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Depression in the elderly: role of the district nurse

Gaynor Mabbett
Lecturer in Public Health and Primary Healthcare  
Swansea University

Depression affects 5% of the population, with depressive symptoms being more common in people over the age of 65.(1) Prevalence rates vary, generally ranging from 10% to 15%, although some studies report rates as high as 26%.(2) As the number of people over 65 continues to rise, there is the potential for an increase in the number of people with depression.
Older people are more likely to have more than one chronic condition. Physical disease can predispose to depression. And depression can result in an inability to cope with everyday living. The refocusing of healthcare towards primary healthcare, in an attempt to provide early intervention to maintain people in their own homes, places a professional responsibility on district nurses to manage people with chronic conditions, including older people with depression.

Recognising depression
Reportings of depression vary depending on the criteria used for definition, the context of the assessment, attitudes and beliefs towards depression, and demographic differences of populations.(3,4) This situation is compounded by an inability of some health professionals to recognise depression, resulting in underdiagnosis and inadequate treatment. This is despite evidence stating that depression is a treatable condition in older people.(5)
Recognising depression cannot be overemphasised, as depression is associated with high levels of morbidity and mortality affecting the quality of life and social functioning of individuals and families. Older adults who are depressed also use substantially more health resources than their nondepressed counterparts. This has been recognised by the National Service Framework for Mental Health and the National Service Framework for Older People,(6,7) which recommend various approaches for the assessment and provision of services for depressed patients in the community. Despite the above policy recommendations, there has been some concerns raised as to the ability of primary healthcare services to respond appropriately to people with mental health problems, including people with depression.(8)
Alexopoulos et al suggest that depression is a disease and not a normal part of ageing; however, in later life it can be difficult to identify depression, as individuals may not present with specific symptoms, such as feeling sad.(9) Older people may present with a wide range of problems, such as poor appetite, undue fatigue, memory loss and sleep problems.(9) These problems may be attributed to physical causes, as opposed to underlying symptoms of depression. The assessment process can be further complicated in patients with long-term chronic conditions. A change in quality of life for a patient suffering from a cerebrovascular accident and cognitive dysfunction may lead to depression. Cognitive dysfunction (eg, poor concentration and memory loss) contributes to disability and social isolation, further promoting depression. Additionally, depression can exacerbate cognitive dysfunction and disability and increase psychosocial problems.(9) It is not surprising, therefore, that community practitioners assessing patients with complex needs could easily miss a problem of depression. Some evidence has identified that older adults attach substantial stigma to having depression, seeing it as a sign of weakness to report feelings of mental distress.(3) Added to this is the nonrecognition by the older person that depression is an illness, believing that the symptoms they experience are attributable to the context of their life in old age. Older men are particularly vulnerable since they are more likely to become socially isolated and less likely to discuss their feelings with others. These issues may explain the difficulties in making an appropriate assessment and diagnosis.

Role of the district nurse
District nurses have the ideal opportunity to assess older people with mental health problems as 80% of their caseloads include patients over the age of 65.(10) District nurses primarily visit patients with physical disorders such as Parkinson's disease, multiple sclerosis, cardiac problems and people who are terminally ill, all  known to be at a higher risk of depression.(11) However, a survey of district nurses identified that they felt that they were inadequately trained in mental health,(12) despite some of their visits including interventions such as bereavement counselling and supporting people with anxiety and depression. The context of their work therefore provides an ideal opportunity to not only react to mental health problems, but also to prevent situations deteriorating. District nurses would not function as specialists in this area of practice, but they could usefully screen patients about whom they have concerns. Providing an assessment tool that would guide them through this process would fulfil the requirements of the national service frameworks and their role in case management and, more importantly, benefit patients and families through a more accurate assessment.

Assessment scales
Edwards describes the use of the Geriatric Depression Scale (GDS) as a screening tool that district nurses could use in practice.(13,14) The GDS has been found to be useful in assessing mood in older people and those with mild or moderate dementia, but has been found to be less accurate in patients with cognitive deficits. The GDS includes 15 items (see Table 1) and a scoring of five or more indicates probable depression.(14) Repeated assessment is required, as symptoms of depression need to be present for two weeks. Although the GDS has been recommended as a reliable instrument for screening older people, Edwards admits that the scale has not been validated with very old and housebound individuals who are most likely to be visited by district nurses.(13) Some of the questions could be insensitive: question 9, for example, would be unsuitable for those who are immobile or housebound.(13) Edwards goes on to recommend the additional use of the International Classification of Diseases-10 (ICD-10),/(13) which was developed by the World Health Organization, in providing diagnostic guidelines for a depressive episode (see Table 2).(15) Patients reporting positively to seven or more criteria included in the ICD-10, as well as achieving high scores on the GDS, should be referred to their GP.



The ICD-10 should be used with caution as false positives can occur, resulting in undue stress to patients and inappropriate referrals. District nurses should also be prepared to offer patients and families basic counselling skills at the time of assessment and when referring to other agencies. Allowing specific time to undertake an assessment therefore requires appropriate planning. Lee and Knight found that district nurses felt they required a wide range of training in relation to caring for patients with mental health problems.(12) District nurses need to be provided with the appropriate knowledge and skills to underpin their decision-making; this should include an ongoing evaluation of the use of the ICD-10 and the GDS by district nurses. This should also be used only as an adjunct to an holistic assessment. 
Home visits provide an appropriate context to assess patients' psychosocial needs. Problems such as social isolation, for example, may result in mild depression, which can be treated through the use of appropriate support mechanisms, as opposed to drug therapy. Improving the quality of life for patients is as important as treating the disease.

Despite older people having significant contact with primary healthcare services, depression often remains unreported and unrecognised. District nurses are the largest group of nurses working in the community focusing on patients who could be vulnerable to mental health problems. The GDS and the ICD-10 could be useful in screening older patients for depression. These scales could be used as part of a wider assessment in the district nurse's case management role. District nurses need to be educated in the issues surrounding mental health problems and older people, with the aim of providing suitable assessment and subsequent intervention.


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