Depression, a common illness among older adults, has been shown to increase morbidity and mortality (Parmalee, Katz, & Lawton, 1992). Depression has been defined as an illness along a continuum from major depression to minor depression. Major depression is defined as meeting the Diagnostic and Statistical Manual (DSM-IV) (American Psychiatric Association, 1994) criteria for major depressive episode, while minor depression is defined as having some symptoms of depression but not meeting the quantity or quality of the DSM-IV criteria for major depression (Burrows, Satlin, Salzman, Nobel, & Lipsitz, 1995; Parmalee et al., 1992; Rovner et al., 1991). Recent studies have reported the incidence of major depression in nursing homes between 12% to 15% (Burrows et al., 1995; Gerety et al, 1994). Kim and Rovner (1995) found minor depression present in 30% to 50% of nursing home residents. Often depression in nursing home residents is not recognized and, therefore, remains untreated (Burrows et al., 1995; Heston et al., 1992; Rovner et al., 1991).
BARRIERS TO ADEQUATE TREATMENT OF DEPRESSION
The National Institutes of Health (NIH) Consensus Development Panel (1992) identified various barriers to adequate treatment of depression in late life. The stigma attached to mental illness and its treatment prevents many elderly people and their families from acknowledging depression and seeking treatment. Ageist attitudes and beliefs among health care providers often prevent them from identifying depression as anything other than a natural consequence of old age. Noncompliance with a treatment regimen often occurs because of the lack of knowledge regarding the course of disease, options for treatment, and the use of medications and their side effects. The fragmentation of mental health services, constraints on reimbursements, or inadequate funding prevents consistent assessment and coherent intervention for depression. There is a lack of trained personnel from all disciplines to intervene with those who are depressed. Finally, family members who can function as a support system for the depressed older adults often are limited or unavailable. These barriers are found both in the community and in long-term care facilities.
TREATMENT OPTIONS FOR DEPRESSED RESIDENTS IN LONG-TERM CARE
The two major categories of treatment for depression are biological (medications and electroconvulsant therapy) and psychosocial. Although there have been few studies that compare the efficacy of various antidepressant drugs in elderly nursing home residents, drugs are the first choice of treatment when depression is identified (Rosen, Mulsan, & Pollack, 1997). In residents for whom drug therapy is not a good therapeutic option, electroconvulsive therapy is the next choice of treatment.
Psychotherapy, one type of psychosocial treatment for depression in nursing home residents, has consisted mainly of group therapy, although studies are inconclusive as to the effectiveness of this approach in reducing depressive symptoms (Abraham, Neudorf er, & Currie, 1992; Yousseff, 1990; Zerhusen, Boyle, & Wilson, 1991). Currently there are no clear indicators that predict an elderly nursing home resident's response to psychosocial interventions based on level of depression. In a recent study, Rosen et al. (1997) found that allowing individual nursing home residents more independence to control selected activities significantly improved depression. The authors suggested that depression in this population is a complex interaction of social and biological factors (Rosen et al., 1997), and therefore, an individualized approach for the treatment of depression is, at present, the best. How to precede with developing such individualized ways of addressing depression is not well understood by nursing home staff.
There is a need for a systematic approach, first to identify and then to treat depression in nursing home residents. As part of a study that explored the effect of having advanced practice nurses (APNs) use scientifically based guidelines in the care of newly admitted residents in three long-term care facilities, protocols for the assessment and treatment of depression were developed. A previous article (Ryden et al., 1998) describes the development of the assessment protocol. This protocol described how to screen for depression using the Geriatric Depression Scale (GDS) (Yesavage, Brink, Rose, & Lum, 1983) and the Philadelphia Geriatric Center Morale Scale (PGCMS) (Lawson, 1975), two widely used instruments with established reliability and validity. In addition, the Apparent Emotion Rating (AER), an observational measure of affect (Snyder et al., 1998), provided the only available means of assessment of depression in individuals with severe cognitive impairment. The GDS scores, which can range from 0 to 30, suggest the presence of depression in individuals who score 11 or higher. For the PGCMS, scores range from 0 to 17, with higher scores indicating better morale. The AER scores range from 0 to 90, with higher scores indicating more positive affect.
