Non-invasive Interventions to Treat Depressed Elders:
A Systematic Review Community-based Intervention to Prevent
Depression in Elderly
Triyana Puspa Dewi, Siti Riskika, Agus Yulianto, Rio Ady Erwansyah. and Makhfudli
Faculty of Nursing, Universitas Airlangga, Mulyorejo, Surabaya, Indonesia
Keywords: Elder, Depression, Non-invasive, Non-pharmacology.
Abstract: Background: The most common psychiatric disorder in the elder population is depression. It may arise as a
result of decrease in adaptation, low income, loss of life partner, disabilities and other factors. Handling
elder depression requires special attention because it may cause ignorance and suicidal desires. The
systematic review aimed to identify and synthesize the available evidence related to non-invasive
interventions for depression. Methods: Multiple databases were used for this review determined from 2011
to 2017 with some limitations include the randomized controlled trial study were analized from Scopus,
Pubmed, and Science Direct database which related to depression and non-invasive treatment. Results:
Overall, 15 journals were conducted in older population with depression symptoms or diagnosed in the age
range ≥ 65 years. This review reveals that cognitive behavior therapy, music therapy and activity therapy,
potentially decrease the depression and anxiety levels in elderly compared with general therapy
(psychopharmaceutical and routine consultation). Conclusions: These interventions which are used in this
review have effective result and cost-effective without causing excessive physical and psychological stress.
In order to maintain long-term effect, the health practitioner should be active to promote these non-invasive
interventions in every level of health care services.
1 BACKGROUND
Depression is mental disorder arising from high and
prolonged stress. This problem is quite possible for
elderly to increase various changes in life. Many
efforts have been taken included pharmacology and
non-pharmacology interventions. Pharmacology
intervention, antidepressant, an option when it
abnormalities major depression (Ahmadpanah et al.,
2017). Although that pharmacology intervention has
been proven clinically may reduce the depression,
but these success followed by effects as impairment
in the functions of awareness resulting in increased
risk of fall. The most highly effective of
antidepressants to block the reuptake of both
adrenaline and serotonin at central nerves system
(CNS) synapses is the tricyclic antidepressants. On
the other hand, the side effects will come to
overweight the function such as dry mouth, blurred
vision, postural hypotension, constipation, urinary
hesitancy, sedation and weight gain (Neville and
Byrne, 2009).
The population estimation of the 2010, 8 %
population in the world, 524 million people aged 65
years or older. A predictor of World Health
Organization has announced that 2050 the
population of the elderly reached three times higher
which is about one and a half billion. Projection
surprising related elderly namely to increase the
elderly population in the developed world only
around 71% . In contrast, in the develop country an
increase in happen until more than 250% (Suzman
and Beard, 2011). This situation was trigger the
worries about the emergence of the various problems
which increase related complex physical
impairment, psychology, social and spiritual.
Depression as a result of untreated emotional and
mental disorders caused by intrinsic factors (frailty,
chronic pain, and immobility) and extrinsic factors
(low income and loss of life partner) may resulted in
isolation, loneliness and long-term psychological
distress. World Health Organization has been
500
Dewi, T., Riskika, S., Yulianto, A., Erwansyah, R. and Makhfudli, .
Non-invasive Interventions to Treat Depressed Elders: A Systematic Review Community-based Intervention to Prevent Depression in Elderly.
DOI: 10.5220/0008327505000507
In Proceedings of the 9th International Nursing Conference (INC 2018), pages 500-507
ISBN: 978-989-758-336-0
Copyright
c
 2018 by SCITEPRESS – Science and Technology Publications, Lda. All rights reserved

released the information about unipolar depression
among older population is 7% and in accounts for
5,7% of Years Life with Disability. The untreated
condition in primary care setting also increases the
perception of poor health, the utilization of health
care services and require high cost of treatment
(World Health Organization, 2017)
The conditions which are related to depression
persistant are the decline of cerebral serotonin levels
and elevated levels of cortisol. The changes of
hormones associated with extra activity of
hypothalamic-pituitary-adrenal (HPA) axis.
Antidepressant treatment aimed to rise the serotonin
synthesis and lowering cortisol, while some research
shows that depression situation not always in line
with cortisol level (Tsang et al., 2013) Some of
depression symptoms that can be observed include a
decrease in energy and concentration, difficulty in
leisure, self care deficit and self confidence
reduction (Chan et al., 2012). Depression in elderly
requires special attention due to Suicidal Ideation.
These problems are two closely linked and serious
issue for elder. Environmental stress, physical stress,
disability and low of adaptation skills and spiritual
can be the emergence of the prolonged depression.
