Download 8.0 Assessment and Care Planning for Mood Disorders.

Document Title and Code:
Version:
Author:
Adapted for Local use by:
Issue Date:
Review date:
Authorised by:
Policy for Management of Mood Disorders NMA-MD.
2
Prepared by Nursing Matters and Associates.
September 2012
September 2014
1.0 Policy Statement:
A proactive and person-centred approach to assessment and care planning will be
adopted for residents at risk of or who present with mood difficulties. Care will be
provided within a framework of promoting health and psychosocial well-being.
2.0 Purpose:
The purpose of this policy is to ensure that residents who are at risk of or present
with mood problems will be identified and cared for according to their needs, known
wishes and preferences.
3.0 Objectives:
3.1
To ensure that nursing staff are aware of the early signs and symptoms of
mood disorders for elderly people in residential care.
3.2
To support resident’s needs to find enjoyment and meaning in every day life.
3.3
To ensure that residents presenting with mood problems /disorders will receive
the appropriate care according to their individual needs, known preferences
and wishes.
4.0 Scope:
This policy applies to all nursing and healthcare professionals providing direct care to
residents in the Centre.
5.0 Definitions:
Page 1
5.1
Mood Disorders: Mood disorders refer to a category of mental health problems
that include all types of depression and bipolar disorder. Mood disorders differ
from feelings of sadness that may occur occasionally. Mood disorders include
major and minor depressive disorders and bi polar disorder.
5.2
Depression: ‘a collective term referring to disorders in which the central feature
is a lowering of mood, usually accompanied by reduced ability to enjoy or take
interest in one’s usual activities’ (Snowdon, 1998 cited in NHS, Quality
Improvement Scotland, 2004).
5.3
Major Depression: To meet criteria for a diagnosis of major depressive
disorder, the resident must exhibit at least 1 of 2 symptoms, depressed mood
and/or lack of interest, for at least 2 weeks. In the nursing home, older adults
are more likely to complain of loss of interest rather than overt depressed
mood. For a diagnosis of major depression, the older adult must exhibit an
additional 4 or more of the following symptoms for at least 2 weeks. Older
adults tend to differ somewhat from middle-aged adults in the presentation of
these criteria symptoms:
■
Feelings of worthlessness or inappropriate guilt (guilt is less frequent among
older adults than among younger adults)
Management of Mood Disorders Policy.
September 2012
■
■
Diminished ability to concentrate or make decisions
Fatigue (a common symptom regardless of age in the
moderate to severely depressed and complicated by co morbid
Physical illness)
■ Psychomotor agitation or retardation (either can be seen in late life and
agitation is frequent in the nursing home)
■ Increase or decrease in weight or appetite (weight loss is very common,
whereas weight gain is rarely seen in older patients)
■ Recurrent thoughts of death or suicide (older adults may ruminate about
death during a depressive episode although they are not as likely to express
suicidal thoughts as younger adults).
(Thakur, M and Blazer, D 2008)
5.4
Minor Depression: Minor depression refers to the presence of at least two but
not more than four of the symptoms of major depression. It is considered ‘subsyndromal’ but may lead to an increased risk of major depression. Depressive
episodes of minor depression may be of two weeks or longer duration but
impairment is less severe (Butcher, K and McGonagal-Kenney, M. 2005).
5.5
Psychotic depression is a subtype of major depression that is frequently seen
in the elderly patients in long-term care than community samples of the elderly.