The purpose of this article is to describe protocols to:
* Prevent depression in nursing home residents at risk.
* Intervene with residents who have depressive symptoms.
The protocols and suggested actions were based on depression guidelines developed by a panel of expert researchers and clinicians convened by the Agency for Health Care Policy Research (AHCPR) (1993) that were adapted for use with nursing home residents. The protocols, which are general guides for treatment, can be useful in the process of determining specific approaches best tailored to individual residents.
All newly admitted residents were considered to be, at a minimum, at low risk of depression simply by virtue of the number and severity of losses typically experienced in relocation to a nursing home. They have had a change in health status and probably some loss of functional independence in activities of daily living that necessitated nursing home care. They have lost familiar living arrangements, both physical and interpersonal. Finally, they are experiencing the inevitable losses in autonomy that accompany institutionalization (Chenitz, 1983; Moody, 1992).
Characteristics of residents at high risk of depression include: a personal or family history of depression; lack of involvement in the decision regarding admission to a nursing home; negative feelings regarding the move; viewing the move as irrevocable; and lack of social support (Chick & Meleis, 1986; Pohl & Fuller, 1980). Empirically, residents whose scores on depression screening instruments put them at the borderline of the cut-off indicating probable depression can be considered at high risk for depression (Ryden et al., 1998).
STRATEGIC QUESTIONS TO GUIDE INTERVENTIONS TO FACILITATE TRANSITION TO THE NURSING HOME
INTERVENTION PROTOCOL FOR PREVENTION OF DEPRESSION IN RESIDENTS AT RISK
A practice protocol for the interventions to prevent depression for residents assessed as "at risk" is depicted on the right side of the Figure. An essential element of assessment performed soon after admission is an exploration by the APNs of the residents' perceptions of how decisions were made regarding entering the nursing home, the extent of involvement they had in the process, how they felt regarding the move, and what their goals were with respect to care (Pohl & Fuller, 1980). Avoiding or ignoring this topic to prevent having to address possible negative feelings is a disservice to the residents and delays early intervention. In this initial interview, it is important to explore prior patterns of behavior and activity so continuity can be maintained to the highest degree possible. Inquiring about the residents' values and beliefs and determining what is most important to them provides the basis for respecting their autonomy and assisting them to maintain a meaningful way of life in this new environment. Identifying strengths of the residents is critical to building and maintaining self-esteem and provides staff with information useful for creative problem solving (Kivnick, 1993). Questions the APNs used to elicit this kind of information are shown in the Table.
As the second step of the protocol indicates, this information was used to develop individualized strategies to ease the transition to the nursing home and to prevent or reduce depression. Some families were a rich resource in this process; other families were unavailable or had so little past contact with the residents that they had little information to contribute. The variety of strategies used are delineated in the Actions section of the protocol in the Figure. Enlisting the help of the families to personalize the residents' rooms with meaningful possessions and to develop a personal biography to acquaint staff with the residents were initial steps.
New residents are strangers to the nursing home environment. A helpful strategy in familiarizing the residents with the new environment is to introduce them to their roommates and tablemates at meals. Residents were encouraged to share information regarding their lives and interests. In addition, it is helpful to accompany new residents to important locations in the facility such as the chapel, the activities and therapies areas, and the sun porch or lounge. At each stop through the facility, the new residents are introduced to other residents and staff. Although new residents do not always remember names, faces and places become more familiar with time. As a result, some new residents become less hesitant to participate in the events of the nursing home.
Simple adjustments in care plans were made to maintain continuity in patterns of daily living that were important to residents. Knowing about the residents' life work, hobbies, and interests increased the ability to link the newcomers with congenial peers who may help reduce the social isolation of the strangers to the facility and make it easier to become involved in group activities. The Sidebar on this page provides an example of an intervention used to prevent depression.
