Date PICO Analysis of Depression Paper
To prepare: • Select one of the following disorders as your topic: dementia, delirium, or depression. • Review the guidelines in the “Literature Review Matrix” • Think about a research question around your issue as indicated in Part I: PICO Analysis of Research Topic. • Consider the resources you will use, search terms and criteria, and Boolean search strings as indicated in Part II: Search Strategy. • Using appropriate databases, locate five articles related to your PICO question. At least one article must be a systematic review. All of the articles should be primary sources. • Reflect on the five articles you selected as indicated in Part III: Analysis of Literature. Consider the conceptual framework/theory, main finding, research method, strengths of study, weaknesses, and level of evidence for each article. • Consider how to use the summaries in Part III to create an evidence table. Use this evidence table to determine appropriate treatment options for patients who present with the disorder you selected as your topic. To complete: • Formulate a question around the disorder you selected as indicated in Part I: PICO Analysis of Research Topic. • Identify the resources you will use, search terms and criteria, and Boolean search strings as indicated in Part II: Search Strategy. • Summarize the five articles you selected as indicated in Part III: Analysis of Literature. Describe the conceptual framework/theory, main finding, research method, strengths of study, weaknesses, and level of evidence for each article. • Create an evidence table based on the article summaries in Part III. Describe appropriate treatment options for patients based on this evidence table.
In the elderly population, depression is a leading cause of low life quality and a significant public health concern. Despite the fact that the rates of depression in elderly patients are gradually declining, the rates are still higher as compared to young adults and adolescents. Date PICO Analysis of Depression Paper. Elderly patients suffering from depression are less likely to display affective symptoms as compared to changes in cognitive function. They might also display loss of interest with the external world among other somatic symptoms. Having depression early in life increases the risk of suffering from its later in life with a complex interaction of stress-related events, neurobiological changes genetic vulnerabilities and cognitive diathesis.
Depression in elderly patients has been associated with high morbidity and morbidity risks, a decline in social, physical and cognitive functioning and self-neglect which are all linked to a high mortality rate. Since the year1996-2016, depression was among the most common conditions treated in primary care settings. The population of elderly’s suffering from depression increased from 50% to 65%. This, therefore, means that primary care settings present greater opportunities for the detection, diagnosis, and management of older adults who are depressed. This paper analyzes specific PICO questions related to depression, identifies sources used in finding supportive literature and reviews the supporting literature based on their strengths, weaknesses, and level of evidence. This is an attempt of determining the best depression management strategies among elderly patients.
Among elderly patients aged 60-65 years with mild and moderate depression, how does regular physical exercise compared to no physical exercise help to reduce the levels of depression?
|Population||Elderly patients aged 60-65 years with Mild and Moderate Depression|
|Intervention||Regular physical exercise|
|Comparison||No physical exercise|
|Outcome||Reduce Levels of depression|
For the purpose of finding the research to support the chosen PICO question, an electronic search in the databases of PubMed, CINAHL, Google scholar and Medline was done. This search used search terms of depression, mild depression, moderate depression, physical exercise, and geriatric patients. The inclusion criteria included articles that were written in English, articles that included a mile or moderate depression and articles that were not older than 5 years. The exclusion criteria included articles published before 2013, those with children participants and adolescent participants as well as those which contained other forms of interventions for depression. Based on the Boolean search strings, the Boolean search operators AND, OR and NOT were used to accomplish a search that was more discrete and ruled out items which were not applicable. A significant effect of the operators is that it benefits researchers with search outcomes that are more applicable and specific. Date PICO Analysis of Depression Paper.
|Citation||Conceptual Framework/ Theory||Main Finding||Research Method||Strengths of Study||Weaknesses||Level of Evidence|
|Steffens D. C. (2013). Exercise for late-life depression? It depends. Lancet (London, England), 382(9886), 4-5.||Predictive Theory||Aerobic physical exercise is highly effective in geriatric depression. Non-aerobic interventions such as Tai Chi were helpful in elderly care homes. Exercise increases vascular perfusion which is significant since deficits in perfusion might result to late-life depression.||Cluster randomized control trial with 891 elderly patients who were enrolled in 78 care homes in England. 35 homes received group exercises weekly. 43 control homes only received depression awareness training for the staff members.||The study used a huge sample size and a comprehensive design approach which guaranteed validity in terms of control of variables, demographic variables and using subjective metrics that formally validated.
