Ellen L. Brown

A Randomized Trial of Depression Assessment Intervention in Home Health Care

OBJECTIVES: To determine whether an educational intervention would improve depression assessment and appropriate referral. Secondary analyses tested whether referral led to depression improvement.

Transition to Home Care: Quality of Mental Health, Pharmacy, and Medical History Information

Objective: To assess the completeness and accuracy of clinical information provided by referral sources to visiting nurses for patients admitted to receive home health care. Methods: Clinical referral information for a representative sample of 243 older adults admitted to receive skilled home-health nursing was compared to medical record information from home-health charts and in-home research interviews to determine their concordance. Measures used included referral information, home-care chart documentation, in-home nurse review of medications, medication allergies, caregiver contact information, cognitive status, depression status, and follow-up plan. Results: There were medication discrepancies between in-home nurse review and admission information in 215 cases (88.4%). Clinical information on medication allergies was lacking from referrers in 85 cases (34.9%). No information was provided by the referrers about cognitive status in 38 (73%) cases classified as cognitively impaired and in only 2 of 35 cases with major depression identified with the Structured Clinical Interview for Axis I Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID), was depression related information provided by referrers. Conclusions: The primary finding of this study is that during a transfer of an older adult to the home care service sector, essential clinical information is often missing, and there are significant discrepancies between medication regimens. These findings support the need for both educational initiatives and technology to address the complex care needs of older adults across settings to reduce the risk for medication errors and poor outcomes.

Does depression predict falls among home health patients? Using a clinical-research partnership to improve the quality of geriatric care.

This study found that patients with depressed mood or anhedonia identified on the OASIS were nearly three times more likely to fall. The authors describe the ways these findings are being used in a fall prevention program. The clinical-research partnership used in the study was found to help agencies develop clinically driven research, analyze clinical and administrative data for quality improvement, and provide a foundation for research consultation/collaboration in applied settings.

Training nursing staff to recognize depression in home healthcare.

OBJECTIVES: To describe the implementation and acceptability of the TRaining In the Assessment of Depression (TRIAD) intervention, which has been tested in a randomized trial. The primary aim of TRIAD is to improve the ability of homecare nurses to detect depression in medically ill, older adult homecare patients.

Detection of Depression in Older Adults with Dementia

Depression and dementia are the two most frequent psychiatric syndromes in the older adult population. Depression in older adults with and without dementia often goes unrecognized and untreated (Charney et al., 2003; Kales, Chen, Blow, Welsh, Mellow, 2005). Estimates of the prevalence of depression in older adults with dementia vary widely (Alexopoulos, Abrams, 1991; Wragg, Jeste, 1989), which is attributed to differences in sampling, diagnostic criteria used to identify depression, and the way it is assessed (Alexopoulos, Abrams, 1991; McCabe et al., 2006). Depression in older adults is not simply due to aging; medical conditions increase the likelihood of depression (Alexopoulos, 2000). Despite expert recommendations (Alexopoulos et al., 2001) and increased availability of a range of depression treatment options (e.g., medication, psychotherapy, combination therapy, and ECT), depression remains a significant public health problem for older adults (Surgeon General Healthy People 2010). Detection is the first essential step to improving depression care for patients with dementia. Major depression is a syndrome characterized by a number of signs and symptoms. According to the DSM-IV TR (American Psychiatric Association, 2000), at least five symptoms must be present for a diagnosis of major depression to be made (see Definitions of Key terms). In a study conducted in a nursing home, 25% of residents screened positive for major depression (Gruber-Baldini et al., 2005). This is close to the prevalence rate of major depression reported for persons with Alzheimer’s disease (Alexopoulos, Abrams, 1991 [15%–20%]; Lyketsos et al., 1997 [22%]; Wragg, Jeste, 1989 [10%–20%]). In recognition that many demented patients experience clinically significant depression that may not meet full criteria for major depression, Olin et al. (2002b) have proposed new provisional diagnostic criteria for depression of Alzheimer disease. Diagnostic criteria include fewer symptoms of depression (three symptoms versus five symptoms required for major depression). In addition, symptoms need to be present for a shorter period of time due to the fluctuating nature of depression in persons with dementia (Abrams, Alexopoulos, 1994; Jost, Grossberg, 1996). However, research studies are still needed to validate these new depression criteria (Charney et al., 2003). Depression screening in persons with dementia is hindered at times by the patient’s inability to self-report symptoms and tendency to underestimate degree of depression, and discrepant caregiver reports (Teri, Wagner, 1991). The assessment of depression in dementia is complicated by the considerable overlap in its clinical presentation with that of dementia.