It is usually characterized by severe depressive symptoms, together with
delusions and/or hallucinations. (Thakur, M and Blazer, D. 2008)
5.6
Dysthymic disorder: is a less severe but more chronic variant of depression. To
meet criteria the older adult must experience symptoms most of the time for at
least 2 years. Although it is rare for dysthymic disorder to start in late life, it can
persist into late life from midlife. Therefore, chronic but less severe depression
in the nursing home may not so much be secondary to living situation as a
pattern laid down many years before admittance to long-term care (Thakur, M
and Blazer, D 2008)
5.7
Bipolar Disorder: Previously known as ‘manic depression’ refers a disorder
where sufferers have periods (or ‘episodes’) of what is called ‘mania’ and
periods of ‘depression’. For this reason, it was once known as ‘manic
depression’. It can affect people of any age, from children to older adults
(National Institute For Health And Clinical Excellence, 2006)
According to the American Geriatrics Society (AGS) any individual over age
60 should be screened for depression periodically. The American Geriatrics
Society (AGS) recommends depression screening two to four weeks after
admission to a nursing home and then repeated screening at least every six
months after admission. In all nursing homes, residents should be screened
at least every six months (AGS & American Association for Geriatric
Psychiatry [AAGP], 2003; Snowden, Sato, & Roy-Byrne, 2003).
In this policy residents should have screening repeated every three months
or where there is a significant change in the resident’s condition or where
staff suspect that there is a significant change in the resident’s mood.
Page 2
Management of Mood Disorders Policy.
September 2012
6.0 Management of Mood Disorders -Quick Reference Guide.
Screening for Mood Disorders/Problems.
 Pre admission assessment for presence of mood disorders.
 Screen the resident on admission using observation and the Centre’s
admission assessment form.
 Ask resident / representative about any history or presence of mood
problems/disorders.
 Where there is a history of or current symptoms suggestive of mood
disorders document and discuss with the resident’s GP.
Comprehensive Nursing Assessment.
o All new residents should have an assessment of mood as part of
their comprehensive assessment.
o Assessment should be based on resident’s history and updated
based on observations during the 5 to 7 days following admission.
o Complete Quick Mild Cognitive Impairment Screen (QMCI) or
Mini Mental State Exam (MMSE).
o Use a formal assessment tool to assess mood status such as the
Geriatric Depression Scale or the Cornell Depression Scale.
o Geriatric Depression Scale should only be used for residents with an
MMSE of 14 or more.
o Complete general admission assessment and determine the impact
of any mood disorders on the resident’s general health, wellbeing,
activities of living and quality of life.
Care Planning and Nursing Management.
 Liaise with resident’s G.P. and/or referring consultant regarding referral
to specialist professionals / services.
 Involve other healthcare professionals involved in resident’s care.
 Plan care in partnership with resident and /or representative in
accordance with resident’s wishes.
 Identify evidence based strategies in keeping with agreed goals.
 Develop and document care plan according to resident’s individual
needs and preferences.
 Include strategies to minimise any negative effect of mood disorder on
the resident’s level of functioning and improvement in quality of life.
 Agree review schedule.
 Communicate care plan to other healthcare staff involved in the
resident’s care.
Monitoring.
 Monitor effectiveness of care and adjust care plan as required.
 Reassess three monthly or more frequently where there is a
significant change in care/condition.
 Liaise with resident’s GP. and other healthcare professionals
involved in the resident’s care regarding effectiveness or
otherwise of treatment.
 Amend/ update care plan in accordance with changing needs.
Page 3
Management of Mood Disorders Policy.
September 2012
7.0 Responsibilities.
Actions
Responsible Person.
This policy will be disseminated to and read by all nursing
and healthcare professionals in the facility.
Person in Charge/ Director of
Nursing.
Where a new version of this policy is produced, the previous
version will be removed and filed away.
Person in Charge/ Director of
Nursing.
An explanation of this policy will be given on induction to all
nursing and care staff.
Person in Charge/ Director of
Nursing or delegated to another
named nurse.
Every resident will be assessed on admission for the
presence of mood problems /disorders and associated risks
factors as part of their initial assessment and every three
months or sooner where changes to care or condition
indicate.
Admitting and/or designated
nurse.
Assessment and care planning to meet the needs of
residents with or at risk of mood disorders will be carried out
as per this policy.
All registered nurses.
