Nurses and Nursing Assistants Recognition of Depression in Elderly Who Depend on Long-Term Care

Karel G. Brhl, MD, Hendrika J. Luijendijk, MD, MPH, and Martien T. Muller, PhD Introduction and Method: Recognition and treatment of depression is a quality indicator for nursing homes. Nurses and nursing assistants are in a particularly good position to recognize depression in long-term care. How well do nurses and nursing assistants recognize depression, compared with a DSM-IV diagnosis of depression? To answer this question a critical review of relevant literature in PubMed searches was performed. Results: It was found that nurses and nursing assistants recognize true depression in about 55% (sensitivity 42% to 78%) and over-recognized depression in about 40% of nondepressed patients (specicity 56% to 67%). Discussion: The prominent role of nurses and nursing assistants in daily mental health care is not reected in the number of methodologically sound studies. Sensitivity of the Geriatric Depression Scale (GDS) is about 50% higher than nurses recognition of depression. A specic recommendation for specially trained nursing assistants in depression management and standard use of screening scales in an update of the American Medical Directors Associations Clinical Practice Guideline on Depression might improve depression recognition, as well as nursing assistants work satisfaction and staff turnover. Conclusion: Recognition of depression by nurses and nursing assistants is low. Standard use of a screening scale like the GDS would improve recognition of depression in the elderly. More research is needed aimed at how nursing assistants can empower their role as mental health care provider in long-term care. (J Am Med Dir Assoc 2007; 8: 441 445) Keywords: Nurse; recognition; depression; care staff

Depression is highly prevalent in older persons: 14% in the general population,1 20% in primary care, and 30% to 40% in nursing homes.2,3 Depression is related to higher morbidity, higher mortality, and a major decline in quality of life.4 The effectiveness of antidepressants for depression in elderly patients, with a number needed to treat of 4, is comparable to the effectiveness in other age groups.5 Collaborative care that combines psycho-education with pharmacological and psychosocial treatment modalities seems to produce the best results.6 It therefore seems worthwhile to have an active approach toward depression. Depression in dementia is also common with a prevalence of 25% to 35%.7 Randomized trials have shown that recreational, structured activities help to reduce depression in dementia. In addition, in some patients antidepressants have proven effective. Thus, sufcient
Geriant Foundation, DOC-team, Alkmaar, the Netherlands (K.G.B.); Erasmus Medical Center, Department of Epidemiology & Biostatistics, Rotterdam and Stiching Parnassia Bavo Groep, Institution for Mental Health Care, Department of Geriatric Care, Rotterdam, the Netherlands (H.J.L.); Free University VUmc, Postgraduate Vocational Training Nursing Home Physicians, Amsterdam, the Netherlands (M.T.M.). Address correspondence to Karel G. Brhl, MD, Le Mairekade 15, 1013 CB Amsterdam, the Netherlands. E-mail: k.bruhl@mac.com.

Copyright 2007 American Medical Directors Association DOI: 10.1016/j.jamda.2007.05.010 REVIEWS

data are available to formulate an evidence-based approach to treatment.8 To enable treatment, depression should be well recognized. In long-term care, information achieved by multidisciplinary means will be used, which is generally provided by nurses and nursing assistants. Not only are they the most prevalent disciplines in long-term care, but also, given their day-to-day contact with patients, they are in a particularly good position to recognize symptoms of depression. Especially in nursing homes they can be considered the primary mental health care providers for the patients. In other words, although formally nurses and nursing assistants do not diagnose depression, their key role is evident: they observe the mental, emotional, or behavioral state of patients, and changes therein and they deliver this information to the registered nurse or doctor in charge. In addition, it is widely accepted that nursing assistants report physical illnesses for further evaluation and it would be valuable if they did so as well for mental illnesses and symptoms of depression.9 As the multidisciplinary approach is essential for the identication of depression in long-term care settings, it is important to know how well nurses and nursing assistants assess depressive symptoms. Our aim was to review published studies that established the diagnostic skills of nurses and nursing assistants to recognize depression in elderly patients in long-term care.
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Falck et al, 199928 6 nursing homes Randstad, Holland 1996? 57 of 101 Rovner et al, 199127 8 nursing homes Maryland 19871988 454 of 562