|Cross-sectional data was used which doesn’t really permit a thorough evaluation of the direction of the subjects. Since there was a moderate response level, this would likely the generalizability of the overall outcomes.||Level III
|Mura, G., & Carta, M. G. (2013). Physical activity in depressed elderly. A systematic review. Clinical practice and epidemiology in mental health: CP & EMH, 9, 125-35.||Descriptive theory||Evidence to support the efficacy of physical exercise on depression is limited. Based on the 44 literature obtained, only 10 which were randomized controlled trials met the inclusion criteria. Physical exercise should be combined with antidepressants in treating depression in late life.||An electronic search in scientific databases of Medline and PubMed were carried out using specific keywords of depression, late life exercise, physical activity and elderly.
|The study used a lot of publications. This study sample acknowledges the ambiguity and reciprocity of the study including interpersonal and intrapersonal determinants.
|The search criterion was based on the inclusion and exclusion criteria. However, gray literature which identified the primary data was not included. Non-English language publications were also not included.
|Level I evidence
|Underwood, M., Lamb, S. E., Eldridge, S., Sheehan, B., Slowther, A. M., Spencer, A., Thorogood, M., Atherton, N., Bremner, S. A., Devine, A., Diaz-Ordaz, K., Ellard, D. R., Potter, R., Spanjers, K., … Taylor, S. J. (2013). Exercise for depression in elderly residents of care homes: a cluster-randomised controlled trial. Lancet (London, England), 382(9886), 41-9. Date PICO Analysis of Depression Paper.||Predictive Theory||3191 group exercise sessions were averagely attended by 5 study participants and 5 non-study residents. Residents who had a GDS -15 score, 374 out of 765 were depressed while 484 out of 765 provided follow-up scores for 12 months. Following a cross-sectional analysis with 132 residents after randomization, the odds of getting depression were 0.76for the intervention group as compared to the control group.||Cluster-randomised controlled trails were done in care homes in England among elderly patients aged 65 years or older. They were divided into two groups: control and intervention groups. The control group received depression awareness training only while intervention group received 45 minutes group exercise sessions led by a physiotherapist.||The study used a large sample size a robust study design strategy which guarantees accuracy in terms of variable control, demographic metrics and using subjective metrics that are formally validated.
|The exercises attended by the intervention group were limited rather than having several.||Level III evidence.|
|Blake H. (2012). Physical activity and exercise in the treatment of depression. Frontiers in psychiatry, 3, 106.||Descriptive Theory||Exercise improves depression symptoms as compared to having no treatment or control interventions. Aerobic workouts,
Outdoor walking, treadmill, elliptical cross trainer exercises or stationary cycle intervention plans. These strategies had illustrated some efficiency in reducing depressive symptoms. There was however some degree of regulation.
|32 RCTs in which exercise was compared to standard treatment of depression among elderly patients were reviewed.
|The systematic review included several publications and represented ambiguity and reciprocity of the publications through loops for criticism from three major outputs including interpersonal and intrapersonal determinants.||The appraisals used trials that revealed constructive work out effects in people medically diagnosed with depression. It, however, failed to explain the cost-benefits of exercise interventions.||Level I evidence
|Ranjbar, E., Memari, A. H., Hafizi, S., Shayestehfar, M., Mirfazeli, F. S., & Eshghi, M. A. (2015). Depression and Exercise: A Clinical Review and Management Guideline. Asian journal of sports medicine, 6(2), e24055.||Descriptive theory||There is also of evidence to explain the effectiveness of exercise programs on geriatric patients with depression who ought to benefit from exercise programs. However, some studies are inconsistent and needed conclusions to be cautiously made.
|Electronic database Cochrane library, ISI web of knowledge, PubMed and Psych Info were searched for systematic reviews, large scale-randomized control trials and meta-analyses on the effects of physical exercise on depression among elderly.
|The study used a lot of publications. This study sample acknowledges the ambiguity and reciprocity of the study including interpersonal and intrapersonal determinants.
