Scott Murray is the Liaison Psychiatry Nurse Specialist for older people at Borders General Hospital, Melrose and is a Dementia Champion and associate lecturer at Queen Margaret University and Borders College. Dr Niall Campbell is a consultant in Liaison psychiatry at the Borders General Hospital, working within general and older adult mental health.
Hospitalised older adults frequently present as depressed on our wards, but research suggests that healthcare staff often struggle to identify depression, let alone provide suitable care and support. Whilst many people with a diagnosis of depression are prescribed antidepressant medication, few are referred for psychological treatments or have this passed on to GPs and primary care teams on discharge, thereby impacting their future care.
The current COVID-19 pandemic has exacerbated depression and anxiety in older adults, not just through fear of a debilitating and fatal disease, but also through the anxiety and loneliness brought on by visiting restrictions on many of our wards, with some studies placing this as high as 43-62% in patients who have had COVID-19.
Care that looks at a ‘whole person’ and that is undertaken by a geriatric MDT is the gold standard of our approach, so why is the mental health component of the person’s care so woefully under-recognised?
The most common response is likely to be time, with professionals juggling competing priorities in overworked, under-resourced departments. Another common cause is lack of clinical confidence in diagnosing depression, or indeed understanding it as something that is common in older people who have multiple co-morbidities and vast life experiences. A key theme is often one of loss; loss of sense of self, of confidence, of independence, loss of friends and family through bereavement. Finally, stigma is a considerable issue as there remains a pervasive stigma around mental illness, particularly in a cohort of people used to stoicism and where such matters were not discussed openly in younger years.
Whilst it is not possible to cover all the reasons why we may fail to recognise depression, it is possible to highlight the three key themes to address this issue, abbreviated to ‘TST’, standing for Training: Screening: Treatment. These interventions will likely be a ‘sticking plaster’ but regardless are the starting point in ensuring no person is left behind.
Training
Before we go diagnosing everyone with depression, we should remember to allow what’s normal.
It is normal to feel afraid in hospital, being surrounded by the sick, frail and dying. It’s normal to feel awful after surgery and normal to feel a bit despondent if we’re not progressing as fast as we would like. It’s normal to be fed up being in a 6-bedded bay, surrounded by equally bored and sick people, when it’s noisy and you can’t hear or see the telly because you don’t have your glasses and hearing aid. It’s normal to feel miserable because it’s been a week since you’ve had a visitor.
Being low in mood will often be a normal adjustment reaction to being unwell, to suffering some loss, or just to being in hospital. Before we call everyone depressed, let’s help people to “Normalise not Pathologise” their reactions.
We should think: is this person sad or afraid because they don’t really know what’s wrong, because they are waiting for important results, or because they are unsure of what is happening? Use your staff to ensure clear communication and to take time and speak to the patient about the nature of their concerns and explain results and diagnoses. Are there simple solutions?
Training doesn’t have to be over-thought, if our aim is to raise awareness as a starting point. (see Osmosis quick video on youtube )
Rapid identification involves considering that ‘depression’ is a low mood or loss of interest or pleasure that lasts more than 2 weeks and also comes with at least 4 of the following;
- significant changes in appetite;
- weight loss;
- loss of energy or motivation;
- sleep problems
- loss of energy;
- self- criticism;
- feeling useless;
- feeling worthless;
- thoughts of suicide or feeling you’d be better off dead.
These signs should be in the absence of other clinically explained phenomena, for example shortness of breath contributing to low energy, or dysphagia to a poor appetite - though as we know in older and multi-morbid adults, this may not be straightforward.
Screening
There are several tools out there that will help clinicians to make a reasonably confident diagnosis, whilst not being encumbered by a lengthy process.
A robust referral system should be top of the priority list and should include a pathway to inpatient support through Liaison Psychiatry, and attention given to clearly recording new diagnoses on discharge documentation, with onward referral for follow up services clearly shown.
Assessments should be done with full consent and consideration of capacity, having explained why you are undertaking it, and what you hope to achieve. Where possible, assessments should be done in a quiet area free from distractions.....and consideration of who might overhear in larger bays.
The list of tools below is useful for ease and speed, but remember, these are just indicators for symptoms and are not a replacement for good clinical history and judgement.
- PHQ-9
- Hospital Anxiety and Depression Scale (HADS)
- Geriatric Depression Scale (GDS)
- CORNELL (where dementia is also a feature)
Treatment
Helping someone maintain normal routines will encourage confidence, and helping them to manage aspects of their care independently (where able) may also reduce deconditioning. We should aim to promote good sleep hygiene, by minimising light, noise and disruption, offering decaffeinated or milky drinks after 6pm, and offering other aids such as sleep masks and ear plugs. Helping people to keep active during the day is also beneficial, and ensuring people have access to those things which make them feel safe, including their mobiles and tablets, but also photos of loved ones. Hospital Spiritual services should also be considered and offered, regardless of faith background.
We should try to help people to verbalise their worries and look for immediate solutions to immediate problems, and to avoid ruminating on the ‘what ifs’ – ask “how can I help you now?” and aim to gently challenge self-criticism to help the person take a balanced view of a problem or response. Mindfulness exercises can also be useful, and there are many online (see NHS Mindfulness or NHS An Introduction to Mindfulness); perhaps a member of staff, or a student on placement could spend a few minutes with a roomful of patients guiding them through such activities?
Where depression is more severe, a referral to your Liaison Psychiatry team is always an option as they can advise on suitable approaches, medications and any follow-up. There are national targets around reductions in anti-depressant prescribing, but they should still be used where clinically indicated. Many do have side effects. A full medical review should be completed before new prescriptions are started, and the person (or their proxy where relevant), should be in agreement. There is no single best anti-depressant for common use. Where being prescribed by a non-mental health professional for moderate depression:
- Sertraline 50mg has the lowest cardiac side effects
- Mirtazapine at 15mg is good for anxiety and improving appetite and sleep at 15mg, but monitoring of renal function is necessary. QTc should also be checked.
Whilst depression is under-recognised in the general hospital environment, it doesn’t need to be, and with small changes, staff can have a hugely positive impact on the patients they care for. Those with depression can be supported, and managing depression can have positive benefits for patient recovery time and rehabilitative success.