Clinical Geriatrics

CASE PRESENTATION
A 91-year-old widowed woman was under the care of a home health agency’s long-term program for skilled nursing care, physical therapy, and home attendant services. She was a native of Puerto Rico and spoke both English and Spanish. After several months of home care, the patient’s primary nurse became concerned about persistent depression, and referred the patient to the behavioral health division of the agency for evaluation.

A social worker saw the patient in her home and agreed that she appeared depressed and withdrawn. A psychiatric consultation was requested through the agency’s mental health program that provided home visits by consulting physicians.

The psychiatrist made a home visit to the patient, who had lived with her daughter since retirement 30 years earlier. Her daughter was a nurse and an excellent source of historical information. Active medical problems included atrial fibrillation, asthma, glaucoma, and bilateral cataracts. There was a past history of subdural hematoma and alcoholism. The patient had become weak and deconditioned after a recent hospitalization but had no recent falls. There was a remote history of prior psychiatric treatment for anxiety and depression, but no details were available regarding medication treatment.

The psychiatrist elicited from the patient’s daughter a history of memory loss that was gradual and progressive. Most recently, the patient’s primary care provider had prescribed escitalopram 5 mg daily for depression. The patient’s daughter indicated concern about her mother’s withdrawn behavior, decreased appetite, and decline in participation in physical therapy sessions. Her present mental status demonstrated depressed mood and restricted affect. In response to the Memory Impairment Screen,1 she recalled 4 of a possible 8 words correctly, indicating significant memory impairment. Her Patient Health Questionnaire (PHQ-9)2 score was 14, consistent with a clinical diagnosis of moderate-to-severe major depressive disorder.

DISCUSSION
Depressive symptoms and undiagnosed major depression are prevalent among older home care patients. Major depressive disorder has been found in 13.5% of elderly home health care patients, in contrast with 6.5% of older primary care patients.3 Treatment of depression enhances self-care, improves compliance with and adherence to medical care, improves treatment outcomes, and reduces the risk of suicide.4 Unfortunately, neither home care agencies nor office-based psychiatrists have traditionally provided the care needed to diagnose and treat this population. Depression is infrequently recognized among older home care patients, and typically becomes a persistent problem.5

The need for training professional home care staff
We sought to address this need at our large, urban hospital–affiliated agency through training of professional home care staff to better identify persons with depression, and by better integrating psychiatric services within the home care agency. The Weill Cornell Homecare Research Partnership was utilized to train nurses, physical therapists, speech therapists, and occupational therapists.6 The format included didactic instruction and interactive learning, with scripted video using professional, ethnically diverse actors to portray patients with symptoms of depression and suicidal ideation. Facilitated group interaction followed the video to reinforce participants’ capacity to screen for depression and suicidal ideation as part of a typical visit to a patient’s home. The PHQ-9 assessment instrument was promoted as a means of both screening and evaluating the impact of treatment.2 (The PHQ-9 may be downloaded free of charge from the website www.pfizer.com/phq-9.)

As a result of the training program, communication of screening results to the patient’s physician or mental health specialist became part of the standard agency protocol.