32000565

REVIEW

A systematic review of the effectiveness of in-home community nurse

led interventions for the mental health of older persons

Penelope Thompson BEd, RN, BNurs (Hons)

Research Officer, School of Nursing and Midwifery, La Trobe University, Bundoora, Vict., Australia;

Lyn Lang MEd, BEd, BHSc, RN

Director, Nursing Studies Unit, La Trobe University (Albury-Wodonga Campus), Wodonga, Vict., Australia;

Merilyn Annells PhD, RN

Professor of Community Nursing, School of Nursing and Midwifery, La Trobe University, Bundoora, Vict., Australia

Submitted for publication: 3 February 2007

Accepted for publication: 14 November 2007

Correspondence:

Merilyn Annells

Professor of Community Nursing

School of Nursing and Midwifery

La Trobe University

Bundoora

Vict. 3086

Australia

Telephone: +61 3 9893 4223.

E-mail: [email protected]

THOMPSON P, LANG L, ANNELLS M (2008)THOMPSON P, LANG L, ANNELLS M (2008) Journal of Clinical Nursing 17,

1419–1427

A systematic review of the effectiveness of in-home community nurse led interven-

tions for the mental health of older persons

Aims and objectives. The aim was to systematically review evidence about the

effectiveness of in-home community nurse-led interventions for older persons with,

or at risk of, mental health disorders, to inform best practice nursing care with this

focus. The primary review question was ‘How effective are in-home community

nurse-led interventions for older persons with or at risk of mental health disorders

for improving mental health?’ The outcome indices of interest were nursing actions

to determine incidence or prevalence of mental health disorders, any change in a

patient’s attitude towards their mental health condition, any change in objective

measurement of mental health, or a change in diagnostic status.

Background. The rising incidence of mental health disorders in older persons is a major

concern for community nurses in developed countries. Effectively facilitating improved

mental health for older persons is necessary in this era of ageing populations with

increased demands on health funding. Disseminating systematically reviewed evidence

for in-home community nursing that positively impacts on the mental health of older

persons is crucial to ensure effective care is provided to this vulnerable patient group.

Results. This review reveals that there is evidence to support the superiority of applying

validated screening tools for mental health disorders over relying on community

nurses’ opinions and non-validated tools about this matter.

Design. Systematic review.

Methods. Search of electronic databases.

Conclusion. A clear need for replication and multi-centre trials of reviewed pertinent

studies is identified.

Relevance to clinical practice. Community nurses should consider using validated

screening tools for this focus. Until such time as higher quality evidence is available

about other nursing interventions, the reviewers suggest that the prime nursing action

� 2008 The Authors. Journal compilation � 2008 Blackwell Publishing Ltd 1419

doi: 10.1111/j.1365-2702.2008.02287.x

should be the identification of whether older persons receiving community nursing

care might have a mental health disorder and, if so, then collaborative referral is made

to appropriate services.

Key words: aged, community nursing, mental disorder, systematic review

Introduction

The de-institutionalisation of persons with mental health

disorders (MHDs) since the 1960s (Morris 1996, Cohen

1999), combined with an ageing population (Jeste et al.

1999), has seen community nurses in many developed

countries increasingly respond to the care needs of growing

numbers of older persons with MHDs. The demand for

community-based nursing care of older persons with, or at

risk of, MHDs is set to increase. For instance, Jeste et al.

(1999) estimate a prevalence of almost 20% of older

persons with significant symptoms of mental illness in

the USA, and projects that the number will more than

triple from four million in 1970 to 15 million by the year

2030.

Nursing care in the home for persons with MHDs has been

demonstrated to have a positive impact on rates of hospital

readmission, quality of life and length of hospital stay (Cohen

1999). Community nurses are in a pivotal position to identify

changes in mental health and for implementing strategies that

might include screening, assistance with medications,

monitoring for changes over time, referral and, perhaps,

psychotherapies like counselling. Globally, it is usual that

actual mental health assessment is conducted only by

qualified mental health professionals, including perhaps

community mental health nurses; however, community

nurses may screen for the possibility of MHDs that may

identify the need for mental health assessment by qualified

others.

There are economic, social and cultural imperatives to

ensure the effectiveness of nursing interventions for older

persons with MHDs and systematic reviews tangentially

related to this topic have examined the effectiveness of

interventions for home-based psychogeriatric patients (Van

Citters & Bartels 2004, Bruce et al. 2005), but no review

has focused on the specific role of the generalist community

nurse who provides home-sited nursing care to older

persons.

Aim

This review aimed to identify the effects of nurse-led

interventions for home-based patients who are older persons

(60 + years of age) with or at risk of MHDs.

Objectives and methods

The objectives of this review were:

1 To present the best available information on the range and

efficacy of in-home community nurse-led interventions for

older persons with, or at risk of, MHDs;

2 To ascertain gaps in knowledge about community nurse-

led interventions for older persons with, or at risk of,

MHDs;

3 To suggest foci for further research regarding this topic.

The primary question addressed by this review was: ‘How

effective are in-home community nurse-led interventions for

older persons with or at risk of MHDs for improving mental

health?’

