The effectiveness of nonpharmacological nursing interventions in elderly with depressive disorders: a systematic review

Review objective/questions The objective of this review is to identify and synthesise the best available evidence regarding the effectiveness of nonpharmacological nursing interventions for older adults with a depressive disorder. More specifically, the review will focus on the following questions: Are nonpharmacological nursing interventions effective for reducing symptoms in older adults with depressive disorders? Does the effectiveness of nursing interventions vary with the severity of symptoms? Is the effectiveness of nursing interventions affected by the presence or absence of simultaneous pharmacological treatment? How does the presence of comorbidities affect the effectiveness of nursing interventions for depressive disorders? Background The concept of depression slightly varies according to which classification is used to establish a diagnosis. The two classifications that are most used in clinical practice - International Classification of Diseases (ICD 10) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) - express different views on the concept of depression. However, they are consensual in what concerns the characteristics of depression, which can be summarised by the following attributes: specific mood change, sadness, loneliness and apathy, low self-esteem, ideas of guilt and unworthiness, regressive and self-punishing drives, longing to escape from a situation or from the world, hiding from oneself, vegetative changes, anorexia, sleep disturbance and loss of libido, and changes in activity level.1–3 Different instruments - questionnaires, scales, tests - can be used to ascertain the presence of depressive symptoms (such as the Geriatric Depression Scale or the Depression Anxiety Stress Scales) with cutoff points generally classifying depressive symptoms as mild, moderate, severe and/or very severe. Research has provided contradictory results as to whether ageing is a risk factor for depression or not. A recent survey for the SUPPORT project - the Survey of Health, Ageing and Retirement in Europe (SHARE) - indicates that the prevalence of depression rises consistently with age.4,5 However studies of prevalence present great variability in study design and sample characteristics making it difficult to compare results and draw reliable conclusions.6 Though it may not be clear whether the prevalence of depression increases or decreases with age, subsyndromal depression is commonly described among the elderly. It has been pointed out that they may be a more vulnerable group due to age-related structural and biochemical changes5 or due to a greater exposure to risk factors such as physical/chronic illnesses, social isolation, or loss of independence.7,8 Such arguments have been used to justify the study of depression in old age separately from depression in other life stages.9 In general, it is recognised that mental disorders are common in old age and that depression is one of the most serious threats to the mental health of older adults.5 Both major depression and subsyndromal depression adversely affect the lives of older adults since they have been associated with impaired health-related quality of life, reduced functioning, disability, and increased mortality rates.5,8,10,11 Moreover, subsyndromal depression has been shown to increase the risk of progression into major depression and of suicide.11 Among older people, depressive disorders are thought to be largely under-diagnosed because symptomatology is frequently different from what is most commonly presented in other age groups and can be mistaken for other illnesses, especially in primary care settings.10 In fact, older adults may report physical rather than emotional problems and present cognitive symptoms usually associated with processes of dementia.12 Due to the worldwide growth of the older adult population, elderly depressive disorders are certain to become a very serious global mental health issue and, according to the World Health Organization13, resources to treat and prevent mental health disorders remain insufficient and are inefficiently utilised. Although best practice guidelines point out that moderate to severe depression should be approached with pharmacotherapy (together with complementary therapies), the use of antidepressant drugs is not recommended to initiate the treatment of mild depression.14 In particular, the disadvantages posed by psychopharmacotherapy (such as long response time, side effects, potential risk of dependency and tolerance, and poor compliance rates)15 may be more prominent among the elderly and there is a greater probability of drug interference.12,16 Older adults tend to be medicated for comorbidities so there is a higher risk of polypharmacy occurring.17 Namely, the effectiveness of antidepressant use in people medicated for dementia remains unproven and best practice recommendations advise caution, particularly in the elderly, because of potential side effects.18 In addition, qualitative studies of depressed people with a chronic illness have indicated that both patients and healthcare professionals prefer a psychosocial treatment for depression over a pharmacological one.19 Nursing scholars have been arguing for the need for a change in the current focus of medical care, from a biomedical approach to a holistic one.20 Integrating nonpharmacological nursing interventions in the care of older adults with depression or subsyndromal depression may be one step towards this change in healthcare focus. The necessity to foster preventive measures for the development of depression among the elderly, as well as the inconveniences of pharmacotherapy