|Cross-sectional data that used which didn’t really permit a thorough evaluation of the direction of the subjects||Level I of evidence|
Purpose of Research Question
The global population is gradually aging and elderly patients comprise part of the population majority. Although this is a desirable demographic change from the perspective of life progression, its financial, health and social consequences cannot be overlooked. Apart from a continuous increase in elderly-related illnesses, aging will result in a significant increase in the number of mental health issues in elderly patients and most particularly, depression. In this population, depression is common and often under-recognized or undermanaged. Therefore, practical health promotion approaches that are likely to enhance primary, secondary or tertiary prevention strategies among them are of utmost importance. Date PICO Analysis of Depression Paper. Physical activity is often considered to be an intervention with a high potential of reducing the burden associated with cognitive impairment and depression in old age. The PICO question, therefore, presents a critical review of the evidence that is in support of a similar association.
Gaps In Existing Literature
Currently, there are very minimal randomized control studies that assess the effectiveness of physical activity in the elderly population with mild-moderate depression in primary care settings. Majority of the studies focused more on generalized physical activities. Besides, it would be difficult to measure levels of depression and improvement in cognitive function in patients. Studies are needed to rigorously identify the specific physical activities that improve depression levels in the geriatric population.
Blake H. (2012). Physical activity and exercise in the treatment of depression. Frontiers in psychiatry, 3, 106.
Mura, G., & Carta, M. G. (2013). Physical activity in depressed elderly. A systematic review. Clinical practice and epidemiology in mental health: CP & EMH, 9, 125-35.
Steffens D. C. (2013). Exercise for late-life depression? It depends. Lancet (London, England), 382(9886), 4-5.
Underwood, M., Lamb, S. E., Eldridge, S., Sheehan, B., Slowther, A. M., Spencer, A., Thorogood, M., Atherton, N., Bremner, S. A., Devine, A., Diaz-Ordaz, K., Ellard, D. R., Potter, R., Spanjers, K., … Taylor, S. J. (2013). Exercise for depression in elderly residents of care homes: a cluster-randomised controlled trial. Lancet (London, England), 382(9886), 41-9.
Ranjbar, E., Memari, A. H., Hafizi, S., Shayestehfar, M., Mirfazeli, F. S., & Eshghi, M. A. (2015). Depression and Exercise: A Clinical Review and Management Guideline. Asian journal of sports medicine, 6(2), e24055. Date PICO Analysis of Depression Paper.
Part I: PICO Analysis of Research Topic
P: Patient or Population
I: Anticipated Intervention
C: Comparison group or Current standard
O: Outcome desired
Source: Adapted from Elkins (2010)
Step 1: Frame your clinical question using the PICO method.
Part II: Search Strategy
Using the Walden Library and other appropriate databases, locate five scholarly articles that pertain to a practice issue of interest to you and that is appropriate for an evidence-based practice project.
Step 1: Identify the resources you will utilize, or utilized, to find articles that pertain to your topic. Date PICO Analysis of Depression Paper.
|Electronic Databases||Research or Professional Organizations||Experts in the Field to Consult||Books, Encyclopedias, Handbooks|
Step 2: Identify search terms and criteria.
|Keywords and Phrases
|Major Authors||Inclusion Criteria||Exclusion Criteria|
Step 3: Identify Boolean search strings.
Part III: Analysis of Literature
Step 1: Summarize the five articles you select from your search efforts in the table below.
Summary Table of Analyzed Articles (you may determine your own headings)
|Citation||Conceptual Framework/ Theory||Main Finding||Research Method||Strengths of Study||Weaknesses||Level of Evidence|
Step 2: Briefly summarize the history and purpose of your research question.
Step 3: Analyze the strengths and weaknesses of the existing literature.
Step 4: What gap exists in the current literature? Explain.
Elkins, M. Y. (2010). Using PICO and the brief report to answer clinical questions. Nursing, 40(4), 59–60.
Retrieved from the Walden Library databases.
