Screening for Depression in Older Adults

**Screening for Depression in Older Adults**

**Intro**

Depression is a common comorbidity in the older adult population.  Depression can have a negative impact on patient outcomes.  As physical therapists we have the opportunity and responsibility to screen our patients for this comorbidity, just as we screen them for other conditions like hypertension.  For purposes of this wiki I have limited the scope to screening tools that were not directly discussed in class.

**Objectives**

1.      Understand why screening for depression in older adults is important

2.       Understand the PHQ-2 screening tool

3.       Understand the GDS 5 item screening tool

4.       Understand the role of exercise in treating
depression in older adults.

**Why is screening for depression in older adults important?**1

Older adults with depression are at an increased risk for morbidity, decreased cognitive function, decreased social function, self-neglect, and suicide.  All of these factors represent negative factors for patient outcomes.  Many older adults diagnosed with major depression have never had a depression diagnosis earlier in life, so a simple screening in physical therapy may be the first time the problem is detected.  Up to 15% of community dwelling older adults are affected by depression.  That is roughly one of every seven, so if you see seven older adult patients a day as a PT at least one is probably affected by depression.

**Using the PHQ-2**
screening tool

There are many self-reported outcome measures available for screening for depression, but the simplest is the PHQ-2.  This short tool has only two items.  The items are scored on an ordinal scale and then summed.  The recommended cutoff score to warrant further screening is 3/6 (higher scores indicate higher risk for depression).  In older adults the tool has been validated for identifying major depressive episodes.2  In a general adult population it has been validated for both major depression and any depressive disorder.3  As a screening tool the IPQ-2 does not diagnose depression, it only indicates when a patient requires referral to another provider for assessment for depression. This tool is ideal for use by physical therapists because it is very fast to administer and is valid for all adults 18+.

**Using the GDS-5 screening tool**4

The original Geriatric Depression Scale was a 30 item questionnaire, later a 15 item version was made, and now a 5 item version has been validated.  The appeal of the 5 item version to physical therapists is the speed and ease of scoring.  The patient responds to each of the 5 items with a yes/no answer.  The score is counted as no for the first question (are you basically satisfied with your
life?) and yes’s for the other four questions.  A score of 2/5 or more indicates the need for referral for further screening.  The GDS 5 has been shown to be just as good as the GDS 15.

**The role of exercise in treating depression**

To date there is not a great consensus on the effects of exercise on depression in the older adult population. A recent systematic review of home based non pharmacological treatments for depression found that a combination of psychological therapy (problem solving therapy, or cognitive
behavioral therapy) in conjunction with exercise significantly increases the likelihood of remission in depression.5  The review did not find exercise alone to be effective.  Another review focusing on the effects of exercise in this population suggests that exercise combined with antidepressants is promising.6  Yet another review reports that some studies found beneficial effects from exercise compared to inactivity, but no better than compared to controls receiving cognitive behavioral therapy or social contact.7  I personally was surprised that the evidence
for exercise in treating depression in this population wasn’t stronger.  One researcher has been pushing back against
the mediocre conclusions drawn by these reviews.  James Blumenthal from Duke University published a summary of the evidence in support of exercise for treating depression.8 In the review he recaps the findings of a 1999 RCT he lead where older adults were divided into an exercise group and a medication
group.  At 16 weeks there were no between group differences in depressive symptoms, suggesting that exercise and the medication were equally effective.  At a 10 month follow up the exercise group showed a lower rate of relapse into depression.  In Blumenthal’s study the exercise was performed three times per week for 30-45min at 70-85% of HRR in a group setting.  Another RCT investigated
the optimal dosing for using exercise to treat depression.  They found that exercise consistent with ACSM guidelines seemed to have the best effect, but no other specifics were given.9

**Suggestions**

1.      Use the PHQ-2 or GDS-5 with every patient as part of intake forms or interview.

2.      If a patient warrants referral based on the PHQ 2 or GDS 5 the PHQ 9 can be used as well.

3.      Identify an appropriate provider in your area to refer patients to if they do not have a primary care physician.

4.      Encourage patients to be physically active following ACSM guidelines for wellness.

5.      Have resources available to give to patients whom you have to refer.

**Resources**

1.      Link to PDF of PHQ-2

a.      http://www.cqaimh.org/pdf/tool\_phq2.pdf

2.      Link to PDF of GDS 5

a.      https://sagelink.ca/sites/default/files/clinical resources/geriatric\_depression\_scale\_5\_item\_how\_to\_use.pdf

3.      Link to NIH older adults and depression webpage– this page will useful both for patients and for PTs

a.      https://www.nimh.nih.gov/health/publications/older-adults-and-depression/index.shtml

4.      Link to NAMI Depression in Older Persons Fact
Sheet – This fact sheet gives a good overview of depression in this
population.  This sheet is probably
better for PTs rather than for patients.

a.      https://www.ncoa.org/wp-content/uploads/Depression\_Older\_Persons\_FactSheet\_2009.pdf

5.      Link to NIMH depression brochure – This patient
brochure is a good resource for patients who may not have access to or becomfortable with using the internet.

a.      https://infocenter.nimh.nih.gov/pubstatic/TR%2013-3561/TR%2013-3561.pdf

**References**

1.      Fiske A, Loebach-Wetherell J, Gatz M. Depression
in Older Adults. *Annu Rev Clin Psychol.*
2009 ; 5: 363–389

2.      Li C, Friedman B, Conwell Y, Fiscella K.
Validity of the Patient Health Questionnaire 2 (PHQ-2) in
identifying major depression in olderpeople. *J Am Geriatr Soc.* 2007
Apr;55(4):596-602

3.      Kroenke K, Spitzer RL, Williams JB. The Patient
Health Questionnaire 2: Validity of a Two-Item Depression Screener. *Medical Care* 2003 (41) 1284-1294

4.    Hoyl MT, Alessi CA, Harker JO, Josephson KR, Pietruszka FM, Koelfgen M, Mervis JR, Fitten LJ, Rubenstein LZ.
Development
and testing of a five-item version of the Geriatric Depression Scale. *J Am Geriatr Soc.* 1999 Jul;47(7):873-8.

5.    Sukhato K,
Lotrakul M, Dellow A, et al.
Efficacy of home-based nonpharmacological interventions for treating
depression: a systematic review and network meta-analysis of randomised
controlled trials. BMJ Open 2017;7:e014499. doi:10.1136/ bmjopen-2016-014499

6.    Mura
G, Carta MG. Physical Activity in Depressed Elderly. A Systematic Review. *Clinical Practice & Epidemiology in*
Mental Health*, 2013, 9, 125-135*

7.    Holvast
F, Massoudi B, Oude VoshaarRC, Verhaak PFM (2017) Non-pharmacological treatment
for depressed older patients in primary care: A systematic review and
meta-analysis*. PLoS ONE*
12(9):e0184666

8.    Blumenthal
JA, Smith PJ, Hoffman BM. Is Exercise a Viable Treatment for Depression? *ACSMs Health Fit J* . 2012 ; 16(4):
14–21. doi:10.1249/01.FIT.0000416000.09526.eb.

9.    Dunn AL, Trivedi MH, Kampert JB, Clark CG, Chambliss HO. Exercise treatment for depression: efficacy and dose response. *Am J Prev Med.* 2005
Jan;28(1):1-8.