Depression

Depression is more than a low mood; it is a serious illness that impairs a person’s ability to function and causes significant distress for them and their family¹.

Depression presents as a complex combination of:

• behaviours – such as withdrawing from people and activities, neglecting personal appearance and commitments
• thoughts – for example, indecisive, negative comments
• feelings– such as moodiness and irritability
• physical symptoms – for example, unexplained headaches or pain, digestive upsets or nausea, dizziness, constipation.

Depression can be an acute or chronic condition. It can occur for the first time in an older person (referred to as late onset or late-life depression) or can be a recurrence or relapse of a previous episode².

Depression is a serious illness

Characteristics of clinical depression

Clinical depression (major depressive disorder or depressive episode) is characterised by five or more of the following symptoms during the same two-week period. The symptoms must represent a change in functioning and include a depressed mood or loss of interest or pleasure. Symptoms include the following³:

• Depressed mood most of the day, nearly every day (subjectively reported or objectively observed; for example, reports feeling sad or empty; appears tearful).
• Marked decreased interest or pleasure in all, or almost all, activities most of the day, nearly every day (subjectively reported or objectively observed).
• Significant weight loss or gain (more that five per cent of body weight in a month) or increased or decreased appetite (nearly every day).
• Insomnia or hypersomnia (feeling sleepy throughout the day) nearly every day.
• Psychomotor agitation or retardation nearly every day (observable and not merely subjective feelings of restlessness or being slowed down). For example, unintentional and purposeless movements due to mental tension (such as pacing or hand wringing); or slowing of thought, coordination and speech, presenting as sluggishness or confusion in speech.
• Fatigue or loss of energy nearly every day.
• Feelings of worthlessness or excessive or inappropriate guilt (may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
• Diminished ability to think or concentrate, or indecisiveness, nearly every day (subjectively reported or objectively observed).
• Recurrent thoughts of death (not just fear of dying) or suicidal ideation without a specific plan, or a suicide attempt or specific plan for committing suicide.
• These symptoms cannot be attributed to direct physiological effects of a substance or general medical condition.

Subtypes of major depression include melancholic (a severe form of depression where many of the physical symptoms are present, particularly moving slowly, and where more likely there is a loss of pleasure in most or all things), non-melancholic and psychotic (include hallucinations and delusions)¹.

Severity of depression

Depression can be divided into four categories of severity:

• Mild: characterised by five to six symptoms with mild functional impairment or the capacity to function normally with substantial effort.
• Moderate: lies between mild and severe.
• Severe (without psychotic features): characterised by the presence of most of the symptoms with observable functional impairment.
• Severe with psychotic features: also includes delusions (for example, false beliefs, typically of being a bad person, deserving punishment or that bad things will happen) and hallucinations (such as hearing voices, smelling bad smells or other physical sensations).

Depression and ageing

Being admitted to hospital can be daunting for older people and their families. People can be afraid of the unknown and concerned about loss of independence. Their concerns may be shaped by their past experience of illness, episodes in hospital and the support systems they have in place.

Treatment for depression can be complicated and take longer to take effect in older people; however, prognosis for depression in older age is no worse than for younger patients⁴.

Given two-thirds of older people in hospital have been found to have a mild depression there is much we can do to improve their experience and outcomes.

In hospital I was so depressed, and I was there for about eight days … it was just the whole experience, I felt depressed because nobody much was around… Nobody is taking any notice because they just think you’re old and quiet I think… [In rehab there are] lots of people around to talk to… They were lovely there and so helpful. Depression is something that a lot of people deny. I got to the point [in hospital] where I was ready to go to the doctor and get an antidepressant ... and I have never been depressed in my life… [Depression can be prevented by hospital staff]. …acknowledging, and talking to you.
- Patient, 87 years old

The experience of loneliness, like mild depression, can change over the day. It may arise due to certain trigger events, or it can be long-lasting. It is also associated with a ‘feeling of disconnection from community, and of feeling like a stranger or an outsider’.⁵ It is important to recognise that loneliness, like depression, can have a negative impact on a person’s health, and some people can feel very reluctant to speak openly about it. ⁵

Risk factors

Depression, like dementia, is difficult to diagnose in hospital due to the high probability of delirium. However, there are key risk factors that we should be aware of in order to investigate further and respond appropriately. Identifying risks early and implementing prevention strategies can help prevent depression becoming severe and improve the older person’s chance of recovery.

