Background:
Depression in patients 71 years and older is approximately 11% and is a leading cause of disability adjusted life years, second only to stroke. Depression is associated with higher pain perception, increased peri-operative analgesic use and directly contributes to patient morbidity. It is also correlated with increased mortality in high risk surgery.
The elderly population is projected to increase considerably over the next few decades. Any increased hospital morbidity and length of stay will result in a drastically increased financial burden. Depression should therefore be actively sought and managed in the peri-operative elderly population. The National Institute for Clinical Excellence recommend using the PHQ-2 to screen for depression when appropriate.

Methods:
We performed a prospective study of all patients aged 75 years and older who were admitted to 2 general surgical and 1 orthopaedic  wards over 3 weeks. We identified elderly patients at risk of depression and whether clinicians had considered referral to specialists for assessment.
In total 33 elderly patients were identified. Patients were asked the PHQ-2 to identify those that should be referred for assessment. A score of 1 or 2 indicated a positive response. A detailed review of the patient’s notes was undertaken to determine whether ‘at-risk’ patients were identified and whether there was any documented consideration of specialist referral.

Results and Discussion:
Approximately one third (10 patients) of the cohort had positive PHQ-2 scores. Of these, only 1 patient was already taking an antidepressant medication. Additionally, 9 of the 33 elderly patients were taking medications with depression listed as a potential side effect.
No patients had any documentation indicating that mental state had been assessed at any point during their admission and no patients had been referred for further specialist review.

Conclusion:
There is a significant unidentified cohort of elderly patients with depression in the peri-operative population. This patient group is not being actively identified and referred for specialist review and an important opportunity to reduce morbidity in this group is therefore being lost.
There are also significant implications regarding increased morbidity in this patient group. This is likely to compromise both the quality of care delivery as well as impact on increased financial burden on secondary care hospitals in a time of financial austerity.

Depression in the elderly: missed opportunities in the perioperative period?