With the aging of our population, cognitive aging has emerged as a leading public health concern. In a 2014 AARP survey, 93% of respondents identified maintaining brain health as a top priority (Inouye, 2015). Yet a substantial void exists in the fundamental understanding of the cognitive aging process and its distinction from cognitive impairments such as delirium and dementia-related conditions. Date PICO Analysis of Depression Paper. Nearly one third of the older population in the United States is hospitalized each year in relation to acute illness or surgery, and delirium is the most common complication of hospitalization in older persons, and it occurs in an estimated 2.6 million of older adults each year. Delirium has been identified as a leading contributor to short and long term cognitive decline after hospitalization, and at least 40% of these cases are preventable when identified. The purpose of this analysis is to ascertain a PICO question related to delirium, identify resources used to find supportive literature, review the supportive information, and create an evidence-based table summarizing the data to determine the best delirium screening options.
In older adult patients with delirium (P), what are the best delirium screening tools (I) compared to the Diagnostic and Statistical Manual or International Classification of Diseases used in defining the diagnosis of delirium (C) to improve early detection and management in older adult patients with delirium (O)?
To find research to support the chosen PICO question, electronic databases such as CINAHL, Google Scholar, PubMed, PsychInfo, and Medline were used. The Hartford Institute for Geriatric Nursing, the American Geriatrics Society as well as the book Evidence-Based Geriatric Medicine were also used as resources. The following keywords and phrases were used to search: delirium screening tools, aging, older adults, geriatric, and primary care setting. Articles that were older than five years old as well as secondary sources were excluded. Articles that applied to the geriatric population, and analyzed the various delirium screening tools and met the criteria were included. The following Boolean search strings were used: delirium screening tools systematic review, and delirium and aging.
Analysis of Literature
|Citation||Conceptual Framework||Finding||Research Method||Implications of Literature Review||Level of Evidence|
|O’Sullivan, D., O’Regan, N. A., & Timmons, S. (2016). Validity and Reliability of the 6-Item Cognitive Impairment Test for Screening Cognitive Impairment: A Review. Dementia and Geriatric Cognitive Disorders, 42(1-2), 42-49. doi:10.1159/000448241
|Descriptive Theory||The Six-Item Cognitive Impairment Test (6-CIT) has been suggested as a useful dementia screening instrument in primary care. The studies on the 6-CIT in primary care present conflicting results and all 3 have significant variations in their selection of cases/reference standards used.||Systematic Review of Literature||Although researchers have investigated its accuracy in diagnosing cognitive impairment in primary and secondary care settings, its validity in primary care use has been questioned and there are limited validation studies on its use in secondary care. In addition, the cut-offs used in 2 of the studies favored specificity over sensitivity, which is not desirable for a screening test. The authors recommend that larger studies, which test the psychometric properties of the 6-CIT in primary and acute care settings, are conducted to establish recommendations for routine screening use.||Level I|
|De, J. & Wand, A. (2015). Delirium Screening: A Systematic Review of Delirium Screening Tools in Hospitalized Patients, The Gerontologist, 55(6), 1079–1099. Retrieved from https://doi.org/10.1093/geront/gnv100||Descriptive Theory||Thirty-one studies describing 21 delirium screening tools were included in the systematic review. Most studies were conducted across a broad range of inpatient settings internationally in elderly inpatients, including patients with dementia but most excluded nonnative language speakers.||Systematic Review of Literature||The Confusion Assessment Method was the most widely used instrument to identify delirium, however, specific training is required to ensure optimum performance. The Delirium Rating Scale and its revised version performed best in the psychogeriatric population but requires an operator with psychiatric training. The Nurses’ Delirium Screening Checklist appears best suited to the surgical and recovery room setting. The Single Question in Delirium shows promise in oncology patients. The Memorial Delirium Assessment Scale, while demonstrating good measures of validity in the surgical and palliative care setting, may be better used a measure of delirium severity. The 4As Test performed well when delirium was superimposed on dementia, but it requires further study.||Level I|
|Iatraki, E. et al. (2017). Cognitive screening tools for primary care settings: examining the ‘Test Your Memory’ and ‘General Practitioner assessment of Cognition’ tools in a rural aging population in Greece. European Journal of General Practice, 23(1), 171-178. Retrieved from http://dx.doi.org/10.1080/13814788.2017.1324845||Predictive Theory||The ‘Test Your Memory’ (TYM) and ‘General Practitioner assessment of Cognition’ (GPCog) instruments appear to be suitable for routine use in the primary care setting as tools for cognitive impairment risk detection in elderly rural populations.
