The aim of this essay will be to discuss and apply selected evidence related to nursing practice within a chosen field. Evidence based practice is an approach used by clinicians to deliver the highest quality care to meet the needs of patients and their families. By finding appraising and using the best evidence, health professionals are able to achieve optimum outcomes for all. (Melnyk & Finout-Overholt 2005). However, an alternative view suggests that evidence exists to inform and guide practice rather than dictate it. (McKenna et Al 1999). When clinicians apply an evidence based model, the best available evidence, modified by patient circumstances and preferences, is applied to improve the quality of clinical judgements. (McMaster Clinical Epidemiology Group 1997)

A recognised framework will be used to identify a question and then a systematic literature search will be carried out to assist in answering this question. A copy of this search will be provided and search parameters will be applied to gain the most relevant literature. After applying these parameters the search will be narrowed down to the five most relevant pieces of research. A table will be provided to show the key findings from each piece of literature, and one piece of research will then be critiqued in depth using a recognised framework.

The question identified in this essay is –

“Can physical exercise or activity help to reduce the symptoms of depression in older adults, compared to other forms of treatment?”

Background and Formulation of Question

The question was devised using the PICO framework. This framework often is used to formulate clinical questions (Craig & Smyth 2002), and it identifies and defines the essential components of a good clinical question. PICO is an acronym for patient population of interest, intervention, comparison intervention and outcome (National Institute for Health and Clinical Excellence 2007). Patient population of interest shall be older persons diagnosed with depression, intervention shall be physical exercise or activity, the comparison intervention shall be other forms of treatment for depression and the outcome will be a reduction in the symptoms of depression. A well thought out and formulated question maximises the potential for finding relevant evidence for a patient population (Craig & Smyth 2002)

Depression in older adults refers to depressive syndromes defined in the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-IV) and in the International Classification of Diseases (ICD-10) that arise in people older than age 65 years. In old age, the symptoms of depression often affect people with chronic medical illnesses, cognitive impairment, or disability. (Alexopolous et al 2002). For a major depressive episode to be diagnosed, five of the following symptoms must be present: depressed mood, diminished interest, loss of pleasure in all or almost all activities, weight loss or gain (more than 5% of bodyweight), insomnia or hypersomnia, psychomotor agitation or retardation, fatigue, feeling of worthlessness or inappropriate guilt, reduced ability to concentrate, recurrent thought of death or suicide.

At least one of the symptoms must be either depressed mood or diminished interest or pleasure. The episode should last at least 2 weeks, lead to distress or functional impairment, and not be a direct effect of substance use, a medical condition, or bereavement. (Depression Today 2010). Two of the symptoms detailed above must be present for a minor depressive episode to be diagnosed.

Between one and four percent of the general elderly population has major depression, and minor depression has a prevalence of between four and thirteen percent (Blazer 2003). Twice as many women as men are affected. Both the prevalence (Palsson et al 2001) and the incidence (Teresi et al 2001) of major depression double after age 70-85 years.

Treatment for depression usually involves a combination of anti depressant drugs, talking therapies such as Cognitive Behaviour Therapy or Interpersonal Therapy and self help. (NHS Choices 2010). A recent review concluded that physical exercise programmes can obtain have a beneficial effect on depressive symptoms in older people. Although not appropriate for all older people exercise may improve mood in those undertaking it. (Blake et al 2009)

Systematic Literature Search

A systematic review of the literature was carried out using the CINAHL and PubMed databases and the search terms ‘depression’ ‘physical exercise’ and ‘old*’ were used. CINAHL was found to be particularly useful as it possible to specify the age group required in the literature search. For the purposes of this search age 65+ was selected. PubMed is the public access version of Medline, a comprehensive database which indexes thousands of journals in the medical sciences field. (TVU 2010a). The Cumulative Index to Nursing and Allied Health Literature Indexes virtually all English language journals from 1983 onwards. This database covers midwifery, nursing and related disciplines (TVU 2010b). Initially the searches indicated a vast array of literature but by applying a systematic review this was reduced. By using a logical search strategy with Boolean techniques the number of documents was limited to thirty. These were then reviewed and five articles were then selected which addressed the question of exercise as a form of treatment for older people diagnosed with depression. The search parameters were limited to studies written in the English language, the age and the subjects, and both sexes were to be included. Harvard (2007) suggests that by applying parameters such as these the most up to date and relevant literature can be sourced. A full record of this search history is attached in appendix 1 and 2.

A summary of the findings in the five pieces of research selected is detailed in the table overleaf. This table follows a structure recommended by Timmins & McCabe (2005).

