Addressing issues related to geropsychiatry and the well-being of older adults
Depression is a major health problem for the approximately 1 million older adults residing in assisted living facilities (ALFs), where one of five residents report depressive symptoms (Mollica, Sims-Kastelein, & O'Keefe, 2007; Watson et al., 2006). However, depression in ALF residents is often undiagnosed or undertreated (Chen, Zimmerman, Sloane, & Barrick, 2007; Smith & Haedtke, 2013). Failure to identify and treat ALF residents with depression places these residents at increased risk of morbidity and suicide (Royall, Schillerstrom, Piper, & Chiodo, 2007). Recognition of depressive symptoms could facilitate treatments for those residents with depression (Chen et al., 2007; McCabe, Davison, Mellor, & George, 2009; Smith & Haedtke, 2013). ALF direct care staff who work with residents on a daily basis may be in the best position to recognize residents' symptoms of depression. However, little is known regarding the extent to which ALF direct care staff know and recognize symptoms of depression.
The current article describes a pilot study that was conducted to determine ALF direct care staff's knowledge of depression in older adults and determine the extent that staff recognized depressive symptoms among residents. Feasibility issues and evaluation of the training program and outcomes of the depression training are also discussed.
Background and Significance
Since the mid-1990s, ALFs have rapidly emerged as the alternative place of residence for older adults in the United States. Assisted living is defined as a long-term care alternative that provides housing with services, including assistance with activities of daily living (e.g., dressing, bathing, medication administration) (National Center for Assisted Living [NCAL], 2013). Older adults relocate to ALFs because of declining health and functional or cognitive impairments that limit their ability to live independently (Chen et al., 2007). In addition, relocation often results in loss of lifelong relationships with friends and is associated with depression in older adults (Walker, Curry, & Hogstel, 2007).
Depression is likely to be overlooked in older adults with chronic illness (Centers for Disease Control and Prevention [CDC], 2015). Chronic medical illnesses, such as cancer, Parkinson's disease, heart disease, stroke, arthritis, or Alzheimer's disease, frequently trigger depression, and often depression worsens the symptoms of chronic illnesses (National Institute of Mental Health [NIMH], 2012). Functional and cognitive decline are associated with depression, negatively impacting quality of life. Depression also significantly increases the risk of ALF residents' transfers to a higher care level, such as a nursing home (Cella et al., 2010). Although depression is serious, it is treatable but must first be recognized.
Depressive symptoms are often mistaken as normal aging responses by many older adults and their caregivers (CDC, 2015; McCabe et al., 2009). Few studies have been conducted regarding ALF direct care staff's knowledge of late-life depression. McKenzie, Teri, Pike, LaFazia, and Van Leynseele (2012) reported that direct care staff were less likely to report depressive-type behaviors than disruptive or memory behaviors, thus questioning staff members' knowledge of depressive symptoms. Similarly, in one study, ALF residents voiced concerns that staff seemed uncomfortable communicating about the residents' moods, suggesting that staff lacked knowledge and skills to recognize and manage depression (Mellor, Davison, McCabe, & George, 2008). The current study assessed (a) the prevalence of depression or depressive symptoms among ALF residents at one facility, (b) direct care staff's knowledge of depression, (c) extent of staff recognition of depressive symptoms among ALF residents, and (d) evaluated depression training conducted at the ALF.
Training content was based on information from the Geriatric Mental Health Foundation (2008) “Recognizing and Overcoming Depression” and the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013). The training was organized into four modules. Module I discussed myths and truths about depression in older adults. Emphasis was placed on risk factors and depression as a treatable condition. Module II presented symptoms of depression and the overlap of depression with anxiety and dementia. Module III focused on staff responsibilities to observe and report depressive symptoms. Module IV discussed how to effectively interact with ALF residents with depression, identify cues of suicide risks, and ask about self-harm intentions. Each session incorporated didactic discussion of new weekly content, exercise of role playing or case study to integrate content to skills, and a fun interactive evaluative activity (e.g., Tic-Tac-Toe, word scramble, Jeopardy®) to review previously learned content. Learning objectives, handouts, and exercises are outlined in Table 1.
Depression Training for Assisted Living Direct Care Staff
The current pilot study used a pretest–posttest design to compare direct care staff's knowledge and recognition of depressive symptoms among participating residents at one ALF prior to and following training. Review of residents' medical records and results of depression screenings determined the prevalence of depression or depressive symptoms among those residents. Convenience samples of direct care staff and residents were recruited for the study.
Setting and Sample
The current study was conducted in Fall 2010 at a privately owned 55-bed ALF in Tennessee. The facility provides residents four levels of assistance determined by the amount of staff member's time needed. For example, Level I provides 24-hour monitoring by trained staff, assistance monitoring medications by a licensed nurse, and assistance with bathing and dressing in the form of verbal prompts, whereas Level IV includes frequent attention and monitoring, hands-on assistance with toileting and bathing, escort service to meals and activities, and reality orientation. The ALF employed a total of 21 direct care staff for all three shifts that included one licensed practical nurse (LPN) who supervised all nursing and personal care, two certified nursing assistants (CNAs), and 18 unlicensed personal care assistants. There were no RNs on staff at this facility at the time of the study, which was in compliance with the Tennessee regulations that required a licensed nurse on staff (NCAL, 2009).