Depression not only affect elderly who live at an
institution care, but also community. When an aging
process of elderly followed by the condition of the
chronic disease, that may arise impairment in the
functions of physical and psychological disorder due
to affordability issues of themselves and lacking
concern.
Based on the problem, then required clarification
and the fact to strengthen the function of non-
invasive treatment and enhance the nurses and
patient relationships. This study is expected to
deliver the benefits especially for nurse to give
intervention of depression for elderly without make
physical and psychological injuries.
2 METHODS
2.1 Aims
The purpose of this systematic review in relation to
review the non-invasive treatments systematically in
elderly with depression. Spesifically, this review
will answer some questions below:
1. What kinds of non-invasive threatment that are
beneficial to resolve depression in elderly?
2. Is the non-invasive threatment overweight
pharmacology therapy?
3. What are the impacts of a non-invasive
threatment to reduce the level of depression?
2.2 Inclusion and Exclusion Criteria
These studies that serve as the basis for the
analysis in this review are randomised controlled
trial study given to the group of elderly with non-
invasive interventions. Focus of the studies is to
explain the effectiveness of various intervention
the elderly who show symptoms depression or have
been diagnosed .the participants who received
psychiatric antidepressant therapy and living in a
prolonged period are not included in this review.
2.3 Search Strategy
Search literature related handling of non-
invasive on elderly depression begins by searching
through the database of Scopus, PubMed and
Science Direct determined from 2010 until 2017.
The searching process was started by entering
keywords related to depression, elderly, non-
invasive and non-pharmacology.
2.4 Study Selection
The studies analyzed in this review are the full
text through an assessment using Critical Appraisal
Skills Programme (CASP) for Randomized
Controlled Study analyzing study (CASP, 1994).
This study involves four reviewers to analyze 15
related literatures.
15 studies randomised trial
included in systematic review
1857 studies identified through
ke
y
words databased searchin
g
1811 studies excluded due to
duplication and irrelevant
46 full-text studies
assessed for eli
g
ibilit
y
35 studies excluded due to
research methodolo
gy
Figure 1: Flowchart for the search and study
selection process.
Non-invasive Interventions to Treat Depressed Elders: A Systematic Review Community-based Intervention to Prevent Depression in
Elderly
501

2.5 Data Collection
Details of related participants, interventions and
effects evoked in each study was done by two
reviewers. The results of the review then discussed
and verified by other reviewers in this study.
2.6 Data Synthesis
Heterogenity in the studies conducted a review
to provide systematic review of p≤ 0.05 criteria that
indicate the effectiveness of an intervention.
Analysis of the research findings will be presented
on the results of the review.
3 RESULTS
3.1 Study Selection
Based on database search, the related studies of this
review are 15 journals that meet the inclusion
and exclusion criteria. A total of 1857 studies were
obtained by keyword searching. After removal of
duplicates and irrelevant studies, 46 studies of full
text articles were identified then 31 studies were
excluded due to not meet inclusion criteria. The
remain 15 randomised studies were considered in
this review.
3.2 Study Characteristics
Criteria of participants are included in this
review were a group of elderly in community as well
as the elderly who showed symptoms of depression
or have suffered diagnose depression basd based on
various instruments for the study of depression.
Given the overall intervention is a non-invasive
intervention with minimal intervention period of a
month. Some of these studies reveal related
cognitive therapy, music therapy, diet therapy,
counselling or physical exercise to reduce
depression level in the elderly.
The main assessment in such is a decrease in
depression level in the elderly after received
the therapy. Other aspects that participated in
the assessment are physical, cognitive function,
quality of life and anxiety.
3.3 Quality Appraisal
Total respondents of this review is 1462 elders with
symptom or have been diagnosed with depression.
The area of several studies that included in this
review are hospital and community setting.
3.4 Synthesis of Result
Group music therapy, a related study of non-
invasive intervention of group music therapy in
group has been conducted by Chu et al., 2014. The
therapy were grouped into 12 session with 6
kategori. Session 1-2 with activity music playing,
session 3-4 with singing activities, session 5-6 with
listening music, session 7-8 aimed to enhance
attention towards music and color, session 9-10
therapist played instrumental which related to
traditional festival, session 11-12 aimed to enhanced
the creativity of elders by create music through
instrumental that they have been selected. The
auditory stimulation against music is highly
potential to distract the elders from stressor and
enhance mind concentration. The Chinese Version of
The Cornell Scale for Depression in Dementia (C-
CSDD) is used to evaluate depression level that
cover five dimensions such as mood and related
signs, behaviour disturbance, cyclic function,
ideational disturbance and physical signs. When the
feeling of fun starting to arise and the the level of
depression decreased, that resulting the lowering
cortisol level. This study reveals there is no
difference of saliva cortisol level between treatment
group and control group which received therapy as
usual. Another positive impact of music therapy is
cognitive enhancement until 1 month post therapy.