INTERVENTION PROTOCOL FOR RESIDENTS WITH DEPRESSION
The left side of the protocol in the Figure describes steps to be taken in working with residents who are known to be depressed or have depressive symptoms. Some subjects in the study were undergoing psychotherapy or pharmacotherapeutic treatment for depression at the time they were admitted. Assuring continuity of such treatment and developing a care plan that acknowledges the depression and suggests approaches are important first steps in individualizing interventions. Other residents were identified as being depressed through the process of assessment of depression that was performed on admission (Ryden et al., 1998).
When depression was identified in a resident who had not previously been diagnosed, the APNs communicated these findings, including the score on the GDS, to staff so the primary care provider could be notified and further evaluation and medical treatment could be initiated. For all residents receiving antidepressants, monitoring for effectiveness and side effects of the drugs was an important element of the protocol.
To plan interventions for residents who are depressed, information from the interview questions posed in the Table again proved useful. Finding a plan of care that was congruent with the residents' choices, preferences, values, and prior patterns of activity could be a buffer against escalating the depression. The depression screen, which was used in the assessment protocol (Ryden et al., 1998) to validate depression, provided valuable information regarding recent losses, sleep problems, weight change, problems with appetite, pain, low self-esteem, or limited social support (all indicators of depression). Knowing which of these symptoms are present provides the basis for specific strategies designed to ameliorate the symptoms. If a depressed resident had a medical condition associated with depression or was taking medications that may cause depression, the APNs alerted staff.
General approaches used to address depression are identified in the Actions section of the protocol in the Figure. However, knowledge about individuals is critical to creating a plan for care that fits their unique needs and characteristics. Involvement of the residents and the families or significant others provides vital contextual information for planning and implementing care. The Sidebar on this page provides an example of an intervention used with a resident who had been identified as depressed.
The APNs participated in interdisciplinary care conferences which used the contributions of various members of the health care team. This widened the scope of planning and provided consistency of approach. In addition to providing inservice education classes for staff, the APNs worked extensively with nursing assistants (NAs), role modeling, doing one-to-one teaching, and acknowledging the importance of NAs in the care of individuals with depression. It was recognized that when care plans remain at the nurses' desk and are not reflected on the worksheets of the NAs, they may appease regulators but do little to benefit residents. Because staff had heavy workloads, the APNs at times suggested a community volunteer be enlisted to provide one-toone social interactions with depressed residents to complement staff interactions.
INTERVENTIONS FOR DEPRESSION IN COGNITIVELY IMPAIRED RESIDENTS
To the extent that a resident was capable of verbal interaction, many of the actions identified in the protocol are appropriate. It is important to know the extent of the impairment in planning and implementing an action plan. The Mini-Mental State Examination (Folstein, Folstein, & McHugh, 1975) was used to determine level of mental function. After the extent of impairment is recognized, one-step or two-step commands can be used as appropriate to facilitate maximum independence in activities of daily living and involvement in activities. In severely impaired residents who lack verbal skills, presence, touch, massage, music, and validating feelings implied by behavior are useful strategies. The Sidebar on page 27 depicts an intervention used with a cognitively impaired resident who appeared to be depressed. Although the effect of interventions such as those used with Mrs. O may be short-lived in cognitively impaired individuals, actions that provide pleasure are an important component of quality of life. For individuals who have lost the ability to experience pleasure via past memories and who are unable to anticipate pleasure in the future, the pleasure of the moment is of increased value.
Not every intervention is appropriate to try with every resident, nor will every intervention be effective for any given resident. Having knowledge of the individual is extremely helpful in selecting interventions that seem to be a good fit. Sound observation skills in monitoring outcomes will provide data regarding the effectiveness, or need for modification, of approaches. The authors found it necessary to continue trying to find creative approaches, despite failures with some interventions.