Inclusion criteria

Types of studies

This review considered any randomised controlled trials,

quasi-experimental studies or studies with a qualitative re-

search design that addressed in-home community nurse-led

interventions intended to facilitate the mental health of

patients who are older persons. Publications that consisted

solely of narrative or opinion were not considered for this

review. Only studies published in English between 1995–

2006 were considered.

Types of participants

The activities of community nurses were the principal focus.

The term ‘community nurse’ was, for the purpose of this

review, confined to registered nurses who were generalists

(non-specialist) and employed by an organisation providing

home-based health care. Nurses with a designated mental

health nursing function or based in community health clinics

were outside the scope of this review. Studies that included

community nurses’ patients who were aged 60 years or

older, male or female, living at home (that is, not in a

managed care facility) and had, or were at risk of, a MHD

were examined.

Types of interventions

Interventions of interest were those carried out by a com-

munity nurse in the patient’s home, and which specifically

intended to facilitate the mental health of the patient.

P Thompson et al.

1420 � 2008 The Authors. Journal compilation � 2008 Blackwell Publishing Ltd

Consequently, interventions sought for review were wide-

ranging and included screening, education, referral, con-

sultation, counselling, medicine administration, comple-

mentary therapy or any psychological intervention that

could be instigated within the scope of a community nurse’s

role.

Types of outcome measure

The outcome measures of interest were those that measured:

• Nursing actions to determine incidence or prevalence of

MHDs;

• Any change in a patient’s attitude towards their MHD;

• Any objective measurement of mental health;

• A change in diagnostic status regarding a MHD.

Search methods

Identification of studies

Using a three-tiered strategy, studies were initially identified

in CINAHL and MEDLINE using the terms ‘nurse’ and

‘mental disorder’ and ‘aged’ in the title or abstract, or

indexed as key words. An in-depth search followed using all

identified index terms and key words, and finally a hand-

search of the bibliographies of all relevant studies was

undertaken. Data bases searched included: CINAHL,

MEDLINE, PsycINFO, Proquest – Health and Medical

Complete (including Dissertation and Theses), Excerpta

Medica Database (Embase), Australian Public Affairs Infor-

mation Service (APAIS) – Health, The Cochrane Library,

Joanna Briggs Institute of Nursing and Midwifery, DARE

and World Health Organisation – Health Evidence Network.

The search was limited to studies published between 1995

and 2006 in the English language.

Publication bias was addressed to a limited extent through

the searching of ‘Dissertation and Theses’ in the Proquest

Database. Time constraints restricted the search strategy and

did not allow for hand-searching of topic-specific journals,

comprehensive searching of the Internet, contacting of

relevant organisations or topic experts for further references,

or replication of the search by an independent person.

Selection of studies

Identified studies were assessed for relevance based on the

title, abstract and body text; those identified from the hand-

search were assessed for relevance on title alone. A full report

of each relevant study was then retrieved and read in detail to

assess whether it met inclusion criteria. Two reviewer units (a

unit of one researcher and a unit of two researchers)

independently evaluated the retained studies to ensure their

inclusion was appropriate.

Critical appraisal

The methodological quality of each included study was

assessed independently by the two reviewer units prior to final

inclusion. The reviewer units were not blinded to the names of

the authors, institutions, journal or results of the studies during

the assessment process. Studies were assessed and rated for the

validity of their design and conduct, specifically focusing on:

• The quality of randomisation;

• Whether or not participants were blinded to treatment;

• Whether or not allocation to treatment groups was con-

cealed from the allocator;

• Whether attrition was adequately accounted for;

• Whether or not those assessing outcomes were blind to the

treatment allocation;

• Whether the control and treatment groups were compara-

ble at entry;

• Whether groups were treated identically other than for the

stated interventions;

• Whether outcomes were measured reliably and in the same

way for all groups;

• Whether appropriate statistical analyses were used.

The protocol for disputations was arbitration by a third

party.

Data collection

To minimise the risk of error during data transcription, data

were extracted independently by two reviewer units using a

quantitative data extraction tool requiring identification of

the number of participants, description of intervention,

outcome measures, the results for dichotomous data for all

groups and of continuous data for all groups, a checklist for

assessing validity of the study and space for recording both

the author’s conclusions and the reviewer’s comments. Data

were compared for differences.

Data synthesis

The review topic was deliberately broad and the identified

studies investigated many different nurse-led interventions for

a variety of MHDs. Statistical pooling of results was not

appropriate; therefore, results were summarised in narrative

form. Consequently, where multiple assessments were used

on a single group of subjects, all outcomes were reported –

typically this would not occur in a meta-synthesis to avoid

over-estimation of the data.

Review Systematic review: home nursing and mental health


Results

Description of studies

The search identified 204 studies of interest, of which only

fourteen met inclusion criteria. Critical appraisal resulted in

five eliminations leaving nine studies that met all inclusion

criteria (see Table 1). Of the nine included studies, only one

was a randomised controlled trial (see Table 1).