The evaluation of cognitive function based on 6
domain of MMSE reveals the enhancement of
cognitive function ing treatment group compared
with control group.
Live music therapy, Cooke et al., 2010 conduct
the research related to music therapy and compared
with reading therapy. The specific result of this
study reported that the first group which received
reading therapy as the first treatment showed the
rising of belonging sensation compared with music
decline in the level of depression.
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Table 1: The randomized controlled trial study which included in systematic review.
Authors, Year
Type
of
study
Population Intervention Outcome
Chu et al.,
2014
RCT
104 older persons
with dementia
- Group music
therapy
- Thera
py
as Usual
- Depression
- Cognition
S.-H. Kwon,
2015
RCT
89 elder in
community
-
Whell of Wellness
Counseling
- Wellness evaluation of lifestyle
- Depression with PHQ-9K
- Health-related Quality of Life
Gustavson et
al., 2016
RCT
221 partisipants
aged ≥65 yo
- Problem Solving
Therapy
Su
pp
ortive Thera
py
The suicide item of The Hamilton Depression
Rating Scale
Hummel et
al., 2017
RCT
155 early
discharged patients
aged 82±6 years
ol
d
- Cognitive
Behavioural Group
Psychotherapy
- Hospital Anxiety and Depression Scale
Kiosses et al.,
2010
RCT 30 elders
- Home- Delivered
Problem
Adaptation
Therapy (PATH)
Su
pp
ortive Thera
py
- Depression
- Disability
Mace et al.,
2017
RCT 220 older patients
- Therapeutic
relationship
- Depression reduction
Sharifan,
Hosseini and
Sharifan,
2017
RCT 180 elders
- Frequent fish
consumption of
fish marinated in
essential oil
- Depression symptoms
Cooke et al.,
2010
RCT 47 elders
-
Live music therapy
- Reading book
- Self-esteem improvement
- Feelings of belonging
- De
p
ression level
Apóstolo et
al., 2014
RCT 56 elders
- Cognitive
stimulation on
nursing
- Therapy as Usual
- Cognitive function
- Depression Level
- Activity Daily Living
Ekkers et al.,
2011
RCT 93 elders
- Competitive
memory training
(COMET)
- Thera
py
as Usual
- Depression level
- Rumination
Tsang et al.,
2013
RCT
38 depressed
elders
- Qigong exercise
-
Newspaper reading
p
rogra
m
- Psycho-physical effect
- Neurophysiological effect
Yap et al,
2017
RCT
54 elders aged
74,65 +6,40 yo in
community
- Rhythm-centred
music making
- Quality of Life
- Deression mood
- Sleep Quality
- Lubben Social Network Scale
(
LSNS
)
Gok Ugur et
al., 2017
RCT
64 elders in
nursin
g
home
- Music therapy
- Depression levels
- S
y
stolic blood
p
ressure
Sabir et al.,
2016
RCT 61 elders
- Integrative
reminiscence
- Depression
- Stress level
- ER visitation
Chan et al.,
2012
RCT
50 older adults in
community-
dwelling
- Listening music - Depression score
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Elderly
503

Whell of Wellness Counseling, researcher
involved 4 research assistans, 2 doctorals and 2
masters of nursing. When the research was begins,
researcher communicate each other via online chat
room as needed. Elders in community received
Whell of Wellness Counseling from well trained
nurses. The weekly education about nutrition,
exercise and another related procedure during 4
weeks. This studi revealed that Whell of Wellness
Counseling is beneficial to enhance health status of
community-dwelling elders. The evaluation of elder
life styles in experiment group are spirituality, self-
esteem, work and leisure, relationship and love,
except realistic belief. Participants in experiment
group experienced significant enhancement of
depression condition compared with control group
between before and after treatment. The evaluation
of physical component scales, mental and quality of
life between 2 group is no significant differences
between both groups (Kwon, 2015).
Problem Solving Therapy. Elders with mayor
depression disorder were diagnosed by Structural
Clinical Interview for DSM-III-R with score ≤ 33.
This intervention well organized for 12 weeks aimed
to compare the effectiveness of Problem Solving
Therapy and Supportive Therapy. Amount 61 % of
participants reported Suicidal Ideation (SI). 27 %
partisipants have history of medical illness as
antidepressant users. Supportive therapy group
reported amount 44,6 % have lower rate of Suicidal
Ideation than Problem Solving Therapy Group
(60,4%). Problem Solving Therapy Group has
significant result to reduce Suicidal Ideation
regarding to logistic regression analysis for 12
weeks of therapy (Kristen A. Gustavson et al.,
2016).