IMPLICATIONS FOR PRACTICE
Ideally, a program designed to ease the transition to the nursing home and prevent depression can begin even before admission. For some individuals, it may be feasible to visit the facility and meet staff and some congenial residents prior to admission. However, for the increasing number of individuals admitted directly from the hospital, less opportunity exists for the anticipatory preparation for the transition to the nursing home. When staff are aware of residents' vulnerability to depression, they can begin at once to attempt to ease the transition to the nursing home and prevent the occurrence of depression. One strategy that has been tested and found useful to ease the transition to a nursing home is a biography developed by the family to acquaint staff with the individual-who-was (Hepburn et al., in press).
Too often, turf issues involving different groups of health care providers create barriers to efforts to prevent and reduce depression in residents. It is inadequate to conceptualize care as compartmentalized, with recreational activities personnel responsible for providing stimulation and pleasurable activities, social work personnel responsible for responding to residents' social and emotional needs, and nursing personnel responsible for their physical needs. In contrast, a shared philosophy that all staff have a responsibility to contribute to some interventions to prevent and reduce depression can lead to consistency of approaches implemented by everyone who has contact with the residents, including housekeeping and physical plant staff. This necessitates continuing education, inservice education, and role modeling by the professional staff. For example, one resource for caregivers is the structured use of pleasant activities for individuals with Alzheimer's disease described by Logsdon and Teri (1997). They have developed a 51item Pleasant Events Schedule that residents and their families complete to acquaint staff with possible activities that may help alleviate depression. Everyone in contact with a depressed, cognitively impaired resident may share in providing "a pleasant event" during their interaction with that resident.
Nursing assistants have a central role to play in reporting observations of behaviors that suggest possible depression. They provided these authors with much needed information because of their intimate, continuing work with the residents. They also are crucial contributors to providing plans of care in ways that prevent or alleviate depression because they assist residents in activities of daily living. However, NAs need training, role modeling, and supervision to move beyond intuitive responses to effective interventions.
Licensed staff have the responsibility for assessing mood state, planning interventions to prevent and treat depression, and monitoring residents' responses to pharmacological and psychosocial interventions. However, some staff may have had inadequate educational preparation for these responsibilities. It is important that licensed staff acknowledge to NAs the importance of their observations and solicit information from them, involving them in a partnership to accomplish the goals of care. Because of their participation in care conferences, licensed staff have an opportunity to become aware of interventions being used by other disciplines and can determine how nursing interventions mesh with those of others. They can be effective role models for NAs. However, time spent in modeling effective psychosocial interventions often has low priority and is limited by demands imposed by requirements for documentation and meager staffing budgets.
Advanced practice nurses bring a broad body of knowledge and expertise to the nursing home setting as a basis for the care of depressed residents. Their skills are valuable in interviewing residents or families at admission or at times when residents experience loss or evidence mood change to elicit information that is critical to making conclusions regarding depressive status, etiological factors, and appropriate actions. The skills of the APNs in this study also were essential in the weekly oneon-one interactions with residents. The opportunity for consistent contact with empathie listeners who could help residents work through the adjustment to the nursing home was a major intervention for many subjects. There is a need for more APNs in long-term care, in positions that provide them the opportunity to build trust and establish good working relationships with staff based on knowledge of each other's expertise.
The ultimate solution to improving recognition, prevention, and alleviation of depression in nursing home residents lies in a combination of factors that include staff and system variables. A recent study of employers' willingness to support continuing education for staff (Ryden & Krichbaum, 1996) revealed that administrators in longterm care facilities provided less support for education for licensed staff compared to hospital administrators. Nursing home organizations must be willing to provide staff with opportunities for formal education related to depression.
Decreasing depression may be accomplished with a combination of psychosocial interventions and psychopharmaceutical treatments. The individualization of psychosocial interventions for depressed residents in nursing homes is complex but achievable in combination with appropriate psychopharmaceutical treatments. Scientifically based protocols to guide this individualization of practice are available. There is great potential for effective treatment of depression to contribute to the improvement of quality of life. A commitment and concentrated effort is needed to improve the effect of nursing home residents by everyone from top administrators to staff in each department.
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STRATEGIC QUESTIONS TO GUIDE INTERVENTIONS TO FACILITATE TRANSITION TO THE NURSING HOME