If you evaluate correctly, treatment can be successful
Your patient is sleeping more, seems less energetic when awake, has lost interest in a favorite hobby, or has trouble following conversations. For home health patients, these symptoms can be the result of myriad conditions from diabetes to neurological problems. The symptoms also can indicate depression, a problem found in many older adults.
In fact, older Americans disproportionately are likely to die by suicide. Although they represent only 13% of the U.S. population, people 65 and older accounted for 18% of all suicide deaths in 2000. Among the highest rates, when categorized by gender and race, were white men 85 and older — 59 deaths per 100,000 people in 2000, more than five times the national rate of 10.6 per 100,000.1
Age is not the only risk factor for depression, says Kathryn Ringham, MA, MSW, care manager and caregiver coach for the Wilder Foundation and ElderCare Partners, a nonprofit health and human services organization in St. Paul, MN. "Home care represents a change in the person’s life, a worsening of their health, and loss of control in their life," she points out. All of these factors increase a person’s risk for depression, she adds. (Ringham recommends using a depression scale.)
It’s more important than ever to properly assess depression as well as other cognitive disorders. Now the results of 11 quality indicators are available to the public for eight pilot states and soon will be available nationwide, says Phyllis W. Fredlund, RNC, BSN, executive director for Health Personnel Inc. in McKees Rock, PA. (For more information about quality indicators, see Hospital Home Health, February 2003, p. 13.) "Being able to correctly assess cognitive problems means that your documentation will be more accurate, and that will mean more accurate outcomes," she explains.
If your patient seems confused, has difficulty concentrating, or seems to be sleeping too much or too little, rule out physical causes by taking the patient’s temperature, checking blood sugar, checking urine, and asking if the patient has experienced diarrhea or skin rashes, Fredlund suggests. Don’t forget to look for signs of hyperthyroidism such as hair loss. As you evaluate the patients for physical problems that might produce the symptoms you are observing, don’t forget to evaluate the patient for depression, as well, she says.
Symptoms of depression can be nonspecific, so it’s important that nurses remember to include depression in their list of conditions to consider when evaluating a patient’s complaints, says Marsha Johnson Schulte, RN, MSN, an adult nurse practitioner with St. Charles (MO) Medical Group. "The physical complaints can include fatigue, sleep disturbances, headaches, and gastrointestinal symptoms," she says. Beyond the physical symptoms are behavior changes such as a loss of interest in a hobby or even the way the patient interacts with the home health nurse.
"You may notice an increase in minor, multiple complaints, with more frequent calls from the patient or a request by the patient for more visits," Schulte points out. "Don’t assume that these behavior changes are part of their illness or the normal aging process." Instead, the nurse should focus on the patient’s history to see if there is a history of depression in the family, or evaluate medications that can increase the risk of depression, she suggests.
Certain physical conditions put patients at more risk for depression, Schulte adds. "Strokes, heart attacks, diabetes, cancer, Parkinson’s disease, and Alzheimer’s disease are more likely to increase risk of depression." This risk is due not only to the severity of the illnesses and the loss of independence they may represent, but to the medications used to treat them, she adds.
In addition to physical conditions, remember to evaluate their lifestyles, Schulte says. "Patients who use alcohol are more susceptible to depression, as are patients who are isolated from others." Two symptoms that are unique to depression are constant sadness or withdrawal from others as well as a loss of interest in people or activities that have been important, she says. "If a patient is no longer interested in gardening or does not want to watch or discuss a favorite television show, the nurse should ask questions about mood, sleep patterns, and other symptoms of depression," Schulte notes.
Look at caregivers for signs of depression as well, she suggests. "If a patient’s husband no longer takes care of the car of which he has always been proud, talk with him to see how he is doing as well," Schulte adds.
The good news is that depression is treatable, Ringham emphasizes. Antidepressants, as well as talk therapy, or a combination of both can be very effective. "Talk therapy is often given short shrift," she says. "Older people think that talking with a psychotherapist means that you’re crazy, and everyone seems more interested in a pill that can eliminate the symptoms. "Don’t rule out talk therapy for all people, though. Be aware of your patient’s personality, and make that suggestion to the social worker or physician if you believe it might help," she adds.
If you think that your patient might be suffering from depression, address the social issues that might exacerbate the depression, Ringham says. "It is critical to find help for patients with substance abuse problems." Also, try to include some sort of exercise, or even getting outside for a period of time in the daily schedule, she adds.
Address isolation by finding other programs that can help your patients, Schulte recommends. Adult day-care programs, art, or social programs offered by the local Agency on Aging, church visitation programs, Meals on Wheels, and other community-based programs that increase the patient’s contact with the outside world can help to reduce the feeling of isolation, she explains.
The key to helping your patients is to realize that depression is not a normal part of aging, Ringham adds. "Although over half of older adults believe that depression is normal, it is up to home health personnel to educate our patients and their families that depression is a biological illness that can be treated."
[For more information on aging and signs of depression, contact:
• Kathryn Ringham, MA, MSW, Care Manager/ Caregiver Coach, Wilder Foundation and ElderCare Partners, 270 N. Kent St., St. Paul, MN 55102. Telephone: (651) 224-2627. Fax: (651) 224-6906. E-mail: [email protected]
• Phyllis W. Fredlund, RNC, BSN, Executive Director, Health Personnel Inc., 1110 Chartiers Ave., McKees Rocks, PA 15136. Telephone: (412) 331-1042. Fax: (412) 331-2774. E-mail: [email protected]
• Marsha Johnson Schulte, RN, MSN, Adult Nurse Practitioner, St. Charles Medical Group, 11 Stone-bridge Place, St. Charles, MO 63301. Telephone: (636) 397-3231. Fax: (636) 397-4543.]
Reference
1. Office of Statistics and Programming, National Center for Injury and Prevention Control, Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System (WISQARS). Web site: www.cdc.gov/ncipc/wisqars/default.htm.
Your patient is sleeping more, seems less energetic when awake, has lost interest in a favorite hobby, or has trouble following conversations. For home health patients, these symptoms can be the result of myriad conditions from diabetes to neurological problems. The symptoms also can indicate depression, a problem found in many older adults.
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