The following are identified risk factors:

• multiple physical health problems and chronic conditions
• a past or family history of depression
• cognitive decline or dementia (approximately 20 per cent of older people with dementia experience moderate to severe depression)
• chronic pain
• medication side effects (particularly drugs used to treat high blood pressure, some steroids and hormonal treatments, painkillers, tranquillisers and tablets or patches used for quitting smoking)
• bereavement, grief and loss, including loss of relationships, independence, work, lifestyle, self-worth, mobility and flexibility
• social isolation, lack of intimacy, poor social supports
• the experience of loneliness
• significant change in living arrangements, such as moving into a residential care setting⁶
• caring for a family member with chronic illness, particularly dementia
• prolonged stress, chronic or acute
• drug or alcohol abuse
• gender - older women have double the risk of depression compared to men.⁶

Screening and assessment

Screening

As mild depression is common among older people in hospital, it is essential to conduct a screen on admission or as soon as the patient’s acute condition has stabilised. At the same time, it is essential to conduct a cognitive impairment screen, which assists us to rule out other possible causes such as delirium, which can be treated, or dementia. This process is known as differential diagnosis.

When screening older people for depression, involve their families and carers as they can recognise a change in the older person’s normal ways of thinking and reacting and may be able to identify early signs of depression in hospital. It is important to recognise that depression and loneliness are closely related.

Screening tools used with older people for depression or loneliness

Geriatric Depression Scale short form (GDS-15 or GDS 5/15)

This is a tool for screening depression in cognitively intact older people. It is available in English and other languages.

Cornell Scale for Depression in Dementia (CSDD)

This tool is designed for people with dementia. It comprises both an informant and patient interview. Many patient interview items can be filled by observing the patient. About 20 per cent of people with dementia have moderate or severe depression; both conditions need to be addressed if present. Instructions and a demonstration are available online.

UCLA Loneliness Scale

Use this scale if you suspect that your patient is experiencing loneliness. It is a set of 3 questions currently recommended in the International Consortium for Health Outcome Measures (ICHOM).

Assessment

A comprehensive mental health assessment involves a one to one interview, patient history and suicide risk assessment. A diagnosis of depression may require the following^{7, 8, 9}:

• a physical examination and laboratory investigations to identify any underlying condition that could be causing the symptoms, such as delirium, anaemia or thyroid problem
• medical history and medication review and reconciliation to identify any medication side effects that may be causing the symptoms
• clinical and/or mental health interview regarding:
  • the number, severity and duration of symptoms, including the risk of suicide or harm due to neglect, and associated disability
  • any major life changes that may have caused the depression; past and family history of mood disorders, successful and unsuccessful past treatment, and availability of social support.

Assessment may also involve families and carers, particularly if the patient has cognitive impairment.

Once we have identified concerns, we should consider the interventions and discuss with the treating team whether the patient would benefit from a referral to a medical specialist to complete a differential diagnosis.

Many hospitals have access to a clinical psychology or older adult psychiatry service to confirm the diagnosis, and to determine the duration and the impact of the patient’s depressive symptoms on their everyday functioning. The degree of impairment is key to developing the most appropriate management and treatment plan⁸.

Preventing and managing depression

We can implement various strategies to improve an older person's outcomes during their stay in hospital, contribute to their recovery and prevent the risk of functional decline.^{8, 9, 10, 11}

We know it's the simple things that actually significantly improve the care of older people, straightforward things, such as …a team-based approach …involving and listening to patients and their families and carers is so important… whether the meal tray is in reach during meal time, whether there's plenty of fluid available during the day to prevent dehydration, it's getting people out of bed and making sure they are kept ambulant and mobilising during the course of the day. It's making sure that we look out for the problems of depression and anxiety and actively manage those with the patient.
-Geriatrician

Encourage patients to be active

Assist and encourage patients to participate in their care and to keep mentally, socially and physically active.

