There are many factors that increase the likelihood of psychological distress or depression in older people, including loss of independence, limited mobility, chronic illness, bereavement and social isolation. It may be difficult to distinguish short-term distress from depression, particularly at the first consultation, which may lead to unnecessary treatment with antidepressants when non-pharmacological treatments would be more appropriate. Overlap in the symptoms of depression, dementia and delirium (often referred to as the 3Ds) can also complicate the diagnosis of depression in older people and may lead to it being under-recognised in this patient group.
Non-pharmacological interventions are the mainstay of distress and depression treatment in all age groups, including older people, and should be first-line for patients with mild to moderate depression and continued alongside any pharmacological treatment. The recommendations may need to be tailored to suit an older person’s capabilities and circumstances. All patients should be given advice about sleep hygiene, exercise, re-engaging with or starting hobbies, connecting with family/friends, getting a pet. Older people who are socially isolated can be referred to local organisations that provide activities, transport and visiting services. Self-guided psychological interventions, e.g. online resources, can be recommended to those who use the internet. Referral to a clinician-led psychological service may also be appropriate. Discussions about treatment options and recommendations should be recorded in the patient’s clinical notes.
Pharmacological treatment is generally only recommended for people with moderate to severe depression, depression that is resistant to non-pharmacological treatments or recurrent depression. Antidepressants will not treat sadness, loneliness or grief. SSRIs (i.e. sertraline, citalopram, escitalopram, fluoxetine or paroxetine) are the preferred pharmacological treatment option for people of all ages due to the more favourable adverse effect profile compared to other antidepressants. SSRIs are also less harmful than other antidepressants in an overdose. Ensuring that SSRIs are only prescribed to those where the benefits of treatment are likely to outweigh the potential harms is important to reduce exposure of older people to unnecessary adverse effects of SSRI treatment, e.g. falls, gastro-intestinal bleeding, medicine interactions and hyponatraemia.
For further information about SSRI prescribing, including personalised prescribing data, see: www.bpac.org.nz/2019/ssri.aspx
For further information on depression, dementia and delirium in older people, see: www.bpac.org.nz/BPJ/2011/July/causes.aspx
A clinical audit of long-term SSRI prescribing is available from: www.bpac.org.nz/Audits/ssri.aspx
Summary
This audit identifies older patients, e.g. ≥ 80 years,* who are taking a SSRI to determine if pharmacological treatment is appropriate.
*Clinicians may choose a younger age range depending upon their patient population
N.B. This audit focuses on the use of SSRIs, however, it can be easily applied to a range of other antidepressants, including mirtazapine,
venlafaxine or tricyclic antidepressants (TCAs).
Recommended audit standards
Ideally, all patients with depression who are prescribed a SSRI should have evidence of an indication for treatment in their clinical notes, i.e. moderate to severe depression or recurrence of depression, and a record of a discussion with the patient about non-pharmacological treatment strategies for managing depression. If there is no documented evidence of an indication or discussion about non-pharmacological treatments, the patient should be flagged for review.
Identifying eligible patients
You will need to have a system in place that allows you to identify patients who are taking a SSRI in your selected age range. Many practices will be
able to do this by running a “query” through their PMS.
N.B. This audit is focusses on patients taking SSRIs for the treatment of depression. People who are taking a SSRI for another indication should be excluded.
Sample size
The number of eligible patients will vary according to your practice demographic. A sample size of 30 patients is sufficient for this audit.
Criteria for a positive outcome
For a positive result for the audit, the patient’s clinical notes should contain both of the following:
- IA record of an indication for SSRI treatment, e.g. moderate to severe depression, persistent mild depression, or
recurrent depression
- IA record of a discussion with the patient about non-pharmacological treatment strategies for managing depression
Data analysis
Use the sheet provided to record your data. A positive result is any patient taking a SSRI who has evidence in their notes of an indication for pharmacological treatment of depression and a discussion about non-pharmacological treatment strategies. The percentage achievement can be calculated by dividing the number of patients with a positive result by the total number of patients audited.
The first step to improving medical practice is to identify the criteria where gaps exist between expected and actual performance and then to decide how to change practice.
Once a set of priorities for change have been decided on, an action plan should be developed to implement any changes.
Taking action
It may be useful to consider the following points when developing a plan for action (RNZCGP 2002).
Problem solving process
- What is the problem or underlying problem(s)?
- Change it to an aim
- What are the solutions or options?
- What are the barriers?
- How can you overcome them?
Overcoming barriers to promote change
- Identifying barriers can provide a basis for change
- What is achievable – find out what the external pressures on the practice are and discuss ways of dealing with them
in the practice setting
- Identify the barriers
- Develop a priority list
- Choose one or two achievable goals
Effective interventions
- No single strategy or intervention is more effective than another, and sometimes a variety of methods are needed
to bring about lasting change
- Interventions should be directed at existing barriers or problems, knowledge, skills and attitudes, as well as performance
and behaviour
Monitoring change and progress
It is important to review the action plan developed previously at regular intervals. It may be helpful to review the following questions:
- Is the process working?
- Are the goals for improvement being achieved?
- Are the goals still appropriate?
- Do you need to develop new tools to achieve the goals you have set?
Following the completion of the first cycle, it is recommended that the doctor completes the first part of the
Audit
of Medical Practice summary sheet (Appendix 1).
Undertaking a second cycle
In addition to regular reviews of progress with the practice team, a second audit cycle should be completed in order
to quantify progress on closing the gaps in performance.
It is recommended that the second cycle be completed within 12 months of completing the first cycle. The second cycle
should begin at the data collection stage. Following the completion of the second cycle it is recommended that practices
complete the remainder of the Audit of Medical
Practice summary sheet.
Claiming credits for Te Whanake CPD programme requirements
Practice or clinical audits are useful tools for improving clinical practice and credits can be claimed towards the Patient Outcomes (Improving Patient Care and Health Outcomes) learning category of the Te Whanake CPD programme, on a two credit per learning hour basis. A minimum of 12 credits is required in the Patient Outcomes category over a triennium (three years).
Any data driven activity that assesses the outcomes and quality of general practice work can be used to gain credits in the Patient Outcomes learning category. Under the refreshed Te Whanake CPD programme, audits are not compulsory and the RNZCGP also no longer requires that clinical audits are approved prior to use. The college recommends the PDSA format for developing and checking the relevance of a clinical audit.
To claim points go to the RNZCGP website: www.rnzcgp.org.nz
If a clinical audit is completed as part of Te Whanake requirements, the RNZCGP continues to encourage that evidence of participation in the audit be attached to your recorded activity. Evidence can include:
- A summary of the data collected
- An Audit of Medical Practice (CQI) Activity summary sheet (Appendix 1 in this audit or available on the
RNZCGP website).
N.B. Audits can also be completed by other health professionals working in primary care (particularly prescribers), if relevant. Check with your accrediting authority as to documentation requirements.