Cognitive Behavioural Group Psychotherapy.
Hummel et al., 2017 was researcher who involved
155 elders of discharged patients with Hospital
Anxiety and Depression Scale (HADS score) > 7.
Comorbid depression in elders has close relation
with functional disorders, recurrent hospitalization
or admissions and mortality rate. CBT treat elders in
community appropriately. The research finding is
significant reduction of Hospital Anxiety and
Depression Scale (HADS score) in CBT group,
18,8% to 11,4%, after 4 months intervention. In
addition, other advantages of CBT in elders are
support the healing process, physical function
enhancement and other functional parameters. CBT
at the first and last meeting its conduct as individual
treatment aimed to obtain individual evaluation.
Home- Delivered Problem Adaptation Therapy
(PATH). The focus of this research is ecosystem
which are patient, care giver, and environment. This
therapy involved the participations of patient and
care giver in order to facilitate problem resolution
and adaptive functional. In general, the participants
graduated from high-school atau higher-education.
Amount 19 caregivers involved in this study. The
advantages comes from this research, namely a
decrease of depression level was higher in PATH
group than Supportive Therapy (ST) group.
Furthermore, PATH was able to reduce disability 3,7
times than ST intervention (Kiosses et al., 2010).
Therapeutic relationship. Executive disfunction
in elder as manifestation of neuropsychological
deterioration due to frontal system damage, resulted
on low response against antidepressants. Participants
in this research are elderly with major depression
based DSM-IV and MMSE (Mini Mental Study
Exam) score that shows the cognitive disorder
globally. Before starting the research, the therapists
were trained to reduce bias. The focus of this
research is Client Perception of Therapist Scale
(CPTS) to understand the dimensions of
understanding and acceptance that demonstrates the
strength of relationship to patient development in
depression reduction. The principle of this research
finding is CTPS and therapist ability may greatly
affects the variation of elder depression level. This
findings rise the expectations that the therapists
should have active contribution to conduct
monitoring as well as attention from the clinic to
give positive reinforcement on reporting result of TR
(R.A. Mace et al., 2017).
Frequent fish consumption of fish marinated in
essential oil. There is a study which reported that a
high quality diet has an important role in controlling
depression. It has widely publicized that high level
of
N-3 Long Chain Polyunsaturated Fatty Acids
(PUFAs) and monounsaturated fatty acid
concentration have positive impact to reduce
depression. Diet fish consumption-based
intervention for mild to moderate depression
preceded by fish analysis related content of mercury
and should be ensured safe for consumption. The
main content of perilla oil is used as a condiment are
octacosanol, ɤ- tocopherol, dan β-sitosterol. Perilla
frutescens mostly found in northwestern Iran with
high ALA and contains saturated fatty acid and
unsaturated fatty acid that proven to prevent
depression and delayed the worsening development.
Yi et al., 2013 has proven that Essential Oil of
Perilla Frutescens (EOPF) may reduce abnormal
behavior induced stress after finish an animal-based
investigation by using mice. In this study, the diet
that given to elder aimed to know about the
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influence of unsaturated fatty acids from either fish
or perilla on elderly depression management. Two of
three groups instructed to consume fish or fish
marinated with EOPF (434 g/week) and one group
as control that consume fish under 6 g/day (Sharifan,
Hosseini and Sharifan, 2017). Statistically, the larger
portion of fish consumption and frequent reveal
positive improvement score of depression in the
elderly. Fish consumption and EOPF is associated
with greater improvement compared to other groups
which only consume small fish portion.
Cognitive stimulation on nursing. Apóstolo et
al., 2016 revealed in his study that cognitive
stimulation may increase cognitive function,
stimulate to thinking, concentration and memory and
sosial circumstances. The increase experienced in
basic level does not affect the independence of ADL
fulfillment. The program has been set for 14 session,
twice/week for 7 weeks.
Competitive memory training (COMET). Ekkers
et al., 2011 has proven his intervention by involving
93 elderly with depression and rumination. Result in
treatment group shows that group which received
Competitive memory training (COMET) showed a
higher rate development to treat depression and
rumination compared to the group which received
usual treatment.
Qigong exercise. Physical exercise as
intervention performed by Tsang et al., 2013
involved 38 elderly who have a history of chronic
disease. Evaluation of symptoms of depression,
phychosocial function, muscle strength, saliva
cortisol and serotonin serum demonstrated
significant reduction of depression level in qigong
group. Qigong is also proven to increase self-
efficacy, self-concept of physical well being and
handrails strength.a decrease in cortisol trends found
in qigong group but did not occurred a significant
difference compared to control group.