For residents with or at risk of mood disorders, a
documented care plan will be in place and will include
specific nursing interventions to meet the resident’s needs
as outlined in this policy.
All registered nurses.
Nurses will maintain their competence in assessment and
care planning and communicate any competency /
knowledge deficits to their line manager/Person in Charge.
All registered nurses
Care given to meet the needs of residents will be in
accordance with the plan of care developed and agreed by
the resident and / or representative and other healthcare
professionals involved in the resident’s care.
All healthcare staff providing
care to residents.
Changes in a resident’s condition will be reported to the
senior nurse in charge and changes to care will be
communicated to all relevant healthcare professionals.
All nurses, care assistants and
other healthcare professionals
involved in the resident’s care.
Page 4
Management of Mood Disorders Policy.
September 2012
8.0 Assessment and Care Planning for Mood Disorders.
8.1 Pre admission Assessment:
Information regarding any diagnosis of or difficulties with mood disorders will be
collected as part of the pre admission assessment.
8.2
Admission assessment.
8.2.1
Each new resident will be screened for the history of or current symptoms of
mood problems / disorders as part of the admission assessment.
8.2.2
Information regarding the presence or history of mood disorders will be
obtained from:
■
■
■
■
■
■
■
Page 5
The pre admission assessment.
Discharge summary.
Nursing transfer forms.
Referral letters.
The resident themselves as far as he / she is able.
Family members as appropriate.
Observation.
8.2.3
The admitting nurse should listen to what the resident is saying, where
possible:
 Is the resident down-hearted, blue, sad, discouraged, or irritable?
 Is this resident listless, exhausted, or tired for no apparent reason?
 Is this resident joyless, feeling hopeless, helpless, and worthless?
8.2.4
The admitting nurse should also observe the residents body language and
how he/she behaves or appears:
 Is the resident slouched with head down or gazing into space?
 Is the resident slow when answering questions using only one or
two words or saying, “I don’t know”?
 Is the resident giving minimal eye contact?
 Does the resident have slow body movement, little verbal
interaction and difficulty concentrating or thinking clearly?
 Does the resident display signs of agitation with anxiety e.g.
difficulty sitting still; hands wringing; pacing; argumentative?
8.2.5
The resident’s representative should be involved in all assessments where
the resident has consented to this.
8.2.6
Where the resident is unable to provide information, the views and
observations of the representative should be sought at all stages of
assessment.
Management of Mood Disorders Policy.
September 2012
8.3
Comprehensive assessment.
8.3.1
Comprehensive assessment will take place on admission and will be formally
reviewed every three months or where there is a significant change in the
resident’s condition.
8.3.2
Where the resident has a previous history of mood disorders, the onset,
duration and frequency of symptoms of the condition should be documented
on the admission assessment form.
8.3.3
The comprehensive assessment should include a formal assessment for
cognitive impairment using the Quick Mild Cognitive Impairment Screen or
Mini Mental State Exam.
8.3.4
Comprehensive assessment should also include the use of a formal
assessment tool such as the Geriatric Depression Scale (for MMSE scores
>14) or the Cornell Scale for Depression in Dementia (MMSE scores<15).
For assistance in completing the Geriatric Depression Scale a video demonstrating
its use can be found at:
http://www.nursingcenter.com/TryThis/Survey.asp?Ep=2&Ch=0
8.3.5
Comprehensive assessment for mood disorders should include the
identification of risk factors that may lead to mood problems / disorders.
8.3.6
Conditions related to mood disorders such as systemic and metabolic
processes e.g. infection, anaemia, hypothyroidism and so on should be
documented as part of the resident’s medical history.
8.3.7
Comprehensive assessment should also identify any nursing problems and
needs related to the impact of any mood disorder on the resident’s functional
ability and activities of daily living.
8.3.8
Residents with an acquired brain injury may have symptoms directly
associated with the injury that can mimic symptoms of depression. These are:
 Emotional disorders associated with the injury such as apathy, emotional
lability may give the appearance of depression in the absence of a
depressive illness.
