As mild depression is common among older people in hospital, it is essential to conduct a screen on admission or as soon as the patient’s acute condition has stabilised. At the same time it is essential to conduct a cognitive impairment screen, which assists us to rule out other possible causes such as delirium, which can be treated, or dementia. This process is known as differential diagnosis.
When screening older people for depression, involve their families and carers as they can recognise a change in the older person’s normal ways of thinking and reacting and may be able to identify early signs of depression in hospital. It is important to recognise that depression and loneliness are closely related.
Screening tools used with older people for depression or loneliness
Geriatric Depression Scale short form (GDS-15 or GDS 5/15)
This is a tool for screening depression in cognitively intact older people. It is available in English and other languages.
Cornell Scale for Depression in Dementia (CSDD)
This tool is designed for people with dementia. It comprises both an informant and patient interview. Many patient interview items can be filled by observing the patient. About 20 per cent of people with dementia have moderate or severe depression; both conditions need to be addressed if present. Instructions and a demonstration are available online.
UCLA Loneliness Scale
Use this scale if you suspect that your patient is experiencing loneliness. It is a set of 3 questions currently recommended in the International Consortium for Health Outcome Measures (ICHOM).
A comprehensive mental health assessment involves a one to one interview, patient history and suicide risk assessment. A diagnosis of depression may require the following1, 2, 3:
- a physical examination and laboratory investigations to identify any underlying condition that could be causing the symptoms, such as delirium, anaemia or thyroid problem
- medical history and medication review and reconciliation to identify any medication side effects that may be causing the symptoms
- clinical and/or mental health interview regarding:
- the number, severity and duration of symptoms, including the risk of suicide or harm due to neglect, and associated disability
- any major life changes that may have caused the depression; past and family history of mood disorders, successful and unsuccessful past treatment, and availability of social support.
Assessment may also involve families and carers, particularly if the patient has cognitive impairment.
Once we have identified concerns, we should consider the interventions and discuss with the treating team whether the patient would benefit from a referral to a medical specialist to complete a differential diagnosis.
Many hospitals have access to a clinical psychology or older adult psychiatry service to confirm the diagnosis, and to determine the duration and the impact of the patient’s depressive symptoms on their everyday functioning. The degree of impairment is key to developing the most appropriate management and treatment plan2.
1. Thomas, A., Depression in older people., in Oxford textbook of old age psychiatry, T. Dening and A. Thomas, Editors. 2013, Oxford University Press: Oxford, UK. p. 545-569.
2. National Institute for Health and Clinical Excellence, Depression in adults: The treatment and management of depression in adults, 2009.
3. State of Queensland (Queensland Health), Queensland Mind Essentials: Mental Health Nursing Documents., 2010.