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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
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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.
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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
� 2008 The Authors. Journal compilation � 2008 Blackwell Publishing Ltd 1421
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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.
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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.
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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)
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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
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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
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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.
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