The variation in study design and purpose made it inappro-

priate to combine results in a meta-analysis. Investigation of

depressive symptomatology was the sole focus of seven of the

nine included studies: two studies investigated any mental

health disorder as defined by the Diagnostic and Statistical

Manual of Depressive Disorders (DSM), version III onwards,

including depression, anxiety, schizophrenia and substance

abuse disorders. Given that the range of mental health

disorders affecting older persons is broad, and the variety of

nursing activities related to mental health care for persons

living at home is extensive, the paucity of rigorously designed

studies is noteworthy. All included studies used nurses to screen

patients for MHDs, either as a component or the primary focus

of the study, reflecting the significant role nurses play in the

early identification of at-risk older persons. The results are

presented as two clusters based on the focus of their interven-

tions: screening and comprehensive nursing interventions.

Screening

Nurse practitioners used the 15-item Geriatric Depression

Scale (GDS-15) to ascertain the prevalence of depressive

symptomatology in a large convenience sample of 345 home-

bound older persons (Engberg et al. 2001). Participants were

sourced from a larger study on homebound older persons living

with self-reported incontinence. Data were collected during the

first 1–2 visits of an in-home face-to-face admission assess-

ment. Clinical recognition of depression was also sought from

in-home chart review and medication review.

Brown et al. (2003) sought to determine the ability of

community nurses to identify depressive symptoms correctly in

older patients living at home (n = 403). The survey responses

of 42 nurses regarding presence of depressive symptoms were

compared with the results of patient interviews by research

assistants using the Structured Clinical Interview for DSM-IV

disorders (SCID). The professional status of the research

assistants was not disclosed; therefore, the quality of the

interviews is questionable. Diagnostic status was confirmed

using multiple methods. Nurses’ opinions about whether or

not, and to what extent, the patient was depressed were

surveyed verbally and compared with the DSM-IV diagnosis of

Table

1In

cluded

studie

s–

auth

or/

s,des

ign,

countr

yand

inte

rven

tion/f

ocu

s

No.

Auth

or/

sStu

dy

des

ign

Countr

yIn

terv

enti

on/f

ocu

s

1B

lanch

ard

etal

.(1

995)

Case

-contr

olled

cohort

UK

Com

munit

ynurs

eim

ple

men

tati

on

of

mult

idis

ciplinary

dev

eloped

managem

ent

pla

ns

of

old

erpati

ents

wit

hdep

ress

ion

2B

lanch

ard

etal

.(1

999)

Case

-contr

olled

cohort

UK

Com

munit

ynurs

eim

ple

men

tati

on

of

mult

idis

ciplinary

dev

eloped

managem

ent

pla

ns

of

old

erpati

ents

wit

hdep

ress

ion

3B

row

net

al.

(2003)

Des

crip

tive

corr

elati

onal

USA

Com

munit

ynurs

ere

cognit

ion

of

old

erpati

ents

’dep

ress

ive

sym

pto

ms

4B

row

net

al.

(2004)

Des

crip

tive

corr

elati

onal

USA

Outc

om

eand

Ass

essm

ent

Info

rmati

on

Set

(OA

SIS

)

5D

alt

on

and

Busc

h(1

995)

Des

crip

tive

corr

elati

onal

USA

15-i

tem

Ger

iatr

icD

epre

ssio

nSca

le(G

DS-1

5)

6E

ngber

get

al.

(2001)

Des

crip

tive

corr

elati

onal

USA

15-i

tem

Ger

iatr

icD

epre

ssio

nSca

le(G

DS-1

5)

7Fla

her

tyet

al.

(1998)

Case

-contr

ol

USA

Tota

lquali

tym

anagem

ent

(TQ

M)

8Pre

ville

etal

.(2

004)

Des

crip

tive

corr

elati

onal

Canada

Pri

mary

Care

Evalu

ati

on

of

Men

tal

Dis

ord

ers

(PR

IME

-MD

),

Psy

cholo

gic

al

Dis

tres

sIn

dex

((PD

I-29),

Case

manager

’s

apri

ori

judge

men

tof

old

ercl

ient’

sm

enta

lhea

lth

statu

s

9R

abin

set

al.

(2000)

Random

ised

contr

oll

edtr

ial

USA

Psy

choger

iatr

icA

sses

smen

t&

Tre

atm

ent

inC

ity

Housi

ng

(PA

TC

H)

P Thompson et al.


major or minor depression. Both the nurses and the interview-

ers were blinded to the results of the initial patient interview.

In a subsequent study, Brown et al. (2004) compared the

accuracy of 64 community nurses start-of-care ‘Outcome and

Assessment Information Set’ (OASIS) ratings of depressive

symptom items (depressed mood and diminished interest in

most activities) against the clinical ratings obtained during

SCID interview of 220 randomly-selected, medical-surgical

home care older people. Unlike Brown et al. (2003), quality

control was attempted with the study psychologist reviewing

the interviews and rating the patients for major or minor

depression. The interviewers and study psychologist were

blinded to the outcomes of the OASIS assessments.

