Tool Kit booklet - GeriU

Depression ScreeningTool Kit

Working together to improve the care and outcomes of depression in home healthcare patients

Introduction

Tool Kit version 1.0 March 2005

© Copyright 2004Weill Cornell Homecare Research PartnershipWeill Medical College of Cornell University

Homecare clinicians are uniquely positioned to screen elderly patients for depression. Depression is a major health problem for the elderly homecare population. It is under diagnosed, under treated and can increase mortality from other medical conditions. Depression is the number one risk factor for suicide in late life. Importantly however, depression is treatable.

Screening for depression requires both direct questioning and observation. The Outcome Assessment and Information Set (OASIS) that is required for admission to a Medicare certified home care agency provides a framework for screening.

The presence of depressed mood and/or diminished interest in activities that the patient once found pleasurable is an indication for further evaluation. Direct questions about thoughts of death and dying and suicide should be a part of routine screening.

The following tools are intended to assist you in screening for depression in older adults receiving homecare. They are designed for direct patient care and use in the field.


Contents1) Questions to Determine Presence of Depression “Gateway Symptoms” (M0590 and M0600)This section provides clinicians with a statement they can use with patients to help ease the transition into a discussion on the topic of depression.

The purpose of the next series of questions is to assess depressed mood and diminished interest in once pleasurable activities. Each is a key indicator that a person may have a clinically significant depression and should be further evaluated.

2) Questions to Determine Suicide Risk (M0590)The purpose of these questions is to elicit information about thoughts of death and the risk of suicide.

While the first two questions are adequate to answer the OASIS items, additional questions may be necessary to ask in some cases to further differentiate the level of suicide risk. These questions are listed after the OASIS M0590 items.

3) Assessing Suicide Risk as a SpectrumThe purpose of this section is to assist the clinician in understanding that there is a spectrum of thoughts of death that range between normal thoughts of death and dying to suicidal thoughts that may indicate a more serious potential for harm.

4) Facts About Depression in the ElderlyThe purpose of this patient education handout is to provide answers to patients and caregivers regarding commonly asked questions about depression.

5) Commonly Used AntidepressantsThe table provides information about commonly used antidepressant medication.

6) Special Considerations for Older Adults Treated with Antidepressants This tool provides general guidelines about the administration of antidepressants to the elderly population. Some useful resources for nurses are also listed.

7) Nurse-Patient Interaction in the Context of DepressionThe purpose of this section is to provide the clinician with suggestions on how to interact with patients suffering from depression.

8) Mental Health ReferralThe purpose of this tool is to assist the clinician in discussing the mental health referral process with patients.


Introductory Statement to Patient“Many times, people who need home care services go through a difficult period of time. Some feel down or upset.”

Depressed Mood (M0590-1)“How has your mood been in the past couple weeks?” “Have you been feeling sad or depressed?”

If yes, ask each of the following questions:“How much of the day do you feel this way?” “How long have you felt this way?”

Diminished Interest in Most Activities (M0600-2)“In the past few weeks, have you found yourself losing interest in activities that you usually enjoy?”

If yes, ask each of the following questions: “How much of the day do you feel this way?” “How long have you felt this way?”

*Check off OASIS items if relevant symptoms have been present to any degree during the past 2 weeks. Follow agency procedures for referral.

Questions to Determine Presence of Depression “Gateway” Symptoms (M0590 and M0600)


Questions to Determine Suicide Risk(M0590)

Recurrent thoughts of death (passive suicide ideation) (M0590-4)“In the past couple weeks, were things ever so bad that you had thoughts that life is not worth living or that you’d be better off dead?”

Thoughts of suicide (active suicide ideation) (M0590-5)“Have you had any thoughts about hurting yourself or suicide?”

If yes, ask each of the following questions: “What have you been thinking of doing?”

“Do you have a plan for doing this?”

“Is there anything preventing you from harming yourself?”

“Do you feel you can resist thoughts about harming yourself?”

“Have you ever done anything to harm yourself?”

*Check off OASIS items if relevant symptoms have been present to any degree during the past 2 weeks. Follow agency suicide risk protocol.


Assessing Suicide Risk as a Spectrum*

*Always follow individual agency procedures for suicidal patients

No suicide ideation

Recurrentthoughts of suicideM0590-4(passive suicide ideation)

Thoughts of suicide M0590-5(active suicide ideation)

Specific suicide plan or intent

Very Low Risk Imminent suicide risk

Normal focus on end of life issues due to advanced age, medical illness, or dwindling social networks.

May have occasional thoughts about own mortality.

Is not preoccupied with death; does not feel that would be better off dead.