Author and Year

Journal

Type of Study

Purpose

Sample

Design

Data Collection

Key Findings

Blake et al 2009

Clinical Rehabilitation

Qualitative

To assess efficacy of physical exercise in

11 trials totalling 641 participants

Varied

Varied

1 Exercise not relevant

2009; 23: 873-887

systematic

treating depression in older adults

to all in group

review

2 May improve mood

3 further research needed

to establish medium to

long term effects and

cost effectiveness

Mather et al 2002

British Journal of

Quantitative

To determine whether exercise is effective

86 participants split into

RCT

clinical

1 Modest improvement

Psychiatry (2002)

as an addition to anti depressants in reducing

two groups

interview

in symptoms after 10

180:411-415

depressive symptoms in older adults

weeks

2 older people should

be encouraged to

attend exercise classes

Brenes et al 2007

Aging & Mental Health

Quantitative

To test feasibility and efficacy of exercise and

37 participants, 32 completed

RCT

structured

1 Both exercise

Jan 2007;11(1):61-68

anti depressants compared with usual

the study

clinical interview

and medication were

treatments for older adults with

observed

shown to be statistically

minor depression

self reporting

more effective than

current treatment

2 Exercise also aided

physical functioning

Kerse et al 2010

Annals of Family

Quantitative

To assess effectiveness of home based

193 participants, 187 completed

RCT

structured

1 exercise and social

Medicine 8:214-223 (2010)

physical exercise plan in treating older

the study

clinical interview

visits showed similar

adults with depressive symptoms compared

effects in improving

to social visits

mood an quality of life

2 More research is required

Blumenthal et al

Archives of Internal

Quantitative

to assess effectiveness of exercise

156 participants

RCT

structured

1 after 16 weeks

1999

Medicine 159(19) (1999)

compared to antidepressants for treatment

clinical interview

exercise equally effective

of major depression in older

as anti depressantsCritical Appraisal

The following appraisal was structured by using an approved and recognised framework for completing such tasks. (Polit et al. 2001)

The article selected for critical appraisal is ‘Effects of exercise on depressive symptoms in older adults with poorly responsive depressive disorder’. (Mather et al. 2002). A copy of the article is attached as appendix 2.

The aim of the study was to determine whether exercise is effective as an adjunct to antidepressant therapy in reducing depressive symptoms in older people. This was clearly defined. In the introduction the authors stated that ‘it is widely held that exercise is useful in depression’, but that there were few studies on the potential effects that exercise may have as an addition to antidepressant therapies for older adults.

The key finding of this study was that at ten weeks older people with poorly responsive depressive disorder showed a modest improvement in depressive symptoms and should therefore be encouraged to attend group exercise activities.

The study conducted was a randomised controlled trial. Randomised controlled trials are the most rigorous way of determining whether a relation exists between treatment and outcome and for assessing the cost effectiveness of a treatment. (Sibbald & Rowland 1998). Patients were randomly selected to attend either exercise classes or health education talks for ten weeks. Assessments were blind and were conducted at baseline, ten and thirty four weeks. The primary outcome was measured with the 17 item Hamilton Rating Scale for Depression (HRSD). HRSD is a multiple choice questionnaire used by clinicians to measure the severity of major depression in patients. (Hamilton 1960). The nature of both interventions is clearly described by the authors. All participants were outpatients recruited from primary care, psychiatric services and direct advertisement. 1885 patients were screened with a view to recruitment, and 86 were selected at random for the study. To be included patients were required to have symptoms of depression, and to be older than fifty three years of age. In addition patients had to have been receiving antidepressant therapy for at least six weeks, without evidence of a sustained improvement in their condition. Patients were excluded if there was: alcohol or substance misuse, structured psychotherapy in place, or were already taking regular exercise. Patients with specific medical conditions preventing physical exercise were also excluded. Both groups were informed of the nature of the trial, and all patients gave written informed consent. The study was approved by a medical research ethics committee.

There were two groups with 43 patients in each and were comparable in terms of age range and symptom presentation. There was however a heavy preponderance of women in the exercise group. The authors suggest that this may have introduced a bias into the results, and suggest a control group could be introduced in the future without either intervention. The outcomes for both groups were measured in the same way by the proportion of participants achieving a greater than thirty percent reduction in HRSD score from baseline. The results are shown in a statistical format and are recorded in a table.

There are twenty four references in the report which support the evidence presented by the authors.

The implications for the health service are that structured group exercise sessions can help to make a modest improvement in patients who are not responding to pharmacological treatment and that older people with depressive disorders should be encouraged to attend group exercise activities. It should be noted that one of the authors of the research is co-director of a company providing exercise classes for older people and whose profits support research into aging.

Review of Literature

This review of literature will show how the five main studies and all available literature assist in answering the set question. The first part of this review will concentrate on the five main studies and the second part will contain evidence from a wide range of sources and relate this combined information to government policy and guidelines. There will also be evidence of how all the information relates back to practice.

It is well acknowledged that depression is widespread (Osborn et al 2003) and is the most prevalent mental health problem for older people (Age Concern 2007) The condition affects one in five people over 65 and rises to two in five in those over 85 (Mental Health Foundation 2008). The use of exercise to combat depression is well supported due to its effects on enhancing mood, improving cognitive function and reducing anxiety; it is also less expensive than medication (Louch 2008). A literature review was conducted to examine whether exercise could be an effective form of treatment for older adults with depressive symptoms.