Similarly, Dalton and Busch (1995) investigated whether

nurses were making depression-related nursing diagnoses for

a convenience sample of 40 patients who were clinically

depressed according to the 30 item GDS (GDS-30). Patient

histories were examined for the presence of relevant North

American Nursing Diagnosis Association (NANDA) diagno-

ses, and opinion reports were sought from nurses regarding

their patient’s mental health status. Evaluation of this study

was constrained by the report not indicating whether there

was blinding during data collection, the number of nurses

involved or how their verbal reports were ascertained.

In a large study (n = 177) comparing accuracy of three

different tools to the SCID (Preville et al. 2004), the necessity

of effective screening by nurses for psychiatric disorders was

demonstrated. Of interest to this review was the study

component whereby the nurse case manager was asked

whether or not there was a probable case of mental health

disorder (yes/no). Within the following four weeks, a

psychologist, blinded to the initial interview results, con-

ducted the SCID interview for DSM-IV disorders and

diagnosed the patient. Psychologists administering the SCID

were trained to do so, providing some quality control.

Comprehensive nursing interventions

Blanchard et al. (1995) sought to ascertain whether depressed

older adults (n = 96) gained mental health benefit from a three-

month intervention of individualised care plans implemented

by a nurse when compared with usual primary care manage-

ment. Each case was randomly allocated to either the study

nurse intervention (n = 47) or usual primary care management

(n = 49). The intervention was implementation of the care plan

through ten weekly nurse visits of 45 minutes duration with

additional liaison with the local general practitioner and the

multidisciplinary team. Data were obtained in three forms at

entry and at three months: firstly, the Short-CARE tool

screened for depression using the imbedded diagnostic depres-

sion scale (DPDS); secondly, detailed assessment through the

Geriatric Mental State (GMS-AGECAT) – History and Aeti-

ology Schedule (HAS) that combines a semi-structured inter-

view with a computer program to generate symptom profiles

and diagnoses according to psychiatric protocols; thirdly,

study nurses kept a diary of their activities. Research workers

blinded to the subject status collected the three month data and

analysed the nurses’ diaries. In a follow-on study, Blanchard

et al. (1999) sought evidence of the longer term benefits by

repeating Short-CARE and GMS-AGECAT on 64 subjects

over 6–23 months: 35 out of 47 of the original intervention

group and 29 out of 49 of the original control group. Variation

in interview time was accounted for.

A five-part total quality management (TQM) plan inter-

vention group was compared with a historical control group

for rates of hospitalisation in the study by Flaherty et al.

(1998). Additional analyses included effectiveness of nurses’

psychosocial assessment in detecting depression compared

with the GDS-30. Patients were not randomised and data

collections were unblinded.

Rabins et al. (2000) tested the impact of a nurse-based

mobile outreach programme on levels of depression, psychi-

atric symptoms and undesirable moves (e.g., to a nursing

home). This tiered study identified psychiatric disorder

screen-positive residents ‡60 years of age (n = 310), and a

random sample of 10% of screen-negative residents (n = 61)

from a cluster of urban public housing buildings. Participants

underwent a SCID for DSM-III disorders and cognition

assessment as administered by trained mental health profes-

sionals at baseline and repeated at 26 months. Outcome

measures of interest were a change in the Brief Psychiatric

Rating Scale-18 item (BPRS-18) and the Montgomery-Asberg

Depression Rating Scale (MADRS).

Methodological quality of included studies

Study designs were appropriate for the phenomena being

investigated. No studies reported power calculations to

estimate adequate sample size, with only two studies having

sufficient participants to be considered moderately sized –

that is, greater than 200 participants (Brown et al. 2003,

2004), and the remainder, bar one, had numbers too small to

be considered representative. Rabins et al. (2000) sampled

their entire population. Limitations to the significance on

generalisability of findings were generally well reported: for

example small numbers, the recruiting of nurses from only

one agency and non-random sampling.

Random sampling for subjects is an important means of

ascertaining a representative sample and controlling for selec-

tion bias. Two studies did report random sampling (Brown et al.



2003, 2004) but did not specify their process beyond ‘designed

to recruit a representative sample of agency patients’ (Bruce

et al. 2002). The remainder used convenience or purposive

sampling (Blanchard et al. 1995, 1999, Dalton & Busch 1995,

Flaherty et al. 1998, Rabins et al. 2000, Engberg et al. 2001,

Preville et al. 2004). The reviewers suggest this lack of

randomised sampling may be in part explained by an attempt

to avoid the problem of who misses out in treatment studies, but

also the design and populations for the majority of the included

studies did not readily lend themselves to randomisation.

Of the three studies reporting randomisation to interven-

tion/control groups (Blanchard et al. 1995, 1999, Rabins

et al. 2000), none reported their randomisation processes or

whether selection bias was controlled for using allocation

concealment. Two studies deliberately matched participants

for duration of diagnosis of depression (Blanchard et al.

