Sandra Davidson1, Stella Koritsas1, David Clarke2, Daniel O’Connor3 and Merilyn Liddell4
1 Department of General Practice, Monash University
2 Department of Psychological Medicine, Monash University
3 Aged Mental Health Research Group, Kingston Centre
4 Monash University Sunway Malaysia
beyondblue Victorian Centre of Excellence
Project completion year
The prevalence of depression is much higher among elderly people living in aged care accommodation than it is amongst their peers living in the community. Certainly, the high rate of cognitive impairment among people living in aged care facilities can make it more difficult for general practitioners (GPs) to detect and treat depression. However, it is also possible that GPs are less likely to attend to the mood state of patients in a nursing home than patients sitting in front of them in their consultation room. Previous research has found that depression is poorly recognised among nursing home residents and that when it is identified it is often poorly managed with inadequate dosage of antidepressant medication, inappropriate class of antidepressant or insufficient time allowed for a treatment effect.
This study evaluated the effectiveness of an educational intervention for GPs and residential care nurses in the recognition and management of depression among older people living in nursing homes. Unlike many previous studies, residents with cognitive impairment were not excluded from the study.
The multifaceted intervention included an interactive workshop conducted by an academic Old Age Professor for the GPs and by a Clinical Psychologist for nursing and care staff. Following the educational forum nurses recorded their observations of resident’s mood state using the Cornell Scale for Depression in Dementia. GPs then reviewed the resident and used the nurses’ observations to inform their clinical judgement. If patients were found to be experiencing significant depressive symptoms GPs used the knowledge gained from the educational forum to guide the patient’s management.
Nine nursing homes, 13 GPs and 55 residents were recruited into the study. Eighty-three per cent of the patient sample had a degree of cognitive impairment ranging from mild to severe. One quarter of patients reviewed by GPs were diagnosed as having probable major depression and an additional third were found to experience depressive symptoms.
Following the GP review, changes were made to the antidepressant medication of 29 per cent of patients. Antidepressant medication was introduced to 8 per cent of patients; 5 per cent had the class of antidepressant changed; 13 per cent had the dose of antidepressant medication changed and one patient had their antidepressant medication discontinued.
Pre and post intervention questionnaires completed by GPs indicated a significant improvement in their knowledge of late-life depression following the education session. The post intervention results also indicated that GPs were significantly more likely to ask their elderly patients about depression and to review elderly depressed patients fortnightly. They were also more confident in using guidelines to treat depression. Generally attitudes recorded by the GPs before and after they attended the education session did not change.
Qualitative interviews with nursing home staff found a varied response to the project. Two facilities reported a very positive response with notable changes in staff behaviour in relation to the recognition and management of residents’ mood. Other nursing homes reported that the projects’ impact was limited by the low numbers of participating GPs.
When asked what, in their opinion, might be the best way to continue raising awareness around depression among residents of aged care facilities, interviewees suggested ongoing education of all aged care staff, registered nurses and Personal Care Attendants alike. They pointed out that high staff turnover was characteristic of the aged care industry and that repetition of education was important. They also considered that having an outside organisation, such as Monash University or beyondblue, endorse and deliver the training increased the impact that such education was likely to have.
Despite the limitations of a small sample size, this study demonstrated that a multi-faceted educational intervention for GPs and nursing home staff effectively increased the recognition of depression among elderly nursing home residents. After receiving training on late-life depression GPs made changes to the antidepressant medication regime for many of their depressed residents. GPs also reported significant changes in several of their clinical behaviours.