Table 1. General Design Characteristics of Included Studies

The Medline search yielded 19 articles. Three articles did not describe original research.1113 Two articles concerned nonelderly patients.14,15 One described the quality of a specic questionnaire to be used by nurses,16 and another the determinants of depression recognition .17 Of the remaining 12 studies, 8 did not use the reference standard a DSM-III-R or DSM-IV diagnosis made by research staff.18 25 No additional articles were found through the reference search. Thus, 4 articles were selected for this review.26 29 Table 1 shows the general design characteristics of the 4 included studies. One study took place in a home care setting, the others in nursing homes. Three were performed in the 1990s, one in the 1980s. The number of patients varied between 57 and 539, the number of nurses and nursing assistants between 26 and 42, although 2 articles did not mention
442 Brhl et al

Setting

Place

RESULTS

Brown et al, 200326 Teresi et al, 200129

Study

JAMDA September 2007

NA, nursing assistant; NS, not specied. * NAs had more recent training in depression symptoms. Research psychiatrist had access to medical records. NAs exchanged opinions about depressive symptoms in patients in groups of 4 to 5 NAs. For nurses. For NAs.

The diagnostic ability of nurses and nursing assistants can be dened in terms of their ability (1) to recognize symptoms of depression in depressed patients, ie, sensitivity, and (2) not to attribute possible symptoms of depression to depression in nondepressed patients, ie, specicity. We considered a DSMIII-R or DSM-IV diagnosis made by research staff during a (semi-) structured interview as the reference standard (gold standard) with which the evaluation by the nurses and nursing assistants was to have been compared. This review encompasses studies that assessed nurses and nursing assistants recognition of depression in this way, either as the main or as an additional goal, in elderly patients depending on long-term care. Articles were retrieved using Medline. The phrase depression and elderly and nurse and recognition appearing in title, abstract, and/or Medical Subject Headings (MeSH) was taken as combination of keywords. No restriction was made with respect to year of publication. We also scrutinized references and related articles of the selected articles for eligible studies. Only those studies that tested the recognition of depression by nurses and/or nursing assistants against the above-specied reference standard were included. In addition, the studies needed to involve long-term care for elderly patients. We excluded reviews and case reports. Next, all authors read the selected articles independently using a checklist of Glasziou et al10 for appraising the quality of studies that determine the diagnostic accuracy of a diagnostic test. First, descriptive information about the general design, such as setting, place, and year; number of patients; number of nurses and nursing assistants; and results were abstracted. Next, possible sources of bias were identied. Important aspects in this respect were that patients and nurses needed to be selected randomly, the nal outcomes should encompass the diagnoses of all included patients, nurses and reference diagnoses should be measured independently, and nally, the time interval between nurses and reference diagnoses needed to be intervention free and as short as possible. The 3 authors evaluated every article with regard to the above-mentioned items. Differences were solved in consensus meetings.

Random Independent Intervention-free Outcome Selection Testing Interval Available

Bias

NS NS Home care New York 6 nursing homes New York 19971999 539 of 889 19951997 270 of 330

No. of Included No. of of No. of Eligible Nurses/ NAs Patients

Year

42 nurses ? nurses/ ? NAs* 26 NAs ? nurses

NS

403/539 (75%) 259/270 (95%) 237/270 (88%) 57/57 (100%) 454/454 (100%)

METHODS

the latter. Table 1 also shows whether the designs of these 4 studies met the quality criteria for studies of diagnostic accuracy that we applied.9 The study by Rovner et al27 was the only study that met all criteria. Table 2 presents the results of the studies in terms of sensitivity and specicity of the nurses and nursing assistants recognition of depression. Sensitivity varied between 42% and 65% for nurses (3 studies), and between 45% and 78% for nursing assistants (2 studies). Specicity varied between 67% and 75% for nurses (2 studies) and was 56% for nursing assistants in 1 study. When nurses used the Cornell scale for Depression in Dementia30 or the Hamilton Depression Rating Scale, sensitivity of recognition increased to 49% to 55% at the cost of specicity in 1 study.29 DISCUSSION In this review we summarize the results of 4 studies that assessed the diagnostic ability of nurses and nursing assistants to recognize symptoms of depression in elderly patients who depend on long-term care. Sensitivity varied substantially between studies, ranging from 42% to 78%. Specicity seemed to be more similar between studies, ranging between 56% and 75%. Our ndings show that depression in the elderly is hard to identify. Even nurses and nursing assistants who are in daily contact with the patients miss a considerable number of depressions. The fact that depression is hard to recognize is true for other health professionals as well. Recognition has been shown to be as low as 44% for psychiatrists and 37% for social workers29; and 14% for nursing home physicians in the study by Rovner et al.27 Only in the study by Falck et al28 was recognition of depression by nursing home physicians found to be 67%, but these physicians all worked in the same nursing home and it is not clear whether this result is generalizable. The specicity of nurses and nursing assistants recognition of depression in the elderly ranged between 56% and 78%. This implies that depression was diagnosed in a quarter or more of nondepressed patients. This nding accentuates the difculty of diagnosing depression. Accuracy of nurses recognition of depression was higher for patients who did not live alone and for patients who had 2 or more disabilities in activities of daily living. Nondepressed patients had a bigger chance to be over-recognized as depressed if they had a great