1995, 1999). Post-hoc analysis for matching of group

demographics was reported in four studies and generally

found to be well-matched. Notable group differences were

reported as rates of marriage (higher in intervention group)

(Rabins et al. 2000) and duration of weeks of home care

service (longer in control group) (Flaherty et al. 1998).

Enumeration of attrition rates is important for the detec-

tion of attrition bias and generally the studies in this review

made some attempt to report these figures. Drop out rates

were relevant for five studies and were enumerated in three

(Blanchard et al. 1995, 1999, Preville et al. 2004), included in

the analyses in two (Blanchard et al. 1995, 1999), but not

reported or not considered in the outcome in two (Flaherty

et al. 1998, Rabins et al. 2000). Attrition rates were relevant

for four studies and were enumerated in three (Flaherty et al.

1998, Blanchard et al. 1999, Rabins et al. 2000), included in

the analysis of one (Blanchard et al. 1999), and not reported

in one (Blanchard et al. 1995). In addition, intention-to-treat

analysis was reported in one study (Blanchard et al. 1999),

although how this was conducted was unclear – that is, were

participants analysed in the groups to which they were

randomised regardless of which (or how much) treatment

they actually received, and regardless of other protocol

irregularities, such as ineligibility, and were all participants

included regardless of whether their outcomes were actually

collected (Deeks, Higgins & Altman 2005).

Detection bias was controlled for by blinding of outcome

assessors in six studies (Blanchard et al. 1995, 1999, Rabins

et al. 2000, Brown et al. 2003, 2004, Preville et al. 2004). Only

one study declared their assessors unblinded (Flaherty et al.

1998). Tools used to measure outcomes or used as criterion

standards were all reported as well-validated (see Table 2).

Reported data were largely in raw form and accompanied by

analyses and estimates of significance, such as p values and

confidence intervals. Despite the use of the ‘gold standard’

SCID for the detection of MHDs, the quality of data collected is

questionable when not conducted by a psychiatrist. Some

attempt at quality control was made: Preville et al. (2004) used

trained psychologists; Rabins et al. (2000) used trained mental

health professionals; and Brown et al. (2004) used research

associates who tested highly on inter-rater reliability with a

second associate (intraclass r = 0Æ91, 95% CI 0Æ86–0Æ95) and

then used a psychologist to review the interviews and assign the

diagnosis. By contrast, the research assistants used by Brown

et al. (2003) are only reported as having training in reliability,

which in no way confers expertise. The quality of the data in

two studies using the GDS is also called into questionas they did

not screen out participants with high level cognitive impair-

ment (Dalton & Busch 1995, Flaherty et al. 1998), despite the

fact that the GDS fails to identify depression in persons with

mild to moderate dementia (Montorio & Izal 1996).

Outcomes

The breadth of the review questions has captured a diverse

range of nursing activities related to older persons with, or at

Table 2 Frequency of use of validated screening or assessment tools

Tool The studies using the tool

Diagnostic Depression Scale (DPDS) Blanchard et al. (1995)

Blanchard et al. (1999)

Structured Clinical Interview for DSM III or IV Disorders (SCID) Brown et al. (2003)

Brown et al. (2004)

Preville et al. (2004)

Geriatric Depression Scale-30 item (GDS-30) Flaherty et al. (1998)

Geriatric Depression Scale-15 item (GDS-15) Dalton and Busch (1995)

Engberg et al. (2001)

Primary Care Evaluation of Mental Disorders (PRIME-MD) Preville et al. (2004)

Psychological Distress Index-29 (PDI-29) Preville et al. (2004)

Brief Psychiatric Rating Scale-18 item (BPRS-18) Rabins et al. (2000)

Montgomery-Asberg Depression Rating Scale (MADRS) Rabins et al. (2000)

P Thompson et al.


risk of, MHDs. The most frequent nursing action uncovered

by this review was screening, with the remaining studies

reporting multi-faceted nursing interventions. Results are,

therefore, presented as two clusters: ‘screening’ and ‘com-

prehensive nursing interventions’.

Screening

Screening for mental health disorders, most often depression,

was the most frequent nursing activity investigated by the

studies. Screening alone was the focus of five studies (Dalton &

Busch 1995, Engberg et al. 1999, Brown et al. 2003, 2004,

Preville et al. 2004) and screening as a component of a more in-

depth intervention, a minor component of four studies (Blan-

chard et al. 1995, 1999, Flaherty et al. 1998, Rabins et al.

2000). In studies where screening alone was the focus, nurse

judgements or usual admission assessments were compared

with validated tools and in each case the tool was superior for

detecting an actionable level of psychiatric symptoms.