An Intervention to Improve Nurse-Physician Communication in Depression Care

OBJECTIVES Depression in older adult home care recipients is frequently undetected and inadequately treated. Failed communication between home healthcare personnel and the patients physician has been identified as a barrier for depression care. The purpose of this pilot intervention study was to improve nurse competency for communicating depression-related information to the physician. DESIGN A single group pre-post experimental design. SETTING Two Medicare-certified home healthcare agencies serving an urban and suburban area in New York. PARTICIPANTS Twenty-eight home care nurses, all female Registered Nurses. INTERVENTION Two-hour skills training workshop. MEASUREMENTS To evaluate the intervention, pre-post changes in effective nurse communication using Objective Structured Clinical Examinations and nurse survey reports. RESULTS The intervention significantly improved the ability of the home care nurse to perform a case presentation in a complete and standard organized format pre versus postintervention. The intervention also increased nurse-reported certainty to communicate depression-related information to the physician. CONCLUSIONS Our findings provide support for the ability of a brief, depression-focused communication skills training intervention to improve home care nurse competency for effectively communicating depression-related information to the physician.

Religious Practice and Depression among Geriatric Home Care Patients

Objective: To examine the relationship between religious practice and depression in a sample of geriatric patients receiving homecare nursing services. Methods: Patients were sampled weekly for six months from all those aged 65 to 102, and newly enrolled in a visiting nurse agency (N = 130). Depression was assessed by home interviews using the SCID and HRSD. Patients reported their religious service participation prior to receiving homecare and currently. Health status, disability, pain, social support and history of depression were also assessed. Results: The current prevalence of DSM-IV Major Depressive Disorder (MDD) was significantly greater (p < .05), and depressive symptoms were more severe (p < .02), among those persons who had not attended religious services prior to receiving homecare. Logistic regression demonstrated that the effect of religious attendance remained significant when controlling for health status, disability, pain, social support and history of depression. A subsequent analysis compared three groups of patients. They were those who had: 1) Not attended religious services; 2) Stopped attending since homecare; 3) Continued attending. Data demonstrated significantly decreasing prevalence of MDD (p < .03) across the groups. Conclusions: Prevalence of DSM-IV Major Depressive Disorder and the severity of depressive symptoms were significantly lower among homecare patients who attend religious services. Because a large proportion of persons stop attending religious services after initiating homecare, it is suggested that visitation by clergy may improve depressive symptoms for these patients.

Symptoms of depression in older home-care patients: patient and informant reports.

The purpose of this study was to examine the level of agreement and patterns of disagreement between home-care patient and informant reports of depressive symptoms. The authors interviewed a sample of 355 older home-care patients and their informants using the Structured Diagnostic Interview for DSM-IV (R. L. Spitzer, M. Gibbon, & J. B. Williams, 1995). Informants reported more psychological symptoms than patients, and this type of discrepancy was higher for patients with cognitive impairment and patients who had younger informants. Younger informants also reported more cognitive symptoms, whereas patients were more likely to report suicidal thoughts or ideation if they were not cognitively impaired. The patterns of these discrepancies may reflect age- and cohort-related response bias in the reports of depressive symptoms obtained from older adults.

Need and Potential Use of Information Technology for Case Manager–Physician Communication in Home Care

Case management has become a popular model for providing home care services to nursing home-eligible older adults. To maximize collaborative decision making and patient outcomes, members of the case management team must engage in ongoing, open communication. However, little is known about the quality of communication between home care case managers and their clients’ physicians. This study examined geriatric home care case managers’ perceptions of their communication with their clients’ physicians. Participating case managers were employed at two large home care agencies located in the South Florida region. The findings suggest that communication between home care case managers and physicians is limited and inefficient. Implication for policy and practice are provided. Finally, we propose ways to leverage Information Technology to bridge this communication gap.

Primary care physicians attitude toward diagnosis and treatment of late-life depression.

Underdiagnosis and undertreatment of late-life depression is common, especially in primary care settings. To help assess whether physicians attitude and confidence in diagnosing and managing depression serve as barriers to care, a total of 176 physicians employed in 18 primary care groups were administered surveys to assess attitudes towards diagnosis, treatment, and management of depression in elderly patients, (individuals over 65 years of age). Logistic regression was performed to assess the association of physician characteristics on attitudes. Nearly all of the physicians surveyed felt that depression in the elderly was a primary care problem, and 41% reported late-life depression as the most common problem seen in older patients. Physicians were confident in their ability to diagnose and manage depression, yet 45% had no medical education on depression in the previous three years. Physicians confidence in their ability to diagnose, treat, and manage depression, and their reported adequacy of training, do not appear to correspond to the amount of continuing medical education in depression, suggesting that physician overconfidence may potentially be serving as a barrier to care.