 Somatic symptoms associated with depression in the normal population
such as loss of energy, appetite and libido; altered sleep habits; poor
concentration and inability to make decisions.
Page 6
8.4
Where a resident has indicators of or diagnosis of depression, the nurse must
assess the resident for risk of self harm / suicide as per the Centre’s Policy on
Prevention and Management of Self Harm and Suicide.
8.5
The assessing nurse must liaise with the residents’ general practitioner
regarding any risks identified and the need for specialist referral.
8.6
If the resident is already attending specialist services, this must be clearly
documented in the resident’s care plan.
Management of Mood Disorders Policy.
September 2012
8.7
Care Planning.
8.7.1
The purpose of care planning is to identify strategies in partnership with the
resident to help him/her adapt to health and life changes; support him/her in
care transitions such as the move to long-term care and maximise his/her
ability to enjoy a meaningful life in the Centre.
8.7.2
The resident’s representative(s) should be encouraged to participate in the
care planning process if this is the wish of the resident.
8.7.3
The care planning process should clearly identify agreed goals and wishes of
the resident for the future.
8.7.4
Where the resident is unable to participate in the care planning process, this
should be documented and the views and observations of the resident’s
representative sought.
8.7.5
Care planning should reflect the need for increased support when the resident
is faced with any health or life change.
8.7.6
The care planning process should involve other healthcare professionals
involved in the resident’s care and address the need for specialist referral
where this is indicated.
8.7.7 Where the use of psychotropic medication is indicated the nurse should
liaise with the resident’s registered prescriber to agree the lowest starting
dose possible, and increasing dosages thereafter until either there is a
therapeutic effect, side effects emerge, or the maximum recommended dose
is reached.
8.7.8
Where a resident is prescribed psychotropic medication the care plan should
include interventions to monitor for potential hypotension, risk of falls, drugrelated cognitive/behavioural function and other adverse effects.
8.7.9
Nurses should liaise with the resident’s prescriber where any of the above
mentioned effects are noted. The resident’s psychotropic medication should
be reviewed every three months or sooner where any adverse effect is noted.
8.7.10 Where such drugs are prescribed on a PRN as required basis, the indications
for giving or withholding the medication, and its effects, must be documented
in the resident’s prescription sheet.
8.7.11 The resident’s care plan should address the following aspects of care related
to mood disorders:
 Consent to treatment as far as the resident is able.
 Any specific safety precautions that may be required, particularly with
regard to risk for suicide; psychotic and or violent and aggressive
behaviours.
 Interventions to maximize physical function through a structured exercise/
daily activity plan in accordance with the resident’s ability and
preferences.
 Interventions to enhance social support through encouraging the support
of family members; support groups and spiritual support in accordance
with his/her religious beliefs.
 Preventative strategies to address the presence of risk factors that may
lead to mood problems / disorders.
Page 7
Management of Mood Disorders Policy.
September 2012
 Interventions to maximise independence and autonomy through active
participation in making daily decisions and setting short term goals.
 Re-inforcement of strengths and abilities.
 Specific interventions to address loss and any bereavement. This may be
related to loss of a loved one, pet, previous lifestyle and roles.
 Supportive nursing care for assistance with daily activities to include
interventions for promoting adequate nutrition; sleep; physical comfort and
pain control.
 Identification of and encouraging involvement in recreational and
relaxation activities in accordance with the resident’s needs and known
preferences.
 Provision of emotional support through allowing time to discuss feelings.
 Administration and monitoring effects of medications and other
treatments. (A sample of a simple method of documenting the resident’s
mood on a daily basis is provided in the appendices).
8.7.12 The resident’s care plan should be documented and communicated to other
relevant healthcare professionals involved in the resident’s care.
8.7.13 Formal reassessment should occur at agreed dates and care amended as
required.