Nurses’ opinion about the mental health status of patients

was consistently found to be inferior to validated screening

tools. Dalton and Busch (1995) found that when the GDS-30

was used as the criterion standard, nurses recognised less than

half (5 out of 11) (sensitivity 45Æ5%) of depressed patients,

but correctly identified absence of depression in 25 out of 29

(specificity 86Æ2%). Brown et al. (2003) likewise demon-

strated that nurses correctly identified depression in less than

half of SCID positive patients (44 out of 97, sensitivity

45Æ4%), and correctly identified no depression in only three-

quarters of SCID negative patients (230 out of 306, specificity

75Æ2%). Higher levels of nursing experience correlated

positively with recognition of depression (20 out of

36 = 56%, OR 4Æ37, 95% CI 0Æ71–26Æ79), as did certain

patient characteristics, such as disability in Activities of Daily

Living (18 out of 31 = 58%, OR 2Æ32, 95% CI 1Æ05–5Æ00)

and living with another person (30 out of 54 = 56%, OR

2Æ56, 95% CI 1Æ05–6Æ25). Three patient characteristics pre-

dicted incorrect identification of depression- living alone (34

out of 117 = 29%, OR 1), use of antidepressants (14 out of

25 = 56%, OR 0Æ22, 95% CI 0Æ11–0Æ47) and reporting a

great deal of pain (26 out of 68 = 38%, OR 0Æ42, 95% CI

0Æ26–0Æ68). Additionally, Preville et al. (2004) report data

suggesting nurses’ a priori judgement identified only a third

of SCID positive patients (22 out of 76, sensitivity 30Æ6%).

General nursing assessment tools were also found to under-

detect psychiatric symptoms in older patients. Flaherty et al.

(1998) determined that organisation-specific psychosocial

assessments were ineffective for screening for depression, with

only 46 out of 81 (sensitivity 57%) of GDS-30 positive cases

identified. Similarly, a study of admission OASIS data (Brown

et al. 2004) reported that nurses identified only one third (12

out of 36, sensitivity 33Æ3%) of SCID positive patients with

depressive mood (36 out of 220) and only one out of 22

(sensitivity 4Æ5%) SCID positive patients for anhedonia (22 out

of 220). Of all the demographic variables, only living alone

demonstrated a negative correlation for the identification of

depression by nurses (n = 87; 19Æ5%, PPV 42Æ9%).

The necessity for effective screening is underpinned by the

prevalence of MHDs in community-residing older persons. In

the small sub-population of the home-bound incontinent older

persons, nurses administering the GDS-15 detected depressive

symptoms (GDS Score ‡5) in 50Æ1% (173 out of 345).

Comprehensive nursing interventions

Given the nature of the work of nurses, it is not surprising that

several studies included in this review investigated compre-

hensive nursing interventions that dealt with the patients from

admission through to discharge. The benefits of individualised

management plans developed during multi-disciplinary con-

sultation were found to be significant in the study by Blanchard

et al. (1995). Patients receiving the nurse-implemented plan

showed more improvement in their mean DPDS score over

three months (8Æ45 SD 2Æ47 to 5Æ88 SD 2Æ6) than the patients

receiving usual care (8Æ41 SD 2Æ33 to 7Æ15 SD 3Æ3, p = 0Æ05).

Although the results have a larger than desirable level of sig-

nificance, given the small sample size, it does suggest a signif-

icant effect by the nursing intervention. Benefits, however,

were not generally sustained over the longer term: at follow up

at 6–23 months an intention-to-treat analysis demonstrated

that the mean DPDS scores of the intervention group as a whole

deteriorated from 6Æ1 SD 2Æ7, p = 0Æ05 (n = 47) to 6Æ3 SD 3Æ3

(n = 43) (Blanchard et al. 1999).

There was a demonstrable benefit to the mental health of

the older persons participating in the TQM intervention

study (Flaherty et al. 1998). The TQM intervention group

showed a reduction in their mean GDS-30 score (17Æ1 SD 4Æ6

to 15Æ4 SD 6Æ8, two-tailed t-test p = 0Æ063) trending towards

significance. The magnitude of this finding is debatable as no

comparable data were collected on the control group. The

authors deduced that while no one specific part of the

intervention could be said to have made a difference to

hospitalisation rates, the entire package of education, plan-

ning and implementing the plan was effective.

Similarly, the PATCH Model intervention was more

effective for reducing psychiatric symptoms for older patients

with a psychiatric diagnosis (BPRS 29Æ7 SD 8Æ4 down

to 27Æ4 SD 7Æ2, p = 0Æ002; MADRS. 13Æ7 SD 9Æ5 down to

9Æ1 SD 6Æ2) than usual care (BPRS 30Æ1 SD 11Æ2 up to 33Æ9 SD

13Æ6; MADRS 11Æ7 SD 5Æ8 up to 15Æ2 SD 9Æ5) (Rabins et al.

2000). In addition, 11% of all Stage 2 (case identification)

subjects had undesirable moves to either a nursing home or to a



board-and-care home, although no difference was detected

between intervention and control (relative risk 0Æ97; 95% CI

0Æ44-2Æ17). The authors concluded that the PATCH Model

is effective for reducing psychiatric symptoms.

Discussion

The objective of this review was to identify evidence of the

effectiveness of community nurse-led interventions for older

persons with or at risk of MHDs. In excess of 200 related studies

were identified by the literature search, suggesting a high level of

interest for improving nursing care to the affected older people.