|Randomized Control Trials (RCT)||The clinical validity of TYM/GPCog was assessed through comparison with a screening test that was used to establish risk for cognitive impairment instead of clinical diagnosis of dementia. Although, MMSE is widely used and considered by many as the gold-standard instrument for dementia screening, it has far from perfect sensitivity or specificity. The limited gender and education-level susceptibility of GPCog render it preferable over TYM for routine use in primary care settings in accordance with a growing number of studies in other cultures.||Level II|
|Bellelli, G., Morandi, A., Davis, D. H. J., Mazzola, P., Turco, R., Gentile, S., … MacLullich, A. M. J. (2014). Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people. Age and Ageing, 43(4), 496–502. http://doi.org/10.1093/ageing/afu021||Prospective Study||The 4AT screening tool is a sensitive and specific method of screening for delirium in older people. Its brevity and simplicity support its use in routine clinical practice.||Cross-Sectional Observation Study||A strength of this study is the provision of a clear description of exactly how the delirium diagnosis was obtained, detailing the procedure which informed scoring by DSM-IV-TR criteria. Some limitations of this study must be acknowledged. The 4AT assessments were performed by experienced physicians, though no specific training in the 4AT was given. Further research is needed to assess the ease of use of 4AT among other professional groups of varying levels of seniority. The clinical outcomes in relation to ‘possible delirium’ as assessed by the 4AT was not studied.
|Fick, D. & Mion, L. (2013). Assessing and Managing Delirium in Older Adults with Dementia. Retrieved from https://consultgeri.org/try-this/dementia/issue-d8.pdf
|Geriatric Models of Care||The Hartford Institute states that the best tools for delirium screening in the older adult population are the Confusion Assessment Method (CAM) algorithm, which relies on the presence of acute onset of symptoms and a fluctuating course, inattention, and either disorganized thinking or an altered level of consciousness; and the Delirium Superimposed on Dementia Algorithm (DSDA) is recommended for delirium for people with a pre-existing dementia (Fick and Mion, 2013).||Evidence-Based Practice Guidelines (systematic reviews, RCTs, Cohorts)||While the CAM is a useful tool, the Delirium Superimposed on Dementia Algorithm recognizes that the patient’s baseline mental status is a critical parameter for assessing and treating delirium. The algorithm presents practical ways for bedside nurses to assess delirium and CAM features such as poor attention and fluctuation. The algorithm can be used with patients with dementia who present to the hospital without previous medical evaluation, and/or family members who cannot describe the patient’s mental status pre-hospitalization, who are at increased risk for undetected delirium. The algorithm helps address ageism, a significant barrier to detecting the presence of delirium, wherein clinicians attribute further cognitive loss or lethargy in a person with dementia as an inevitable fact of life for older adults.||Level I|
Purpose of Research Paper
Delirium is a common, often underdiagnosed, geriatric syndrome characterized by an acute change in attention and consciousness. The elderly population, especially those who are age 70 and older are particularly vulnerable to delirium than those younger due to changes in brain function, multiple general medical problems, polypharmacy, reduced hepatic metabolism of medications, multisensory declines, and brain disorders such as dementia. Polypharmacy is very common in the elderly, and the possibility of drug-drug interactions must be considered as a cause of agitation. According to Rosen et al (2015), Delirium is frequently seen in older patients in the emergency department (ED), is under-recognized, and has potentially serious consequences. About 7–17% of older adults who present to the ED suffer from delirium (Rosen, 2015). Delirium is a medical emergency with significant associated morbidity and mortality requiring rapid diagnosis and management. Date PICO Analysis of Depression Paper. Delirium has been identified as a leading contributor to short and long term cognitive decline after hospitalization, and at least 40% of these cases are preventable. As a neuropsychiatric disorder with an underlying organic cause, delirium is known to occur as both an acute and subacute condition that carries significant morbidity and mortality. Combined with its association with dementia and aging, this makes delirium an important topic for primary care providers to become more familiar with as they are tasked with caring for an aging population (Setters and Solberg, 2017).