Each state regulates training requirements for direct care staff (NCAL, 2013). In Tennessee, personal care assistants must have a minimum level of training of cardiopulmonary resuscitation (CPR) and First Aid. In addition, all direct care staff must have 8 hours of ongoing training regarding care of older adults, although specific content is not noted in the regulations (Tennessee Department of Human Services, 2009). According to the ALF administrator and nurse supervisor, the usual training sessions for direct care staff focused on safety issues and were presented quarterly at staff meetings. Staff had not obtained any training about depression prior to this pilot study.
Recruitment. At their monthly staff meeting, the principle investigator (PI; L.B.), a gerontological advance practice nurse (APN) who was not a staff member, invited all direct care staff members to participate and then met individually with those interested to complete the consent process. Those who were unable to attend the meeting were recruited on an individual basis by the PI. The nurse supervisor provided a list of potential resident participants from the 55 residents. Inclusion criteria were the ability to sign informed consent and absence of dementia. ALF residents were recruited through individual visits by the PI and an accompanying research assistant. Residents were asked standardized questions to confirm their capacity to consent: name at least one potential risk that may be involved when participating in this study; describe one purpose of the study; and explain what to do if they decide they no longer wish to participate in the study. The university-affiliated institutional review board (IRB) approved the pilot study and consent procedures.
The depression training, conducted by the PI, comprised four weekly 30-minute informational and interactive sessions followed by 15 minutes to complete the accompanying exercises. The training was held in the nurse supervisor's office. Direct care staff were allotted paid time to attend the training sessions. Additional sessions were held for staff members who were unable to attend the regular training sessions. All training material was given to the nurse supervisor for future training of new staff. Each participating staff member received a folder to record notes and store handouts. Staff members also received a certificate of completion at the training conclusion.
The summary of staff and resident outcome measures are shown in Table 2.
Comparison of Pre- to Post-Training Staff (N = 7) Knowledge of Depression Scores
Resident Outcomes. These measures included a review of the resident's medical record and score from the validated 15-item Geriatric Depression Scale (GDS-15; Sheikh & Yesavage, 1986). These data were collected prior to the first meeting with the ALF staff. Residents' medical records at the ALF were reviewed by the PI for medical information pertinent to depression, such as: depression symptoms; mental health history; prescribed antidepressant agents; current medications that may cause depression symptoms side effects, such as analgesic, anti-hypertensive, corticosteroid, and anxiolytic drugs and comorbidities associated with depression (e.g., diabetes, heart disease, chronic pain, dementia). Each resident was asked by the PI to complete the GDS-15. This instrument was selected because it is a reliable and valid instrument in older adults and its yes/no format was viewed as being less complicated and easier for older adults to use than the four-option formulation of the Beck Depression Inventory II (Steer, Ball, Ranieri, & Beck, 1999).
Staff Outcomes. Staff outcomes were assessed by four self-report measures. Demographics included personal background and work experience. The “Views about Depression in Older People,” a validated tool (Mellor et al., 2008), evaluated direct care staff's knowledge about late-life depression in three aspects: (a) depression symptoms, (b) myths about depression, and (c) responding to depression symptoms. The Depression Symptoms among Assisted Living Residents Questionnaire was an investigator-developed questionnaire that evaluated direct care staff's recognition of depression symptom presence among the consented ALF residents. It also measured staff's perceived severity of depression symptoms among these ALF residents. First, staff were asked to assess only those residents who they confidently knew. Staff then rated each resident's depressive symptoms as none, slight, moderate, or severe. The severity ratings were then compared to that particular resident's GDS-15 score (e.g., none , slight [1–5], moderate , and severe [7–8], respectively). This information helped determine whether staff recognized depressive symptoms among ALF residents. Staff evaluation of the training program determined the extent the training helped them recognize depressive symptoms and how training changed any preconceived ideas about depression in older adults. Staff were also asked to describe the best part of the training and information they wished to further explore.
Data Handling and Analysis
All data were entered into a Research Electronic Data Capture database (Harris et al., 2009) by the research assistant. The PI cleaned the data, which were then imported into Stata version 10.0 for analysis by a statistician (M.D.). Residents' ages, medical histories, medications, and GDS scores were descriptively analyzed for frequencies. Comparisons of pre- and post-training knowledge data were conducted using Wilcoxon signed-rank test. Comparison of the pre-training scores of the five staff who only completed the pre-training assessment to the seven who completed both was conducted using the Mann-Whitney test. Comparison of agreement between staff recognition of residents exhibiting depression symptoms and ALF residents with GDS-15 scores >5 was determined by the percent agreements and kappa coefficient. Staff demographic data and training evaluation information were summarized descriptively. The individual responses to the open-ended questions of the training program evaluation were reviewed for collective content by the PI.
