Dr. Smith is Associate Professor, Ms., Haedtke is Doctoral Student, and Ms. Shibley is Doctoral Candidate, College of Nursing, The University of Iowa, Iowa City, Iowa.
The authors have disclosed no potential conflicts of interest, financial or otherwise. Copyright © 2014 The University of Iowa John A. Hartford Foundation Center for Geriatric Nursing Excellence.
Address correspondence to Marianne Smith, PhD, RN, Associate Professor, College of Nursing, The University of Iowa, 50 Newton Road, Iowa City, IA 52242; e-mail: email@example.com.
Posted: January 29, 2015
Nurses and allied health providers who provide care to older adults are uniquely positioned to recognize changes in behavior and function that signal the onset of a clinically significant depressive episode. Daily providers often observe a range of depressive syndromes that are associated with greater functional impairment, disability, and reduced quality of life, including subthreshold forms (also called clinically significant or minor depression) that do not meet full criteria for major depressive disorder (MDD) (Strine et al., 2009). Clinically significant depression is common in diverse health settings, including home health (14%), assisted living (32%), hospitals (37%), and nursing homes (44%) (Anstey, von Sanden, Sargent-Cox, & Luszcz, 2007; Ciro et al., 2012; Teresi, Abrams, Holmes, Ramirez, & Eimicke, 2001). Depression is highly associated with medical problems that pervade later life, including cancer, chronic pain, diabetes, heart disease, osteoporosis, Parkinson’s disease, stroke, low vision, chronic obstructive pulmonary disease (COPD), anxiety, and dementia (Kempen, Ballemans, Ranchor, van Rens, & Zijlstra, 2012; Lowe et al., 2008; National Institutes of Health [NIH], 2014; Rapp et al., 2011; Schneider, Jick, Bothner, & Meier, 2010).
Depression-related behaviors, thoughts, and feelings interact with social stress and physical health in a “cycle of depression” (IMPACT, 2007, p. 37), which, if unrecognized and untreated, perpetuates distress and dysfunction. Late-life depression increases the risk of needing a higher level of care, including hospitalization among older adult home health patients (Sheeran, Byers, & Bruce, 2010) and nursing home placement for community-dwelling older adults (Harris, 2007). Depression also reduces the likelihood that community-dwelling older adults who are admitted to acute care settings will recover their prehospitalization level of mobility following discharge (Barry, Murphy, & Gill, 2011).
Despite its frequency and known risks among medically ill older adults, depression is often not recognized as a treatable problem by providers (Irwin et al., 2008) or older adults themselves. The stigma associated with mental illness, acceptance of depression as an understandable reaction to social and health problems, and beliefs that older adults do not want to talk about their feelings are common barriers to depression recognition (National Institute of Mental Health [NIMH], 2012). In short, additional efforts are needed to ensure that health care providers recognize depression symptoms as an important focus of care and treatment. Optimal depression outcomes are associated with using depression-specific scales; targeting high-risk individuals; and following detection with coordinated care, treatment, and monitoring (Thota et al., 2012).
Purpose of the Guideline
The purpose of the current guideline is to improve detection of depression symptoms in cognitively intact older adults who may be at higher risk because of social and health-related changes that cluster in late life. The current article is derived from the evidence-based practice guideline, Detection of Depression in Cognitively Intact Older Adults (Smith, Haedtke, & Shibley, 2014), which can be purchased from the University of Iowa Hartford Center of Geriatric Nursing Excellence (access http://www.nursing.uiowa.edu/excellence/evidence-based-practice-guidelines). Detecting depression through screening is recommended by the U.S. Preventive Services Task Force (“Screening for depression in adults,” 2009) and is the essential first step in providing collaborative care that improves depression outcomes across populations, settings, and organizations (Thota et al., 2012).
All levels of depressive symptoms are important to consider, from clinically significant symptom clusters that cause distress and functional impairment (Lyness et al., 2007) to syndromes that likely meet diagnostic criteria for MDD (American Psychiatric Association [APA], 2013) (Table 1 and Table 2). Variability in late-life depression presentation demands thoughtful consideration of diverse levels and types of symptoms, including symptoms that may not be traditionally associated with depressed mood. For example, depression without sadness is common in later life (Gallo & Rabins, 1999); the hallmark symptom of loss of interest or pleasure often occurs without the presence of depressed mood in older adults. Variations in mood, such as irritability or worry, and focusing on depression-related physical symptoms (e.g., appetite and sleep disturbances, fatigue, psychomotor changes) are also more common in late life (Kane, Ouslander, Abrass, & Resnick, 2009). Depression often overlaps with other psychiatric syndromes, such as anxiety and dementia (Huang, Wang, Li, Xie, & Liu, 2011), and a wide variety of medical problems that are common in later life (APA, 2013; NIH, 2014). Finally, lost quality of life and disability associated with subsyndromal depression (Lyness, Chapman, McGriff, Drayer, & Duberstein, 2009) underscores the importance of recognizing symptoms before they meet diagnostic criteria.