deal of pain.25 In general, nurses with more geriatric experience had a higher accuracy. If spontaneous recognition is low, the question is which intervention might enhance it. When nursing assistants evaluated mood of the patients in groups of 4 or 5 before they gave their denitive answer, sensitivity rose to 78%. Moreover, in the study by Falck et al,28 sensitivity rose to 100% if both the nursing assistant and nursing home doctor agreed on the existence of depressive symptoms. In the study by Teresi et al,29 recognition increased to only 42% to only 47-55% when nurses used the Cornell scale for Depression in Dementia or the Hamilton Depression Rating Scale. Some have advocated the standard use of screening instruments such as the Geriatric Depression Scale (GDS) as an addition to the Minimum Data Set (MDS).31 Given the sensitivity of staff recognition and that of the GDS (75% for the GDS-30 and 81 for the GDS-15),32 standard addition of such a structured screening scale would increase the number of depressions identied by a third. It would be crucial that all screening scale results are subsequently communicated to the health care professional who actually diagnoses depression. Another issue that studies have suggested is that nurses and nursing assistants do not assess their patients for depression, even though they know the symptoms well.33 Thus, valuable diagnostic information is not being collected to start with. Studies are needed to nd out what the barriers for depression recognition are in daily practice. A large proportion of elderly living in a long-term care setting have dementia. Depression is a common comorbid disease, with an estimated prevalence of 25% to 35%.7 As depression in dementia often presents itself differently, provisional diagnostic criteria for depression in Alzheimers disease have recently been developed.34,35 Use of these criteria could enhance the identication of depression in dementia patients. The studies included in this review concerned demented and nondemented patients. The patients with more cognitive impairment were also more likely to have unrecognized depression29 while intact cognitive functioning was associated with over-recognition of depression.26 Only 4 of 12 potentially eligible studies met our inclusion criterion that a DSM-III-R or DSM-IV diagnosis of depression as assessed by research staff was used as a reference standard. This might indicate that our selection criterion were very conservative. However, we felt that this expertise of

Table 2. Sensitivity and Specicity of the Nurses and Nursing Assistants Recognition of Depression Study Nurses Sensitivity Brown et al, 2003 Teresi et al, 200129 Falck et al, 199928 Rovner et al, 199127
26

NAs Specicity 75 NS 67 Sensitivity 45* 78 Specicity NS 56

45 for nurses 42* 65

NA, nurse assistant; NS, not specied. * Sensitivity 49% to 55% (nurses NA) after using Cornell scale and Hamilton Depression Rating Scale. positive predictive value 71. positive predictive value 63%. REVIEWS Brhl et al 443

mental health professionals is crucial in diagnosing depression in the elderly. They have been trained to assess whether symptoms are the result of depression or some other psychiatric or medical disease, and to infer a diagnosis from the nature and severity of all symptoms. In the 8 studies that did not meet this criterion, the reference diagnosis was either made with a screening instrument or was missing altogether. The prominent role of nurses and nursing assistants in daily mental health care is not being reected by the number of methodologically sound studies. The Clinical Practice Guideline for Depression36 notes that nursing assistants are in a particularly good position to recognize depression. It would be even better if their task in depression assessment would be specied and formalized. Choosing specially trained certied nursing assistants as key players in depression recognition in a future update of the American Medical Directors Associations Clinical Practice Guideline on Depression (2003)36 might make their role more visible, improve their work satisfaction, and lower staff turnover. Enhancement of assessment skills of nurses and nursing assistants for mental health issues have to be initiated from within care staff with consideration of psychological barriers to change.37 Recognition and treatment of depressive symptoms constitutes a quality indicator for nursing facilities.38 Only if the whole organization and all members of the multidisciplinary team acknowledge and allow strengthening of the specic role of nurse assistants in mental health care can changes be made and recognition of depression in long-term care improve. CONCLUSIONS Recognition of depression by nurses and nursing assistants is low. Active communication between nurses as well as between different professionals about the presence of depressive symptoms could enhance recognition of depression. The regular use of a screening scale would further improve recognition of depression in the elderly. More research is needed aimed at how nursing assistants can empower their role as mental health care providers in long-term care. REFERENCES
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