Rhythm-centred music making (RMM).
Intervention in the form of listening to music was
performed by Yap et al., 2017 with the elderly as a
sample of 54 people in nursing homes. Previously
carried out assessment of the elderly which include
EQ5D (European Quality od Life-5 Demension),
GDS (Geriatric Depression Scale), LSNS (Lubben
Social Network Scale), PSQI (Pittsburgh Sleep
Quality Index). The granting of the music
intervention on the elderly was performed for 1 hour
each session 1 a total of 10 sessions with a group A
as the intervention group and the control group B as
group later in the second session as the control group
A and Group B as the intervention group. The
results of this study show no significant results on a
scale of measurement of EQ5D, GDS, and PSQI
LSNS.
Music therapy. Related study which used
listening music as intervention was performed by
Gök Ugur et al., 2017 with 64 elders as sample in
nursing home. Previously, collecting data was done
by using Elderly Information Form and Geriatric
Depression Scale. Participants have been given
intervention to listen music 3 days in a week for 8
weeks. Depression level was assessed since first
week to 8
th
week. The research finding reveals that
music therapy be able to reduce depression level and
systolic blood pressure in elderly. In line with the
study, Sejalan dengan penelitan tersebut, Chan et al.,
2012 also proved the effectiveness of music therapy
through interventions during 8 weeks therapy with
30 minutes of listening the chosen music in every
weeks.
Integrative reminiscence. The related study of
reminiscence showed significant result in decreasing
depression and stress level and rarely ER admission.
Depression level was measured by CES-D scale and
reveals that reminiscence is suitable for mild to
moderate depression.
4 DISCUSSIONS
Based on the results of the review of 15 randomized
controlled trial journals related to depression
treatment in elderly, proved that non-invasive
therapy provide a positive impact against depression
level in the elderly. The number of participants
involved in each study at least 30 people who
showed symptoms of depression or diagnosed. The
non-invasive therapies such as music therapy, Whell
of Wellness Counseling, Home-Delivered Problems
Adaptation Therapy, cognitive behaviour therapy in
treatment as well as Competitive Memory Training
(COMET) proved to be able to reduce the level of
depression in the elderly.
Music theraphy may reduce the level of
depression by increasing feeling of enjoy and fun by
listening selected music that occurs cortisol level
reduction. Whell of Wellness Counseling which
performed by online chat with elders that involved
good relation and health promotion between nurse
and client. The intervention by changing behaviour
with cognitive behaviour therapy in group
potencially reduced the level of depression by giving
support during healing process and also enhancing
physical function. The Home- delivered Problems
Adaptation Theraphy requires family support as
caregiver can help older people with depression to
Non-invasive Interventions to Treat Depressed Elders: A Systematic Review Community-based Intervention to Prevent Depression in
Elderly
505

deal with problem and resolve together.
Furthermore, good relation between care giver and
elders may resulted in feeling of loneliness
reduction. Competitive Memory Training helped
elder to deal with depression by giving motivation,
rational treatment, awarenees enhancement, support
letting go precess, combine the previous successful
and generalization in letting go of rumination in the
furture
The common main tool depression level
evaluation which is used in this study is Geriatric
Depression Scale. The therapeutic relationship is
beneficial to lower depression in elderly with
impaired cognitive disorders and major depression
globally by relying on the ability of therapists in
communicating with elderly who suffered
depression disorders. Qigong exercises as physical
activity treatment requiring special skills by
therapists trained in delivering the intervention.
A wide variety of forms of non-invasive
interventions might be applied not only on
institutional health services, but also on community.
These interventions are not only beneficial to
decrease the level of depression. In additions, some
of the other benefits that are brings in effect quality
of life, self-esteem, cognitive function and decrease
the occurrence of suicide and rumination.
Each intervention requires skill for any therapist
to be able to achieve optimal results. Therefore, the
nurse as the care giver of non-invasive intervention
need support through a policy applied means of
service delivery. The application of related
techniques of intervention have the advantages of
minimal trauma on the elderly and cost-effective.
5 CONCLUSIONS
This systematic review reveals various non-
invasive treatments to treat elders with depression.
These therapies can apply in symptomatic
depression, major depression, mild cognitive
disorder, dementia and patient with a history of
chronic illness. The non-invasive treatment need a
role of nurse in reducing elder depression level by
giving intervention and conduct therapeutic relation.
ACKNOWLEDGEMENT
The authors thank Makhfudli for his contribution to
the idea development in this systematic review.
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