Article 1 (Blake, Mo, Malik and Thomas 2008) conducted a systematic review of eleven randomized control trials in order to establish whether physical activity interventions were successful in alleviating depressive symptoms in older people. Trials were included in the review when more than 80% of the participants were greater than sixty years old. In nine of the eleven studies short term positive outcomes were found, although the mode, intensity and duration of the exercise program differed across the studies. The medium to long term effects of exercise as an intervention were less clear. This outcome is backed up by Mead et al (2008) who concluded that exercise seems to improve depressive symptoms in people with a diagnosis of depression, but the effects are moderate and not statistically significant.

However a randomized controlled trial conducted by Blumenthal et al (1999) (Article 2) had reached different conclusions. One hundred and fifty six men and women aged over fifty were split into groups randomly to a program of aerobic exercise, antidepressants (sertraline hydrochloride) or combined exercise and medication. After sixteen weeks of treatment the patients did not differ significantly statistically either on Hamilton Rating Scale for Depression or Beck Depression Inventory scores. The study concluded that antidepressant medication had the most rapid effect, but after sixteen weeks exercise was equally effective in reducing symptoms of major depressive disorder.

Article 3 (Brenes et al 1999) conducted a pilot study designed as a randomized clinical trial to test the feasibility and efficacy of an exercise program and antidepressant treatment compared with usual care in improving emotional and physical functioning in older adults with minor depression. A total of thirty seven participants aged over sixty five were randomized to treatment: fourteen to exercise, eleven to sertraline and twelve to usual care. Patients who received either exercise or sertraline treatments demonstrated improvement both in clinician led and self reported measures of depressive symptoms. Those participants who received the usual package care experienced small or no improvement in mental state. There are some limitations to this study however. The sample size was small and thus the statistical power was weak. The diagnosis of minor depression was based on self diagnosis rather than clinical interview. It was also not stated in the report what the usual care was. There were however significant trends to suggest that sertraline and exercise could be used as treatments for mild depression in older adults, and that a more in depth study should be undertaken.

Article 4 (Kerse et al 2010) published a study comparing the effects of a home based exercise program with regular social contact in improving function, quality of life and mood in older people with depressive symptoms. A randomized controlled trial was conducted in which one hundred and ninety three people aged over seventy five with depressive symptoms received either an individualized physical activity program or social visits delivered over six months. The social visits were of the same time span as the exercise program. Outcome measures were obtained at three, six and twelve months. Both physical and mental well being was measured using a variety of techniques including a short function test, and the Nottingham Extended Activities of Daily Living Scale (Nouri & Lincoln 1987). It was concluded that a structured activity program improved mood and quality of life for older people with depressive symptoms as much as the effect of social visits. There was however no control group being measured that was receiving usual care.

Article 5 (Mather et al 2002) set out to determine whether exercise is effective as an adjunct to antidepressant therapy in reducing depressive symptoms in older people. A randomized controlled trial was conducted in which eighty six participants aged between fifty three and ninety one already receiving anti depressant therapy were given either exercise classes or health education talks over a ten week period. Assessments were made blind at baseline, ten and thirty four weeks using the Hamilton Rating Scale for Depression as the primary outcome. At ten weeks a significantly higher proportion of the exercise group (55% compared with 33%) experienced a greater than 30% decline in depression. In an article in The British Journal of Psychiatry in 2002, Jagadheesan et al critiqued this study and stated that it could have been more meaningful if a control group had been added which received no additional treatment other than continuing antidepressants. (Jagadheesan et al 2002).

The majority of research above suggests that physical exercise reduces depression and depressive symptoms in the short term in older adults, but additional well controlled studies are required to determine the long term efficacy. A systematic review carried out by Sjosten & Kivela supports these findings (Sjosten & Kivela 2002). Direct comparisons between studies is difficult as they differ greatly in characteristics, nature of control comparison group, age of the participants, type and intensity of exercise and outcome measures used to follow up.

National Institute for Clinical Excellence guidelines are set out to assist clinicians and patients in making decisions about appropriate treatment for specific conditions. The guidelines for depression suggest that for particularly for patients with mild or moderate

depressive disorders, structured and supervised exercise can be an effective intervention that has a clinically significant impact on depressive symptoms. There is also evidence to suggest that individuals with low mood may also benefit from structured and supervised exercise. (NICE 2005).

Conclusion

Physical exercise is clinically beneficial in the short term for treatment of depressive symptoms in older people. Exercise, although not appropriate for all older persons with depression, may improve mood in this group. Evidence of the cost effectiveness of providing exercise interventions would be beneficial in helping decision making regarding service use and delivery. More well designed research studies are needed to examine the medium and long term benefits of exercise as a treatment for depressive symptoms in older adults, and to examine the types and duration of interventions that have the most positive effect.

Word Count 3008

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Appendix 1

Copies of Search Strategies