Only one randomised controlled trial was eligible for

inclusion in this review. Bearing in mind that the inclusion of

non-randomised studies in a review increases the risk for bias,

we justify the inclusion of quasi-experimental studies as the

nature of the nurse activities of interest in this review were

unlikely to lend themselves to study designs using true

randomisation.

The dearth of studies on the role of generalist community

nurses caring for older persons with, or at risk of, MHDs is a

concern, given the rising numbers of older persons using

community services. Moreover, whilst the emphasis on

depression-related research is encouraging, the absence of

research into generalist community nurse interventions for

other mental health disorders in older persons is noteworthy.

Of equal note, given the chronic nature of most MHDs, was

the scarcity of studies measuring the outcomes of treatment

interventions long-term. It was also of interest to the

reviewers that, although this review is reporting globally,

the site for the review was in Australia and no Australian

studies met inclusion criteria for this review. Overall, given a

lack of comparable ‘gold standard’ studies, and considering

the small subject numbers, study designs used, and the lack of

multi-site trials, the findings of this review constitute

suggested trends rather than high level evidence.

The single, unambiguous theme to emerge from this review

is that validated screening tools are consistently and signifi-

cantly more accurate for detecting symptoms of MHDs than

either the nurses’ opinions or a non-validated or non-MHD-

specific tool. This finding is suggestive of the need for sensitive,

pragmatic screening tools to be readily available for commu-

nity nurses to detect actionable levels of MHD symptomatol-

ogy. It is quite possible that without the use of validated

screening tools, community nurses may well be contributing to

the under-detection and hence under-treatment of mental

health disorders in the older population. Engberg et al. (2001,

p. 136) comments that studies that have measured depressive

symptoms among older adults have generally reported higher

levels of depression than those using clinical diagnostic criteria

such as the DSM-IV criteria, and questions whether standard-

ised screening measures overestimate the prevalence of

depression or whether current clinical diagnostic criteria fail

to recognise forms of depression that are common among

older adults. Despite this concern, detection of symptoms as in

screening and diagnosis of disorders are two different activ-

ities, and the presence of MHD symptomatology may have a

clinically significant impact on an individual even in the

absence of a DSM-IV diagnosis.

Beyond screening alone, three nurse-led interventions were

reported as having some benefit: individualised management

plans, TQM approach and the PATCH Model Intervention,

with each intervention embedded in inter-disciplinary collab-

oration. While the findings of these studies were not in

themselves generalisable, the fact that there is research of this

nature tacitly acknowledges that nurse-led interventions are

relevant and potentially beneficial.

Screening and comprehensive interventions for older persons

with, or at risk of, MHDs are intrinsically linked as, without

effective screening, it is certain that at least some patients would

inevitably miss out on comprehensive intervention with poten-

tially detrimental consequences for them, their families and the

health budget in general. Nurses must have confidence in the

screening strategy theyuse inorder toreferappropriately toother

services and to maximise the effectiveness of an interdisciplinary

team’s collaboration. The importance of such confidence is

underscored by the finding that more experienced nurses

performed better than less experienced counterparts, emphasis-

ingtheimportanceofexposureto,andeducationregarding,older

persons with MHDs, and the need for reliable screening tools in

practice.The lackofhighqualityevidenceisconcerning,butmust

be seen incontextwith the fact that, inmostareasof nursing care,

large deficits in the evidence-base for practice persist.

Conclusions

Implications for practice

On the present evidence, the key recommendation for clinical

practice is that home healthcare providers consider making

available validated screening tools for MHDs for use by nurses

during admission assessments or when an older patient is

identifiably at risk. At first glance, this may seem simple but in

reality there are many considerations for implementing such a

change. The tool needs to not only be sensitive but quick to

complete, as the burden of documentation and assessment is

already considerable for most community nurses providing

care in homes (Trossman 2002). Within Table 2, a number of

screening tools for MHDs are listed for the consideration of

community nurses, with the Geriatric Depression Scale (either

P Thompson et al.


15 or 30 item) being that most commonly applied in the

reviewed studies, and probably so in clinical situations as well.

Moreover, such a change in practice would require funding

support for any additional work burden during and after the

change, and enough time for nurses to undertake education

before and during operationalisation.

Meanwhile, until higher quality evidence is available,

raising nurses’ awareness of MHDs in older home healthcare

patients would be advantageous. Agencies could benefit from

conducting a basic educational needs analysis of their nurses

to determine their level of knowledge about MHDs in older

persons, and then implementing an ongoing, focussed

education programme to enhance ability to recognise and

manage MHDs.

Implications for research

Further research is clearly indicated from the findings of this

review. The trend in the literature suggests a role for effective

routine screening for MHDs, particularly depression. Re-

search efforts should now build on this understanding and the

known accuracy of validated screening tools to discover

sensitive, pragmatic and cost-effective processes to implement

such screening of all older recipients of home health care.

