the medication. Mental health patients often believe they are cured after noticing significant improvement after taking an antidepressant for a prolonged period of time. However,if used for longer than six weeks, all antidepressants have the potential to cause withdrawal syndromes if they are stopped or rapidly reduced (Keks, Hope, & Keogh 2016, p. 76). Therefore, the risks of abruptly stopping their medication should be emphasized by the patient's health care team.

Conclusively, as the baby boomer generation continues to age, physical and mental health illnesses will rise. The geriatric population may actively seek medical help in order to treat their physical illnesses, however, healthcare personnel from all areas of the field should be cognizant of unrecognized depressive symptoms. A diagnosis of depression should be taken seriously and acted upon. After recognition, healthcare teams should act quickly and implement non-pharmacological and if needed, pharmacological measures immediately.

References

Ahmadi, S.M., Mohammadi, M.R., Mostafavi, S.A., Keshavarzi, S., Alikooshesh, S.M., Joulaei, H., Sarikhani, Y., Peimani, P., Heydari, S.T., & Lankarani, K.B. (2013). Dependence of the geriatric depression on nutritional status and anthropometric indices in elderly population. Iranian Journal of Psychiatry, 8(2), 92-96. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3796300/pdf/IJPS-8-92.pdf

Bartels, S. & Naslund, J. (2013). The under side of the silver tsunami-older adults and mental health care. The New England Journal of Medicine, 368(6), 493-496. Retrieved from https://www.nejm.org/doi/pdf/10.1056/NEJMp1211456

Chang, C.F., Lin, M.H., Wang, J., Fan, J.Y., Chou, L.N., & Chen, M.Y. (2013). The relationship between geriatric depression and health-promoting behaviors among community-dwelling seniors. Journal of Nursing Research, 21(2), 75-82. doi: 10.1097/jnr.0b013e3182921fc9

Cooney, G.M., Dwan, K., Greig, C.A., Lawlor, D.A., Rimer, J., Waugh, F.R., McMurdo, M., & Mead, G. E. (2013). Exercise for depression. Cochrane Database of Systematic Reviews, 9, doi: 10.1002/14651858.CD004366.pub6

Greenberg, S.A. (2012). The geriatric depression scale (GDS). Hartford Institute for Geriatric Nursing, 4. Retrieved from https://consultgeri.org/try-this/general-assessment/issue-4.pdf

Keks, N., Hope, J., & Keogh, S. (2016). Switching and stopping antidepressants. Australian Prescriber, 39(3), 76“83. Retrieved from https://doi.org/10.18773/austprescr.2016.039

Nair, S.S., Hiremath, S.G., Ramesh, Pooja, & Nair, S.S. (2013). Depression among geriatrics: prevalence and associated factors. International Journal of Current Research and Review, 5(8), 110-112. Retrieved from https://pdfs.semanticscholar.org/730e/5946fb4d126fd54512bd8a6c1472ed53160c.pdf.

Underwood, M., Lamb, S.E., Eldridge, S., Sheehan, B., Slowther, A.M., Spencer, A., Thorogood, M., Atherton, N., Bremner, S., Devine, A., Diaz-Ordaz, K., Ellard, D., Potter, R., Spanjers, K., & Taylor, S. (2013). Exercise for depression in elderly residents of care homes: a cluster-randomised controlled trial. The Lancet, 382(9886), 41-49. Retrieved from https://www.sciencedirect.com/science/article/pii/S0140673613606492

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