Prevalence of Depression Following Orthopaedic Surgery
In the Geriatric Population
Amanda McConnell
Ohio University College of Osteopathic Medicine
Athens, Ohio
Introduction
The elderly can experience a complex array of challenges following surgery
including co-morbid health problems, financial hardship, loss of autonomy and
isolation. These factors may contribute to an increase incidence of depression in this
population. However, depression is often improperly diagnosed and inadequately
treated in the elderly. (2) Depression, a complex illness affecting one’s behaviour,
cognition and mood, can cause significant morbidity and can lengthen the
rehabilitation process. (5, 17) Furthermore, patients suffering from depression while
recovering from an orthopaedic surgery complain of greater pain as compared to nondepressed patients. (6) This increased pain further compounds the negative effects of
depression and contributes again to a prolonged rehabilitation process. Therefore, it is
imperative that depression is quickly identified and that appropriate means for
diagnosing and treating depression are implemented.
It has been estimated that nearly a third of individuals over the age of 65 meet
the DSM- IV criteria for depression. (5) This staggering statistic reflects the
biological, psychological and social challenges that persons in this age group face.
Biologically, as a person ages there is both a decrease in the bioavailability of
serotonin and norepinephrine in the brain and an increase in monoamine oxidase, the
enzyme responsible for the degradation of these neurotransmitters. (3) These two
phenomena contribute to the lack of serotonin and norepinephrine, two
neurotransmitters which are decreased in patients suffering from depression.
Likewise, the elderly are more likely to have the psychological and social risk factors
that are common in the diagnosis of depression. These risk factors include the
presence of physical illness, functional limitations, small social network and an
external focus of control. (10) These cumulative challenges are likely the cause of the
increased incidence of depression in the geriatric population.
Elders suffering from depression are often unrecognized and undertreated by
physicians. (12) This lack of diagnosis may be due to physicians who consider
depression a normal consequence of the natural aging process. Research suggests that
physicians often equate the depressive symptoms their patients are feeling with the
“normal” sadness of old age. (3) Furthermore, this phenomenon has also been shown
to be consistent with most doctors’ impression of the sadness seen in post-surgical
patients. (11) The author notes that it is important to recognize these stereotypes and
become alert that depression at any age is abnormal. Furthermore, when physicians
do recognize depression in the elderly, studies demonstrate that the patient is often
treated with insufficient dosages or shortened duration of medications. (2) The
apparent deficiency in the diagnoses and treatment of depression in the geriatric
population has contributed to the increased incidence of depression.
Although much research has been conducted on depression in the elderly
population, little research has focused on depression in patients following an
orthopaedic surgery. Therefore, this study will examine the prevalence of depression
in elderly individuals who are participating in physical rehabilitation following an
orthopaedic surgery. Patients will be accessed for depression using the 15-point
Geriatric Depression Scale (GDS), which is an abbreviated 15 question version of the
original 30-point GDS. This 15 point version has been shown to be as effective as the
longer scales, with a sensitivity of 79% and specificity of 97% in detecting depression
in the elderly. (1, 9) The advantages of this shortened scale include increased patient
compliance, decreased time necessary to screen patients and lessened patient fatigue.
This study recruited patients who had recently received an orthopaedic surgery
and were participating in rehabilitation in the Astley Ainslie Hospital (AAH). AAH is
an extended care and rehabilitation facility located in Edinburgh, Scotland. Patients
are referred to this rehabilitation facility by specialists within the National Health
Service (NHS.) Specifically, AAH has three wards that serve as short-term
rehabilitation facilities for geriatric patients following orthopaedic surgery. The
average length of stay for patients in this facility is approximately six weeks.
Following rehabilitation, patients are discharged to their home, an assisted living
community or a nursing home facility.
In the Astley Ainslie hospital, a collaborative team of physicians,
physiotherapists, occupational therapists, social workers, and nurses provide
comprehensive care to this geriatric community. Each member of the team works with
the patient daily to achieve the greatest improvement. Furthermore, this team meets
once a week for a clinical case conference in which they discuss each patient and their
treatment goals. Often this same team will meet with members of the patient’s family
to further discuss rehabilitation goals and housing placement following their hospital
stay. Together the team is responsible for seeing that the patient is ready for discharge
and will make a successful and healthy transition once out of the hospital.