Morbid preoccupation with death; thoughts that life is not worth living or that would be better off dead (eg, “I pray that God will take me soon”).

Has not considered a Method to harm self.

Has considered a Method to harm self (eg, “I’ve thought about taking all my pills, but I would never do it”).

Does not report a specific detailed Plan or current intention to harm self.

Demonstrates reasons for living and good impulse control.

Reports a specific detailed Plan and/or current intention to harm self (eg, “I’m planning to take all my pills tomorrow morning before my aide arrives”)or does not have good impulse control (eg, “I may not be able to stop myself from doing this”).

Mild Risk

Requires

Referral

Ver

y Lo

wR

isk

Moderate RiskRequiresImmediate

Referral High R

isk

Contact MH

Clinician

Do N

ot

Leave Hom

e


Facts About Depression in Older AdultsWhat Is Depression?Depression is a medical illness. Depression is not an understandable reaction to loss. Depression is not a customary response to the physical ailments of growing old. Depression is not an expected part of the aging process. Depression usually does not improve in response to different circumstances, good news or the passing of time. Depression can last months or even years if it is not treated.

Cardinal Symptoms:• Depressed or sad mood • Decreased interest or pleasure in activities

Other Symptoms: • Significant changes in appetite or weight• Sleep disturbances• Restlessness or sluggishness• Fatigue or loss of energy• Lack of concentration or indecision• Feelings of worthlessness or inappropriate guilt• Thoughts of death or suicide

What Causes Depression?Depression is caused by multiple factors ranging from genetic predisposition to biological changes, to psychological trauma. Often depression results when these factors interact with one another, although depression can also occur without any obvious stressful event.

How Is Depression Treated?Depression is treatable. Examples of appropriate treatment include medication and/or psychotherapy. Equally important to treatment is monitoring and follow-up over time. Appropriate treatment relieves symptoms for seventy percent of older adults. If people receive proper treatment for depression they will feel more energetic, hopeful, focused, and involved in daily activities.


Commonly Used AntidepressantsGeneric Brand Usual DailyName Name Dose Range Common Side Effectsescitalopram1 Lexapro 10–20 mg. Nausea/constipation/diarrhea, Dry mouth, Sleepiness, Insomnia, Increased sweating, Headache, Restlessness, Sexual dysfunction

citalopram1 Celexa 10–40 mg. Nausea/constipation/diarrhea, Dry mouth, Sleepiness, Increased sweating, Sexual dysfunction

venlafaxine1 Effexor 75–225 mg. Nausea/constipation/diarrhea, Dry mouth, Sedation/fatigue, Sleepiness, Headache, Increased sweating, Increased blood pressure, Sexual dysfunction

paroxetine1 Paxil 20–50 mg. Nausea/constipation/diarrhea, Dry mouth, Sleepiness, Insomnia, Increased sweating, Headache, Restlessness, Sexual dysfunction

fluoxetine1 Prozac 10–40 mg. Nausea/constipation/diarrhea, Dry mouth, Sleepiness, Insomnia, Increased sweating, Headache, Restlessness, Sexual dysfunction

sertraline1 Zoloft 50–150 mg. Nausea/constipation/diarrhea, Dry mouth, Sleepiness, Sedation/ fatigue, Insomnia, Increased sweating, Headache, Restlessness, Tremor, Sexual dysfunction

mirtazapine2 Remeron 15–45 mg. Sedation/sleepiness, Weight/appetite increase, Dizziness

bupropion Wellbutrin 150–450 mg. Headache, Dry mouth, Insomnia, Nausea/constipation/diarrhea, Anxiety/restlessness, Tremor

nortriptyline3 Pamelor 50–100 mg. Sedation, Constipation (moderate), Blurred vision, Orthostatic Hypotension, Slowed cardiac conduction, Increased sweating, Tremor, Urinary retension

1 SSRI (selective serotonin reuptake inhibitor), 2 Heterocyclic, 3 Tricyclic


Special Considerations for Older Adults Treated with AntidepressantsMedical Comorbidity and Drug InteractionsSSRIs are used widely for the elderly because they have few contraindications and risky side effects.

MAOI antidepressants should not be combined with antidepressants of any other type. Drug interactions can have grave consequences.

Coumadin-SSRIs may modestly increase coumadin effects, so INRs should be rechecked after starting these antidepressants.

Antidiuretic Hormone (ADH)- Rarely, inappropriate ADH secretions can occur early in treatment, leading to hyponatremia. If confusion occurs, blood electrolytes should be assessed.

Sensitivity to Side EffectsElderly patients may be more sensitive to side effects, particularly constipation, nausea and restlessness.