Variations in Late-Life Depression Presentation
Depressive Disorders and Syndromes
Management of depressive symptoms and related problems can only be addressed if clinically significant depression is identified. In turn, the risks of major depression, increasing disability, higher health costs, and admission to more restrictive levels of care are all reduced. The large and increasing numbers of frail older adults at risk for depression makes depression detection and screening an important focus of care and treatment, one that will continue to grow as the population ages. Detection is the necessary first step in making referrals to ensure that late-life depression is fully evaluated and treated.
Searches were performed using the PubMed database, which comprises more than 22 million citations for biomedical literature from MEDLINE, life science journals, and online books. The primary search focused on articles that included the word depression in the title, combined with the following additional terms in the title: detection, assess, assessing, assessment, scale, risk, recognize, recognition, screen, screening, PHQ-9 (i.e., 9-item Patient Health Questionnaire), and PHQ-2 (i.e., 2-item PHQ). Search limits included articles in English, samples 65 and older and 80 and older, and publication after 2004.
Inclusion criteria included articles that addressed (a) rates of depression in late life, (b) risk factors for onset of depression, (c) barriers to detection of late-life depression, and (d) approaches to depression screening. Exclusion criteria were (a) depression in cognitively impaired individuals; (b) age younger than 65; (c) measurement, detection, or instruments not primarily focused on depression (e.g., disability, pain); (d) unusual or rare medical conditions that are associated with depression (i.e., only one report on the topic identified in the review); and (e) intervention or treatment studies. A total of 851 articles were identified in the primary search using the search terms described above. Another 731 articles were identified using related literature search and key topics and references from articles in the primary search. A total of 271 articles were included in the depression detection guideline.
Individuals at Risk for Depression
Four categories of risk factors for MDD are identified by the APA (2013):
- Temperamental: negative affectivity (i.e., neuroticism), particularly in response to stressful events;
- Genetic and physiological: having a first degree relative with MDD;
- Environmental: stressful life events; and
- Course modifiers: substance use, anxiety, and chronic or disabling medical conditions.
Although women are more likely to have depressive episodes, there is no evidence that symptoms, course, or treatment response varies by gender (APA, 2013).
Risk factors that are particularly salient to late-life depression include (a) medical illnesses; (b) persistent pain; (c) stressful life events (e.g., loss of a spouse, new onset of illness, loss of functional abilities, relocation); (d) lack of social support or social isolation; and (e) being a caregiver (Alexandrino-Silva, Alves, Tofoli, Wang, & Andrade, 2011; Garcia-Alberca, Lara, & Berthier, 2011; Thielke & Unutzer, 2008). Any individual 60 or older who is identified as being at risk using the factors listed herein should be screened for depression.
Systematic Depression Assessment
A wide variety of assessment tools are available to assess older adults with depression. This guideline recommends the PHQ-9 (Kroenke, Spitzer, & Williams, 2001; Spitzer, Kroenke, & Williams, 1999) and PHQ-2 (Kroenke, Spitzer, & Williams, 2003; Lowe, Kroenke, & Grafe, 2005) to detect depression in cognitively intact older adults. The PHQ-9 and PHQ-2 have the advantages of concentrating on MDD symptoms and being brief, self-administered, free (in the public domain), easy to score, reliable and valid in older adults, and multipurpose (i.e., can be used for screening, assessing severity of symptoms, and monitoring change over time) (Kroenke, 2012).
Scale Characteristics and Scoring
The PHQ-9 assesses the nine diagnostic criteria of MDD (APA, 2013), as described in Table 2. Each item starts with the question, “Over the last 2 weeks, how often have you been bothered by any of the following problems?” Items are scored as 0 = not at all, 1 = several days, 2 = more than half the days, or 3 = nearly every day. The PHQ-9 can be interpreted as a continuous measure to identify severity of depression symptoms, including mild (5 to 9), moderate (10 to 14), moderately severe (15 to 20), and severe (>20) levels of depression symptoms (Kroenke, Spitzer, Williams, & Lowe, 2010). A score ≥10 is considered clinically significant and worthy of further evaluation (Kroenke et al., 2010). The scale can also be used as a diagnostic algorithm, in which MDD is suspected when five or more of the nine symptoms are present more than half the days (score = 2) and one of the five is either depressed mood or anhedonia. Other depression is suspected when two to four depression symptoms are present more than half the days and one is depressed mood or anhedonia (Kroenke et al., 2010). The PHQ-2 assesses only the hallmark symptoms of MDD (i.e., depressed mood and loss of ability to experience pleasure [anhedonia]). Each item is scored from 0 to 3, and a score ≥3 suggests MDD or other depressive disorder (Lowe et al., 2005). The brevity of the PHQ-2 makes it an attractive alternative in busy clinical settings or an initial bedside screen, but should be followed with the PHQ-9 if positive.