Methods
In this study, three wards at AAH were examined which included Millbank A
and Millbank B wards which houses female geriatric rehabilitation patients and Mears
ward, which serves to rehabilitate elderly males following orthopaedic surgery. First,
each patient’s chart was examined and the diagnoses, co-morbid conditions, date of
admission were all recorded. All patients were then reviewed for dementia using the
abbreviated mental test (AMT). This metal cognitive test requires the physician to ask
the patient a series of ten questions to determine if the patient suffers from dementia.
These questions include asking the year, time, patient’s address, patient’s age, name
of hospital, date of birth, date of World War I, name of present monarch, recognition
of two relatives by name, and the ability to count backwards from 20 to 1. (7) This
test has been validated for use in the elderly population as a screening tool for
dementia and is commonly used throughout Scotland to access cognitive impairment.
(8, 16) The AMT is scored out of ten points with cognitive decline being evident
when patients receive only six questions correct. (13) Therefore, in this study patients
were excluded if their AMT score was less than or equal to six.
Likewise, the medical history of each patient was thoroughly examined. If a
patient had been previously diagnosed with depression the date of diagnosis, method
of evaluation and treatment was recorded. These patients were also eliminated from
the study as they had previously been diagnosed with depression and were already
receiving treatment for this condition.
The remaining patients that had not been diagnosed with depression and had
appropriate AMT scores were then screened for depression using the Geriatric
Depression Scale. (Appendix A) Patients were attempted to be screened in a
consistent manner with all patients screened in the morning shortly after their
breakfast meal and before they received their daily physiotherapy. Patients were given
informed consent and were informed that this depression screening was for research
purposes. The patients were then described the screening and were asked if they
wished to participate. Once the patient agreed to participate, they were encouraged to
answer the screening questions honestly and were reminded that their answers would
be kept confidential.
Results
In Millbank A, four women had previously diagnosed depression with
documented GDS scores ranging from 9-14, which represents moderate to severe
depression at time of diagnosis. Three of these women were being treated for
depression and one patient had declined treatment. The medications prescribed
included fluoxetine, citalopram and amitriptyline. There were six other women who
had no prior diagnosis of depression and were not found to be demented from the
AMT tests. In this ward, the mean GDS score was 4.16 with a range of 1-9.
In Millbank B, there were four women who had previously been diagnosed
with depression. In regards to treatment for their depression, three of these women
were on fluoxetine and one woman was being treated with amitriptyline. There were
also eight other women who had an appropriate AMT score to qualify for the study.
These women had a mean GDS score was 3.75 with a range of 1-10. Specifically, two
women in particular had an elevated GDS of 9 and 10. In examining the likely
contributing factors for these women’s newfound depression, it becomes evident that
both women have been in the facility for greater than 8 weeks. Also, both women
have extensive co-morbid conditions, including COPD, rheumatoid arthritis, HTN,
and seeing and hearing impairments. Therefore, these factors coupled with the
patient’s recent surgery could have contributed to the patient’s depression.
In Mears ward, there were four men with a previous diagnosis of depression.
In regards to treatment, one patient was being treated with fluoxetine and another
patient was prescribed citaloprane. The other two patients had documented depression
but were not currently being treated for the disease. The men that were not being
treated as well as five other men who were not demented were given the GDS. Of
these patients, the mean GDS score was 7.6 with a range of 2- 10 being noted. It
should be noted that six of the seven men surveyed in this ward were noted to have
some degree of depression.
Overall, 40% of the patients who were screened for depression using the GDS
exhibited some degree of depression. The mean GDS score for all the patients who
were screened was 4.84 with a standard deviation of 3.78. The GDS is scored using
the following scale: 0-5 positive answers is normal, 6-10 represents mild depression,
and 11-15 represents severe depression. Of all the patients accessed at AAH, only one
patient had severe depression and most patients exhibited no signs of depression.