The focus of further, in-depth investigations should include

controlled trials examining mental health outcomes from care

provided by community nurses who have undertaken extra

mental health education. Additionally, research to describe

specific actions nurses currently use when identifying and

managing older persons with MHDs should be undertaken,

for which qualitative methods may initially be best used.

Having established a broad baseline for comparison, well-

structured randomised controlled trials should be the pre-

ferred research design for the testing of interventions.

Given the varied composition of nursing workforces across

the globe and the possible small numbers of patients and

nurses at many agencies, replication and multi-centre trials

should be considered to enhance generalisability of findings.

Also, allowing for the chronic nature of many MHDs,

measurement of outcomes over several months would better

determine effectiveness of an intervention rather than short-

term studies.

Finally, but crucially, more studies analysing the cost–

benefit ratio of nursing interventions are needed to support

fiscally sound spending of healthcare budgets.

Contributions

Study design: PT, MA, LL; data collection and analysis: PT,

MA LL and manuscript preparation: PT, MA, LL

Acknowledgements

The authors gratefully acknowledge the assistance from

Jacqui Allen for her assistance with data analysis. This

review was funded by a La Trobe University Faculty of

Health Sciences Research Grant, Melbourne, Australia.

References

Blanchard MR, Waterreus A & Mann AH (1995) The effect of primary care

nurse intervention upon older people screened as depressed. International

Journal of Geriatric Psychiatry 10, 289–298.

Blanchard MR, Waterreus A & Mann AH (1999) Can a brief intervention

have a longer-term benefit? The case of the research nurse and depressed

older people in the community. International Journal of Geriatric Psychiatry

14, 733–738.

Brown EL, McAvay G, Raue PJ, Moses S & Bruce ML (2003) Recognition of

depression among elderly recipients of home care services. Psychiatric

Services 54, 208–213.

Brown EL, Bruce ML, McAvay GJ, Raue PJ, Lachs MS & Nassisi P (2004)

Recognition of late-life depression in home care: accuracy of the outcome

and assessment information set. Journal of the American Geriatrics Society

52, 995–999.

Bruce ML, McAvay GJ, Raue PJ, Brown EL, Meyers BS, Keohane DJ,

Jagoda DR & Weber C (2002) Major depression in elderly home health care

patients. American Journal of Psychiatry 159, 1367–1374.

Bruce ML, Van Citters AD & Bartels SJ (2005) Evidence-based mental health

services for home and community. Psychiatric Clinics of North America 28,

1039–1060.

Cohen B (1999) Innovatory forms of evaluation for new crisis services. Science,

Discourse and Mind 1, 20.

Dalton JR & Busch KD (1995) Depression: the missing diagnosis in the elderly.

Home Healthcare Nurse 13, 31–35.

Deeks JJ, Higgins JPT & Altman DG (2005) Analysing and presenting results.

In Cochrane Handbook for Systematic Reviews of Interventions 4.2.5

(Higgins JPT & Green S, eds). (updated May 2005); Section 8. Available at:

http://www.cochrane.org/

resources/handbook/hbook.htm (accessed 11 September 2006).

Engberg S, Sereika S, Weber E, Engberg R, McDowell BJ & Reynolds CF

(2001) Prevalence and recognition of depressive symptoms among home-

bound older adults with urinary incontinence. Journal of Geriatric Psychi-

atry & Neurology 14, 130–139.

Flaherty JH, McBride M, Marzouk S, Miller DK, Chien N, Hanchett M,

Leander S, Kaiser FE & Morley JE (1998) Decreasing hospitalization rates

for older home care patients with symptoms of depression. Journal of the

American Geriatrics Society 46, 31–38.

Jeste DV, Alexopoulos GS, Bartels SJ, Cummings JL, Gallo JJ, Gottlieb GL,

Halpain MC, Palmer BW, Patterson TL, Reynolds CF III & Lebowitz BD

(1999) Consensus statement on the upcoming crisis in geriatric mental

health: research agenda for the next 2 decades. Archives of General

Psychiatry 56, 848–853.

Montorio I & Izal M (1996) The Geriatric Depression Scale: a review of its

development and utility. International Psychogeriatrics 8, 103–112.

Morris M (1996) Patients’ perceptions of psychiatric home care. Archives of

Psychiatric Nursing 10, 176–183.

Preville M, Cote G, Boyer R & Hebert R (2004) Detection of depression and

anxiety disorders by home care nurses. Aging & Mental Health 8, 400–409.

Rabins PV, Black BS, Roca R, German P, McGuire M, Robbins B, Rye R &

Brant L (2000) Effectiveness of a nurse-based outreach program for iden-

tifying and treating psychiatric illness in the elderly. Journal of the American

Medical Association 283, 2802–2809.

Trossman S (2002) The documentation dilemma: nurses poised to address

paperwork burden. Tar Heel Nurse 64, 10–11.

Van Citters AD & Bartels SJ (2004) A systematic review of the effectiveness of

community-based mental health outreach services for older adults. Psychi-

atric Services 55, 1237–1249.



32000565

Documents

Transcript of 32000565