Page 8
Management of Mood Disorders Policy.
September 2012
9.0 Assessment for Risk Factors for and Symptoms of Mood Disorders.

Risk Factors:













Depressogenic Medications
Non-Verbal Cues / Symptoms.
Page 9
Current alcohol / substance
misuse.
Specific co morbid conditions
such as dementia; stroke; cancer;
arthritis; and other chronic
conditions.
Functional loss.
Social isolation.
Hearing, vision and
communication difficulties.
Recent bereavement.
Chronic pain.
Incontinence.
Transfer to long-term care.
Vitamin B12 deficiency.
Malnutrition.
Sudden onset of disability and life
changes associated with acquired
brain injury.
Altered biochemical balance
directly as a result of brain injury.
Previous history of mood
disorders.









Steroids.
Narcotics.
Sedatives/hypnotics.
Benzodiazepines.
Anti-hypertensives.
Histamine-2 antagonists.
Beta-blockers
Anti-psychotics.
Immunosupressants and
cytotoxic agents.
 Stooped posture.
 Slowed speech and movement.
 Lack of interest in self-care.
 Aggressive behaviour.
 Unrealistic fears.
 Repetitive verbalizations such as
calling out for help.
 Agitated shouting, yelling or
screaming.
 Repeated questions.
 Health related concerns.
 Foreboding statements.
(These are especially common in
long-term care facilities).
Management of Mood Disorders Policy.
September 2012
10.0
References.
Health Act (2007) Care and Welfare Of Residents In Designated Centres For Older
People) Regulations 2009
Health Information and Quality Authority (2009) National Quality Standards
for Residential Care Settings for Older People
Brown, El; Raue, PJ; and Halbert, KD (2007) Detection of Depression in Older
Adults. University of Iowa Gerontological Nursing Interventions Research Centre.
Accessed at www.guidelines.gov
Kurlowitcz, L.H. (2003) Depression in Older Adults. In Mezey, M., Fulmer, T.,
Abraham, I., Zwicker, D.D., editors. Geriatric nursing protocols for best practice 2nd
edition. Springer Publishing Company. New York.
Mugdha Thakur, MD, and Dan G. Blazer, (2008) Depression in Long-Term Care
Journal of the American Medical Directors Association Vol. 9 pp 82– 87.
NHS Quality Improvement Scotland, (2004). Best Practice Statement: Working with
Older People Towards Prevention and Early Detection of Depression. NHS Quality
Improvement Scotland.
Butcher, H, and McGonigal-Kenney, M. (2005) Depression and Dispiritedness in
Later Life. American Journal of Nursing. December. Vol. 105 (12) pp. 52-61.
Hemingway, S. and McAndrew, S. (1997) Acquired Brain Injury: Identifying Emotional
and Cognitive Needs. Nursing Standard. Vol. 12(10). Pp. 40-48.
Royal College of Physicians Clinical Effectiveness and Evaluation Unit, (2005)
National Clinical Guideline. The use of anti-depressant medication in adults
undergoing recovery or rehabilitation following acquired brain injury.
Page 10
Management of Mood Disorders Policy.
September 2012
Appendix 1: Mood and Engagement Chart for Recording Changes in Mood.
MOOD
Page 11
ME VALUE
Very happy, cheerful.
Very high positive mood.
Content, happy, relaxed.
Considerable positive mood.
Neutral. Absence of overt signs of
positive or negative mood.
+5
Small signs of negative mood.
-1
Considerable signs of negative
mood.
Very distressed. Very great signs of
negative mood.
-3
+3
+1
ENGAGEMENT
Very absorbed, deeply
engrossed/engaged.
Concentrating but distractible.
Considerable engagement.
Alert and focussed on
surroundings. Brief or intermittent
engagement.
Withdrawn and out of contact.
-5
Management of Mood Disorders Policy.
September 2012