Discussion
In examining the patient’s who were newly diagnosed with depression, a few
common characteristics became evident. First, overall there appears to be a direct
correlation to the patient’s GDS score and the amount of time the patient has spent in
rehabilitation. (Appendix B) This trend has been documented in prior research which
demonstrated that following an orthopaedic surgery elderly patients were found to
have decreased anxiety and pain but increased depression. (14) It appears from these
studies that the patients who require longer rehabilitation time may be more likely to
suffer from depression. This information may be beneficial to health care officials
working in long-term care facilities to recognize this trend and screen elderly patients
for depression who have had longer rehabilitation times.
Furthermore, it was noted that the number of co-morbid conditions had little
influence on whether a patient was found to be depressed. For example, some patients
were noted to have only one other condition but were found to be depressed whereas
other patients had ten other co-morbid conditions yet scored normal on the depression
curve. It would be interesting to examine whether the types of co-morbid illness had
any effect on whether patients were diagnosed with depression. Unfortunately, this
study did have enough participants to be able to significantly stratify patients based on
specific co-morbid illnesses.
Conclusion
This study suggests that depression is prevalent following orthopaedic surgery
and unfortunately is not always recognized. It is apparent from previous research and
from case studies from patients at AAH that treating depression increases a patient’s
demeanour, improves physical functioning, and lessens time needed for rehabilitation.
(5, 17) Therefore, it is recommended that all patients are screened for depression on
admission into the rehabilitation ward. Likewise, the research has shown that the
prevalence of depression is directly proportional to the length of stay in the
rehabilitation ward thus periodic depression screenings of patients in the wards would
be beneficial.
Further studies concerning the prevalence, diagnosis and treatment of
depression would be advantageous to increase the numbers of patients in the study.
Moreover, it would be interesting to follow the patients who were newly diagnosed
with depression with another GDS once the patient had received treatment for their
depression. This would provide information concerning whether treatment was
successful. Likewise, it would be intriguing to examine the patients that declined
treatment for depression and reassess their depression with another GDS once they
were finished with rehabilitation and were in their usual environment.
Acknowledgements
I would like to offer my sincere thanks to Dr. Colin Currie, M.D. who was
vital in organizing this project and allowed me to work with his patients at AAH.
Likewise, I appreciate the help of Professor Young, and Doctors Steve Carty and Tash
Chaudry who also answered numerous questions and discussed specific patient cases
with me. Furthermore, the entire AAH staff of nurses, physiotherapists, and
occupational therapists was extremely helpful and provided much needed information
concerning the patients’ progress. Also, sincere thanks to Joan Bell, Administrative
Assistant Department of Geriatrics, Scotland, Wayne Carlsen, D.O., and Deborah
Meyers, Ph.D., RN who were instrumental in organizing this elective rotation.
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Appendix A
Geriatric Depression Screening Form
Patient’s Name:_____________________
Diagnosis:_________________________
Secondary Dx: ______________________
Date of Admission:_____________
AMT Score: __________________
GDS Score:___________________
Previous Diagnosis of Depression:____________________________________________
Treatment:_________________________________________________________________
Geriatric Depression Scale (short form)
Choose the best answer for how you have felt over the past week:
1. Are you basically satisfied with your life?
Yes No
2. Have you dropped many of your activities and interests?
Yes No
3. Do you feel that your life is empty?
Yes No
4. Do you often get bored?
Yes No
5. Are you in good spirits most of the time?
Yes No
6. Are you afraid that something bad is going to happen to you?
Yes No
7. Do you feel happy most of the time?
Yes No
8. Do you often feel helpless?
Yes No
9. Do you prefer to stay at home rather than going out and doing new
things?
Yes No
10. Do you feel you have more problems with memory than most people?
Yes No
11. Do you think it is wonderful to be alive now?
Yes No
12. Do you feel pretty worthless the way you are now?
Yes No
13. Do you feel full of energy?
Yes No
14. Do you feel that your situation is hopeless?
Yes No
15. Do you think that most people are better off than you are?
Yes No
Answers in bold type indicate depression, and each answer counts as 1 point.
Scores: Normal 0 - 5, Mildly Depressed 6 - 10, Very Depressed 11 - 15
Appendix B
Graph 1: Length of Stay vs. GDS Score
125.00
Length of Stay (# of days)
100.00
75.00
50.00
25.00
R Sq Linear = 0.047
0.00
0.00
2.00
4.00
6.00
GDS Score
8.00
10.00
12.00