Gaps in Existing Literature
Presently, there are very few RCTs and studies assessing the effectiveness of delirium screening tools in older adults with delirium in primary care settings. Most of the research focused mostly in acute care/hospital settings. A role for routine delirium screening can be clarified through a well-designed delirium screening trial investigating the benefits of delirium screening, coupled with a multicomponent intervention versus usual care. It could be challenging to measure emotions and cognitive improvement in a consistent manner across patients. Studies are needed to rigorously evaluate the benefits and potential harms of screening in relation to multiple outcomes such as medical intervention requirements, preventive strategies, delirium reversibility, care needs and economic burden.
Despite the limitations on the available research, most data show that the Confusion Assessment Method is widely used, and can used in any clinical setting. And for the patients with underlying dementia conditions, then, the Delirium Superimposed on Dementia Algorithm is recommended per evidence-based practice guidelines. Poor attention is a key marker in delirium and delirium superimposed on dementia patients. In addition, evaluations of the elderly should include a comprehensive review of all drugs being taken, including those that are prescribed, and those taken OTC and herbals. Delirium is often multifactorial and requires an immediate medical attention. Health practitioners should make it a habit to evaluate elderly patients for signs of delirium in every clinical setting especially in primary care settings as it often overlooked. Date PICO Analysis of Depression Paper.
Alaglakrishnan, K. (2017). Delirium. Retrieved from
Arcangelo, V. P., & Peterson, A. M. (2013). Pharmacotherapeutics for advanced
practice: A practical approach (3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Bellelli, G., Morandi, A., Davis, D. H. J., Mazzola, P., Turco, R., Gentile, S., … MacLullich, A. M. J. (2014). Validation of the 4AT, a
new instrument for rapid delirium screening: a study in 234 hospitalised older people. Age and Ageing, 43(4), 496–502. http://doi.org/10.1093/ageing/afu021
De, J. & Wand, A. (2015). Delirium Screening: A Systematic Review of Delirium Screening Tools in Hospitalized Patients, The
Gerontologist, 55(6), 1079–1099. Retrieved from https://doi.org/10.1093/geront/gnv100
Fick, D. & Mion, L. (2013). Assessing and Managing Delirium in Older Adults with Dementia.
Retrieved from https://consultgeri.org/try-this/dementia/issue-d8.pdf
Fong, T. G., Tulebaev, S. R., & Inouye, S. K. (2009). Delirium in elderly adults: diagnosis,
prevention and treatment. Nature Reviews. Neurology, 5(4), 210–220. http://doi.org/10.1038/nrneurol.2009.24
Iatraki, E. et al. (2017). Cognitive screening tools for primary care settings: examining the ‘Test Your Memory’ and ‘General
Practitioner assessment of Cognition’ tools in a rural aging population in Greece. European Journal of General Practice, 23(1), 171-178. Retrieved from http://dx.doi.org/10.1080/13814788.2017.1324845. Date PICO Analysis of Depression Paper.
Inouye, S. K. (2015). Enhancing cognitive aging: clinical highlights of a report from the Institute of Medicine. Annals Of Internal
Medicine, 163(4), 307-310. doi:10.7326/M15-1228
National Institute on Aging (2013). The Dementias: Hope through Research. Retrieved from
O’Sullivan, D., O’Regan, N. A., & Timmons, S. (2016). Validity and Reliability of the 6-Item Cognitive Impairment Test for Screening
Cognitive Impairment: A Review. Dementia and Geriatric Cognitive Disorders, 42(1-2), 42-49. doi:10.1159/000448241
Rosen, T., Connors, S., Clark, S., Halpern, A., Stern, M. E., DeWald, J., & Flomenbaum, N.
(2015). Assessment and Management of Delirium in Older Adults in the Emergency Department: Literature Review to Inform Development of a Novel Clinical Protocol. Advanced Emergency Nursing Journal, 37(3), 183–E3. http://doi.org/10.1097/TME.0000000000000066
Setters, B., & Solberg, L. M. (2017). Delirium. Primary Care, 44(3), 541-559. doi:10.1016/j.pop.2017.04.010 . Date PICO Analysis of Depression Paper.