Depresjon i sykehjem. Underdiagnostikk og overbehandling

Abstract

Depression is prevalent among nursing home patients. Depression may have various clinical expressions and symptoms of dementia and depression may overlap, which makes diagnostic work-up challenging. Treatment for depression is environmental therapy, psychotherapy, antidepressive medication and ECT. However, most often the patient is only offered medication. Sadness is a core symptom of the medical defined depression, but sadness is not always present in old persons with depression. Patients newly admitted to long-term care in nursing homes are vulnerable and may be especially prone to depression. High quality diagnostics is crucial for precise diagnosis and treatment options. There is little knowledge on the nursing home patient’s perception of own sadness. My thesis consists of three empirical studies. Clinical study: Aim: To gain knowledge on depression among newly admitted long-term care patients in nursing homes, and associations between depression, diagnostic workup and treatment. Participants and methods: 88 newly admitted long-term care nursing home patients were diagnosed according to the ICD-10 criteria for depression within three months after admission. We used evaluation scales in order to screen for depression, cognitive function and activities of daily living. We looked for associations between depression and data on documented diagnostics and treatment, which we extracted from the patients’ medical records. We analysed the data using descriptive and univariate methods in order to estimate prevalence of depression and evaluate diagnostics and treatment options documented in the medical files. Results: The prevalence of depression among newly admitted long-term care nursing home patients was 28 % according to ICD-10 and 31 % of the patients had scores ≥ 8 on Cornell Scale for Depression in Dementia screening tool. Approximately half of the patients with depression had any diagnostics documented in the medical files. Screening tests for depression were hardly in use. Altogether 44 % of the patients were given antidepressive medication. The indication was depression for half of them. There were no withdrawals of antidepressant medication. Focus group study: Aim: We wanted to explore doctors’ and nurses’ decision-making on depression treatment in nursing homes. Participants and methods: We performed three focus-group interviews. Two groups consisted of doctors working either part-time or full-time in nursing homes, and one group comprised nursing home nurses. The interviews were transcribed verbatim and analysed by systematic text condensation. Results: The first theme was the diagnostic process. The nurses and doctors in the focus groups revealed challenges differentiating between sadness in depression and sadness as part of grief and sorrow. Nevertheless, they seldom performed systematic diagnostics on depression. Doctors relied on nurses information in pre-round case conferences when decisions on depression treatment where accomplished. The second theme was treatment. Most often antidepressive medication was the only treatment option offered, even though the doctors and nurses seldom deliberated any effectiveness of the treatment. Even so withdrawal was considered to be undesirable, since the nurses and doctors were hesitant on the withdrawal-consequences. The third theme was who actually decided the treatment. Doctors told about nurses deciding on treatment initiating process. On the other hand, the nurses wanted more discussion with the doctors on treatment decisions. Moreover the nurses claimed that unskilled nursing staff questioned pharmaceutical depression treatments for the patients. Interview study: Aim: To explore the patient’s perception of sadness. Participants and methods: 12 nursing home patients without cognitive impairments in long- term care were included for semi-structured individual interviews. The individual interviews were audio-taped and transcribed verbatim. The empirical data were analysed by systematic text condensation. Results: Analysis of the interview study showed that patients experienced sadness when experiencing losses of health and functional level. They also expressed sadness about dysfunctional technical equipment associated with motion or toileting. Loneliness, lack of social support and harsh nurses were other causes of sadness as expressed by informants. Nevertheless, informants stated a variety of coping strategies, including religion and accepting the losses of old age, providing satisfaction and tranquillity in spite of losses. Conclusion The results from the three studies revealed that depression according to ICD-10 is prevalent, nearly every third newly admitted patient in long term care in nursing home being depressed. Systematic diagnostics is seldom performed and there is ambiguous responsibility on treatment decisions. The treatment option most frequently offered is antidepressive medication, even though the effectiveness is doubtable. The nursing home patients perceive sadness due to many losses; however, they also possess different coping strategies.