• Encourage and help patients to eat and drink well and help prevent constipation. Depressed patients have more eating and digestive problems and there is a significant link between under-nutrition and depression¹¹.
• Encourage patients to care for themselves when they can, such as washing, dressing etc.
• Provide stimulation and interaction.
• Encourage or assist patients to get out of bed and move regularly.
• Implement and monitor strategies to reduce the patient's risk of falls and pressure injuries.
• Minimise isolation. Frequent brief visits from staff, volunteers, family and friends can help maintain the patient's morale. If family, friends and carers can't visit, encourage them to telephone the patient.

Communicate with patients

Communicate with patients and provide reassurance, encouragement and comfort.

• Acknowledge the patient and help them maintain their sense of self; consider their physical, emotional, social and spiritual needs.
• Encourage communication by demonstrating warmth, concern, a non-judgemental attitude and patience.
• Give the patient time to respond to questions and requests. Speak calmly and give clear and concise explanations about care and treatment.
• Use gentle but persistent encouragement and reassurance to engage the patient in tasks. Ask the whole healthcare team to adopt a consistent approach.
• Encourage patients to talk about their mood. Respond with respect; gently challenge negative thoughts by providing an alternative perspective; avoid dismissive statements such as “It can't be that bad”.
• Reinforce positive responses; reinforce the patient's strengths and positive attributes; avoid criticism.
• Point out progress in the patient's condition no matter how small (patients may not recognise these).

Consider night-time strategies

Difficulty getting to sleep, restlessness, nightmares, waking early, loneliness, and the lack of distractions can lead patients to ponder over fears or feelings of hopelessness.

• Encourage habits that promote sleep, for example don't have caffeine before bedtime, avoid afternoon napping, make sure the room is dark and noise is minimal.
• A familiar staff member who listens can be comforting. It may be easier for some people to express their thoughts and feelings when the ward is quieter.

Explore treatment options

Talk to the person and the healthcare team about treatment options.

• Encourage strategies to reduce anxiety, such as relaxation techniques.
• Request a medication review to determine whether pharmacological treatment is appropriate. Note that antidepressants may be overprescribed and should be reserved for patients with chronic, recurrent or severe depression.
• Discuss whether a referral to a psychologist for Cognitive Behavioural Therapy (to change negative thought patterns) and Interpersonal Therapy (to improve relationships and cope with grief) may be appropriate. In mild cases of depression therapy may be more effective than medication.
• During admission have volunteers and pastoral care workers spend time with patients, helping them explore their feelings of loneliness, and keeping them company.
• Explain the importance of maintaining social connections. If someone is socially isolated, encourage them to initiate new social activities and contact their local council, neighbourhood house or library to find out about activities in their area.

Involve patients and families

Always involve the patient and their carers and family in the care plan and decision making. Give patients and their family and carers information about depression and how to stay well.

Discuss lifestyle changes

Talk to the older person about incorporating some lifestyle changes to manage their symptoms, such as diet, nutritional supplements, exercise and social activities.

Depression and discharge planning

The discharge plan promotes continued improvement in a person’s mental health through psychological intervention, medication, physical activity, social connection, and regular contact with the patient’s GP.

A discharge plan must address issues such as the risk of self-harm and self-neglect, non-compliance with diet and medication instructions¹, low social supports and limitations in daily activities.²

Discharge planning should involve educating the older person, family and carers and identifying strategies to enhance recovery. Provide patients and families or carers with information about depression and staying well.

In addition to referring to the patient’s GP, consider the following referrals:

• Aged Care Assessment Service for follow up in the community
• planned activity groups and local councils, neighbourhood houses, libraries, churches and men’s sheds to enhance opportunities for social connection based on patient's interests
• community supports such as Home and Community Care (HACC) and Meals on Wheels
• psychologist, psychiatrist, old age psychiatrist or aged psychiatric team.

If the patient is at risk of developing depression post discharge, monitoring (via the GP) is important.