Dosage ConsiderationsDue to potential sensitivity of older persons, clinicians may start antidepressants at low doses and increase them slowly (“start low & go slow”). HOWEVER, the SSRI target dose is usually the same as that of younger patients.

Family InvolvementFamily involvement is central to recovery from depression. The presence of support has been linked to recovery from depression and family members can help ensure medication adherence.

Resources:www.psychceu.com/quickreference.doc.html(Preston’s Psychopharmacology List)

Mosby’s Drug Guide for NursesFifth Edition, Skidmore-Roth, Linda, RN. MSN, NP, Mosby, Mo. 2003

Psychiatric Medications for Older Adults: The Concise GuideSalzman, Carl MD, The Guildford Press, 2001.


Nurse-Patient Interaction in the Context of Depression

REASSESS symptoms at each visit. If symptoms persist after a month of treatment, contact physician.

REASSURE patients that depression is a medical illness, and is not their fault.

SUPPORT patients by reassuring them that they can always call on you or other health care providers for help and support.

ENCOURAGE patients to engage in activities that are pleasant to them and that they are still able to do.

REMIND patients that depression is treatable, but it takes time.

REMAIN positive.

DO NOT… Ignore the depression. Track changes in depression and adherence just like any other medical illness. DO NOT…Allow patients to be hopeless. Hopelessness is a symptom of depression; with proper treatment patients become more hopeful about their health, their lives, and their future.


Mental Health ReferralReferring a patient to a mental health specialist can be challenging. Sometimes older adults with depression are reluctant to seek help. Perhaps the person is not convinced that she or he needs help, or is skeptical that seeking help will be of any consequence. The person may have previously had a negative experience when seeking mental health care. Some older adults avoid seeking help because they believe that having a mental health problem is stigmatizing or shameful.

While there is no simple solution, often the best approach is to discuss mental health treatment and referral in the context of other medical conditions. Involving family members in the discussion can sometimes be helpful.

Advise patients that receiving mental health care is a necessity and as important as taking care of a chronic physical condition like diabetes.

Inform patients that a mental health problem is not a character flaw but rather a problem involving brain changes causing disturbances in thoughts, emotions, behaviors, and somatic functions.

Here is a suggested way to introduce mental health referral to your patients:“It sounds like you have been going through a difficult time recently. I’d like to have a nurse counselor (specialist) visit you to discuss some of these issues. She/he will be able to spend more time talking with you. Is that alright with you?”

“Mental Health Referral Tips: Encouraging a client or patient reluctant to seek mental health services.” NY: Division of Geriatrics and Gerontology, Weill Medical College of Cornell University.

Available at:http://www.cornellcares.org/tips/tips3.html?name1=Mental+Health+Referral+Tips&type1=2select


© Copyright 2004Weill Cornell Homecare Research PartnershipWeill Medical College of Cornell University

Credits Co-producers• Martha L. Bruce, Ph.D., M.P.H.• Ellen L. Brown, Ed.D, M.S., NP, RN

Writers• Ellen L. Brown, Ed.D, M.S., NP, RN• Patrick J. Raue, Ph.D.• Martha L. Bruce, Ph.D., M.P.H.• Thomas F. Sheeran, Ph.D., M.E.

Director/Contributing Psychiatrist• Barnett S. Meyers, M.D.

Development Team• Denise C. Fyffe, Ph.D.• Amy E. Mlodzianowski, M.S., LMSW

Mental Health Nursing Consultant• Judith C. Pomerantz, M.S., APRN-BC

Actors• Nurse: Susan J. Bodell• Mr. James: Arthur French• Mrs. Lee: Margaret Wright• Narrator: Katie Karlovitz

Video Production and Graphic Design• Center for Biomedical Communications, Audio Visual Services (a division of Columbia University Health Services at Columbia University Medical Center)

Funding Source:• National Institutes of Mental Health (R24MH64608; PI: Martha L. Bruce, Ph.D., M.P.H.)

With additional funding from:• K02 MH01634, K01 MH066942, Weill Cornell Center for Aging Research and Clinical Care, and the Institute of Geriatric Psychiatry, Weill Medical College of Cornell University

• Developed as part of the Weill Cornell Homecare Research Partnership, with special thanks to the staff of Dominican Sisters Family Health Service (DSFHS), Visiting Nurse Association of Hudson Valley (VNAHV), and Visiting Nurse Services in Westchester (VNSW) for their contributions and ongoing collaboration.

Cover of the DSM-IV-TR: Reprinted with the permission from the Diagnostic and Statistical Manual Disorders, Text Revision, Copyright, 2000 American Psychiatric Association

Documents

Tool Kit booklet - GeriU