use in this population and patients' and nurses' preferences for psychosocial treatment, justifies the need to compare the effectiveness of nonpharmacological approaches to this problem. Different nonpharmacological interventions such as music therapy, massage, reminiscence therapy, or physical exercise, have been reported to have an effect in reducing depressive symptoms in the elderly without any adverse side effects.21–24 However, the comparative effectiveness of such interventions has not been determined. Recent systematic reviews and protocols have focused on nonpharmacological approaches to the treatment of depression in populations other than older adults11,25 or have excluded some types of interventions that can be included in the category of nurse-implemented nonpharmacological interventions.9,26 There is a Joanna Briggs Institute Evidence Summary regarding the effectiveness of complementary therapies in older adults but it is not specifically directed towards the treatment of depressive symptoms.27 The effects of interventions for reducing depressive symptoms are expected to have correlated outcomes such as an improvement in autonomy level in activities of daily living, in cognitive function, health-related quality of life and associated variables. Considering the importance of this health issue in this rapidly growing population and the privileged position of nurses to establish working relationships with patients from a broad range of settings, it is important to produce evidence that clarifies which interventions can successfully be used, how to use them and in which cases and contexts. Therefore, we consider that a systematic review on the effectiveness of nurse implemented nonpharmacological interventions to treat older adults with depressive symptoms is timely in order to generate best practice guidelines specifically directed to nurses who work in this area. Inclusion Criteria Types of participants This review will consider studies that include elderly people: 1) adult patients, over 65 years old 2) with any type of depressive disorder, regardless of co-morbidities and any previous treatments, but will exclude those with manic or psychotic episodes/symptoms. 3) patients receiving pharmacological treatment for depression or for other illnesses will be included. Types of intervention(s) This review will consider studies that utilise nurse implemented nonpharmacological interventions for older adults with depressive disorders. These interventions may include, but not be limited to, music therapy, massage, reminiscence therapy, or physical exercise. Type of outcomes This review will consider studies that include the following outcome measures: depressive symptomatology, measured by any depression scale (such as the Geriatric Depression Scale), or change in severity of depressive symptoms, as assessed against diagnostic criteria (such as the ICD 10 or the DSM-IV-TR). The secondary outcomes will be level of autonomy in activities of daily living, cognitive function, health-related quality of life or well-being, measured by appropriate instruments (such as the Lawton-Brody Instrumental Activities of Daily Living Scale, Mini Mental State Examination, Montreal Cognitive Assessment, or the World Health Organization Quality of Life instrument WHOCOL-100). Types of studies This review will consider any experimental study design including randomised controlled trials, non-randomised controlled trials, or other quasi-experimental studies, including before and after studies for inclusion. Search strategy The search strategy aims to find published and unpublished studies. A three-step search strategy will be utilised in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Studies published in English, Spanish and Portuguese will be considered for inclusion in this review. Studies published from January 2000 to March 2012 will be considered for inclusion in this review in order to cover a considerable time span. The databases to be searched include: Academic Search Complete CINAHL Plus with Full Text MEDLINE with Full Text Cochrane Central Register of Controlled Trials LILACS Embase Scopus Library, Information Science & Technology Abstracts Nursing & Allied Health Collection: Comprehensive MedicLatina Scielo - Scientific Electronic Library Online The search for unpublished studies will include: Agency for Healthcare Research and Quality (AHRQ) GoogleScholar ‘Grey Literature Report’ from New York Academy of Medicine Mednar Scirus.com website National Library of Australia's Trove service ProQuest - Nursing and Allied Health Source Dissertations Banco de teses da CAPES (www.capes.gov.br) RCAAP - Repositório Científico de Acesso Aberto de Portugal Initial English language keywords to be used will be: depres* old* elder* interven* nonpharmacologic* nurs* Initial Portuguese and Spanish language keywords to be used will be: idos* não farmacológic* enferm* anciano* no farmacológic* Assessment of methodological quality Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Data collection Data will be extracted from papers included in the review using the standardised data extraction tool from JBI-MAStARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Data synthesis Quantitative data will, where possible, be pooled in statistical meta-analysis using JBI-MAStARI. All results will be subject to double data entry. Effect sizes expressed as odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated. Heterogeneity will be assessed statistically using the standard Chi-square. Where statistical pooling is not possible, the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate. Conflicts of interest There is no conflict of interest.

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