Populations and Settings
The PHQ-9 has been validated and used successfully with diverse subsets of medically ill older adults, including those with cognitive impairment, diabetes, cancer, stroke, vision loss, COPD, and heart disease (Acee, 2010; Almeida et al., 2011; Boyle et al., 2011; Haq, Symeon, Agius, & Brady, 2010; Lamoureux et al., 2009; Thekkumpurath et al., 2011). Of equal importance, the PHQ-9 has been shown to be effective for use in diverse health care settings, including primary care, home health, community-based, and assisted living settings, and is part of the Minimum Data Set Version 3.0 used in nursing homes (Arroll et al., 2010; Centers for Medicare & Medicaid Services [CMS], 2010; Ell, Unutzer, Aranda, Sanchez, & Lee, 2005; Richardson, He, Podgorski, Tu, & Conwell, 2010; Watson, Zimmerman, Cohen, & Dominik, 2009).
Description of the Practice
The recommended screening process is a simple but effective practice that can be widely used to detect clinically significant depressive symptoms. However, an important consideration in adopting the practice is the associated need for referral for diagnostic evaluation by a qualified provider so that treatment can be provided as indicated (Figure). Screening alone is not effective in changing outcomes for older adults with depression: it must be part of an established practice or routine effort that systematically refers, evaluates, and treats older adults for depression.
Depression detection flowchart.
Note. MDD = major depressive disorder; SIS = Six-Item Screener; PHQ-9 = 9-item Patient Health Questionnaire.
The first consideration is the older adult’s ability to accurately self-report symptoms of depression. If the individual seems confused, he or she should be screened for cognitive impairment using the Six-Item Screener (SIS; Boyle et al., 2011; Callahan, Unverzagt, Hui, Perkins, & Hendrie, 2002). If the older adult makes three or more errors on the SIS (i.e., score of 1 to 3), it must be established whether this result is an indication of an acute change in mental status (i.e., rapid onset of confusion) that may be better addressed using the Acute Confusion/Delirium guideline (Sendelbach & Guthrie, 2009). If depression overlapping with dementia is suspected, the Cornell Scale for Depression in Dementia (Alexopoulos, Abrams, Young, & Shamoian, 1988) should be applied, as outlined in Detection of Depression in Older Adults with Dementia (Brown, Raue, & Halpert, 2007).
If the older adult has normal cognitive function (i.e., SIS score of 4 to 6, or appears intact and able to self-report symptoms without cognitive screening), the PHQ-9 should be administered. By design, the PHQ-9 is a self-report measure, but the scale can also be clinician-rated based on an interview. Scores ≥10 on the PHQ-9 should be reported to the older adult’s primary health care provider for further evaluation and treatment (Thota et al., 2012).
The PHQ-2 may be substituted for the PHQ-9 if time constraints do not allow use of the 9-item scale. A score ≥3 on the PHQ-2 signals the need for further evaluation and treatment. Low-level symptoms of depression should be systematically monitored to detect changes that may place older adults at higher risk for functional impairment and depression-related disability. In particular, mild depression (i.e., scores of 5 to 9 on the PHQ-9) should be assessed at weekly intervals or more frequently. Transfer or discharge plans should include recommendations for monitoring depression levels in the community or other health care settings to ensure that symptom levels are within the target range (i.e., 0 to 9).
Implementing Depression Detection
A number of factors may influence the adoption and implementation of the recommended depression detection practice. Overcoming barriers related to providers and older adults may be an important first step (Table 3). Having a clear plan for making referrals following detection of clinically significant symptoms is another important consideration and may require organizational planning and input based on the availability and preferences of primary care and specialty care providers (Bartels et al., 2004; Bruce, Van Citters, & Bartels, 2005).
Overcoming Barriers to Depression Detection
Developing rapport with the potentially depressed older adult is another important consideration. The symptoms of depression, such as fatigue, apathy, psychomotor retardation, and worthlessness, may present challenges to assessing depression. Allowing sufficient time to talk with the older adult about his or her mood and understanding that response time may be slowed are often important communication strategies. Focusing on “low mood” without using the word depression, attending to distressing symptoms, communicating concern for the individual’s well-being, staying focused on quality of life and optimal outcomes, and listening without judging may help older adults discuss painful emotional experiences.
Older adults may express unrealistic fear or worries; seemingly exaggerated levels of pain or emotional distress; and overly critical opinions of themselves, family members, or providers that are driven by the underlying depression. Allowing the older adult to express strong emotions without correcting them (e.g., “It’s really not that bad”; “Your family cares about you”; “We have worked hard to help you”) is critical. Offering gentle, conversational education about depression as an illness that robs older adults of their quality of life and makes all problems more intense is an important and effective intervention (Unutzer et al., 2002).
As noted in the guideline, monitoring the level and type of depressive symptoms across time and care settings is another important focus of nursing care. Transitions from one residential and/or treatment setting to another are common among medically ill older adults. Depression-related monitoring information and recent PHQ-9 scores should be included in discharge and admission information to ensure follow up by subsequent providers.
Depression detection outcomes may also be monitored at the organizational or systems level. Main outcomes include (a) the total number of older adults who are screened for depression; (b) the number who are screened, and based on a significant cluster of symptoms, are referred for comprehensive evaluation and treatment of depression; (c) the number who are screened, and based on low-level symptoms, are monitored over time to evaluate the number and intensity of symptoms; and (d) the number who are screened and monitored (as in b) and whose depression symptoms resolve on their own, or whose symptoms increase and require referral for comprehensive evaluation and treatment.
Summary and Conclusion
The depression detection guideline provides a simple-to-use approach that can be easily implemented in diverse practice settings where older adults live and are routinely treated. Understanding the variability in depressive symptoms, knowing factors that place older adults at high risk for depression, and rejecting common societal beliefs that depression is a natural consequence of age-related health and social changes are essential to depression detection. The self-rated PHQ-9 is easy-to-use and score and provides many opportunities to engage older adults in their care. The multipurpose scale may be effectively used to (a) screen older adults for clinically significant levels of depressive symptoms, (b) guide diagnosis following an algorithm, (c) monitor level and type of symptoms over time, and (d) stimulate discussion with older adults about additional problems and symptoms. The primary focus of the guideline is detecting clinically significant levels of depression symptoms so that referral may be made for further evaluation and treatment by qualified health providers. Thus, screening practices must be part of a larger established practice that systematically directs referral, evaluation, and treatment of older adults.
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Variations in Late-Life Depression Presentation
Apathy, indifference, withdrawal
Pessimism, expecting the worst
Feeling like a failure
Feeling unable to cope
Feeling emotionally “empty”
Aches and pains
Digestive problems, stomachaches
Decreased sexual interest
Slowed movements and responses
Slowed or decreased speech; low or monotonous tone of voice
Persistent headaches, other chronic pain that does not go away when treated
Depressive Disorders and Syndromes
|Major depressive disorder (MDD)
||Hallmark symptoms: Depressed mood (e.g., sad, low, blue); loss of interest or pleasure in approximately all activities that are usually enjoyed (i.e., anhedonia)
Additional symptoms: Significant weight loss/gain; insomnia/hypersomnia; psychomotor agitation/retardation; fatigue (e.g., loss of energy); feelings of worthless-ness or guilt; impaired concentration (e.g., indecisiveness); recurrent thoughts of death or suicide
Level/duration: One or more hallmark symptoms plus four additional symptoms for a total of five that occur approximately every day for at least 2 weeks
||Level/duration: One or more hallmark symptoms plus three to four additional symptoms (not five) over 2 weeks; also described as subsyndromal or subclinical depression in the literature
Risks: More common than MDD; highly associated with physical disability, increased health costs, and risk of developing MDD
|Clinically significant depression
||Level/duration: A cluster of depressive symptoms that causes sufficient distress and impairment to be a focus of clinical care
Risk: More common than MDD; highly associated with functional decline and onset of MDD
|Persistent depressive disorder (i.e., dysthmia)
||Symptoms: Depressed mood and associated symptoms, including poor appetite or over-eating; insomnia or hypersomnia; low energy or fatigue; low self-esteem; poor concentration or difficulty making decisions; feelings of hopelessness
Level/duration: Symptoms occur for more days than not for at least 2 years
Overcoming Barriers to Depression Detection
|Provider perceptions and beliefs
Older adults focus on somatic versus mood complaints
Older adults do not want to talk about feelings
Depression is an “understandable” part of aging
Inadequate training in psychiatry among primary care providers
Educate providers about variations in depression presentation in late life.
Use short self-report measures (e.g., PHQ-2) to screen for depression.
Institute computer screening (e.g., in the waiting room).
Identify and use billing codes that reimburse for time spent conducting depression screening (e.g., Medicare, Medicaid, some private insurances now pay).
Develop collaborative care teams with consulting psychiatrists and psychiatric nurse practitioners to promote best practices in primary care settings.
|Older adults’ perceptions and beliefs
Fear of stigma associated with depression
Belief that depression is “normal” with advancing age
Fear of antidepressant medication effects (e.g., make “high” or giddy)
Provide simple, easy-to-use educational materials to older adults and their family members, such as those available through the NIMH.
Offer educational videos about depression in late life.
Involve family in patient teaching, particularly younger family members who may have different life experiences related to depression and its treatment.
Emphasize depression as a medical, not mental, illness that must be treated like any other disorder.