Resident Participants and Outcomes
Eight female and seven male residents (n = 15; mean age = 78.7 years, SD = 6.5 years) completed the study. Initially, 32 residents consented to participate in the current pilot study but 17 were lost to follow up: two died, two relocated, three were hospitalized, and 10 withdrew because they refused to answer the depression screening questions. The most frequent comorbidities included hypertension, diabetes, atrial fibrillation, hypothyroidism, chronic obstructive pulmonary disease, and arthritis-related diagnoses. Medication review revealed all but one resident received medication that has depressive symptom side effects (mean = 4.2 medications per resident, range = 0 to 8 medications per resident).
Prevalence of Depression. Twelve (80%) residents had a current diagnosis or history of depression reported in their medical chart. Ten were currently prescribed antidepressant medications. Residents' GDS-15 scores ranged from 0 to 8 (median = 2, mode = 0). Three residents screened positively for depression with GDS-15 scores >5. Two residents were not taking any antidepressant drugs and the remaining resident was taking a low-dose antidepressant drug, indicating it was not therapeutic. None of these three residents had a diagnosis of dementia. The nurse supervisor was notified of these positive scores and contacted the residents' medical providers. All three residents began treatment or had their antidepressant drug dose adjusted. A copy of the completed GDS-15 became part of the resident's chart, and a copy was sent to the resident's medical provider. Four residents on antidepressant agents scored 0, suggesting their antidepressant agents were effective.
Staff Participant Outcomes
Demographics. Fifteen of 20 direct care staff, including the nurse supervisor, participated in the training sessions. The majority of staff were 46- to 55-year-old (n = 7), Black (n = 8, 57%) women (100%) with post-high school education (n = 10, 71%). Their median job experience was 96 months (range = 36 to 360 months). Their time at the study ALF ranged from 3 to 96 months (median = 36 months). All 15 consented staff did not complete all training sessions or the post-training assessments. Two terminated their jobs and one left on medical leave.
Staff Knowledge of Depression. The scores of the pre-training staff knowledge questionnaire (n = 12) ranged from 34 to 74, indicating low to moderate level of knowledge about depression. Of the 12 staff members, seven also completed the post-training assessment. The scores of the post-training knowledge questions ranged from 55 to 73. Comparison of pre- to post-training scores conducted by the Wilcoxon signed-rank test revealed a statistically significant difference (p = 0.018) regarding staff members' knowledge of depression (Table 2). Their median scores improved from 56 to 64. The pre-training scores of five staff members (i.e., including the nurse supervisor and one CNA) who only completed the pre-training assessment were compared to the scores of seven staff members who completed both assessments, finding no statistically significant difference (Mann-Whitney test, p = 0.684).
Recognition of Depressive Symptoms. Staff believed they knew all residents well enough to confidently complete this measure. Six (40%) residents reported no depressive symptoms (GDS-15 score = 0), six (40%) had slight depression (GDS-15 score = 1 to 5), and three (20%) scored in the moderate to severe range (GDS-15 score = 6 to 8). The Depression Symptoms among Assisted Living Residents Questionnaire was completed by staff both pre- and post-training. Before training, staff rated all participating residents as having at least some depressive symptoms. They rated 12 (80%) of 15 residents at the moderate to severe level. All three residents with GDS scores >5 were rated as moderately/severely depressed; however, five residents with GDS scores equal to 0 were also rated as moderately/severely depressed by staff (Kappa = 0.12, p = 0.227). Following the training, the distributions of staff ratings remained essentially the same. The only exception was that one of six residents with a GDS score of 0 was now rated as not having any depression symptoms by staff (Kappa = 0.12, p = 0.245).
Training Program Evaluation. All staff who completed the evaluation form (n = 11) reported they had a better understanding of late-life depression. Most importantly, they perceived the training was helpful in recognizing residents' depressive symptoms. The open-ended responses also reflected these points, with staff stating, “…I learned something in every session” and “to identify some of the symptoms we see among our residents.” All staff requested additional information on “more ways to respond to someone who is depressed.”
The current pilot study found a significant improvement in staff knowledge following training, as expected (Davison, McCabe, Mellor, Karantzas, & George, 2009; Mellor et al., 2008). A more revealing outcome was the inaccuracy of staff to recognize depressive symptoms among their own residents. The current study also provided insights of feasibility issues. Outcomes and feasibility issues of both residents and staff are discussed along with strategies to address these issues in future research.
The prevalence of depression in the participating ALF residents was much higher than expected although the resident sample only represented one fourth of the participating ALF's residents. As the study was conducted in the early fall, it is reasonable to conclude that the prevalence did not encompass seasonal holiday depression. One possible explanation for the high prevalence is that residents already diagnosed with depression were more motivated to participate. Mellor et al. (2008) reported that residents included in their study were curious as to whether staff recognized their depressive symptoms. Perhaps this was a motive for resident participation in the current pilot study. Future research should consider an outcome measure that determines a comparison between residents' view of their depressive symptoms and staff's recognition of their symptoms.
Two additional outcome measures for future research are the length of stay at the ALF and chronic pain. Both are important variables to understand a resident's risk factor for depression. Pain from associated medical diagnosis and administered pain medications should be retrievable data from the medical records. A comprehensive pain assessment that addresses the potential negative impacts of pain, such as functioning, energy, sleep, mood, activity, appetite, energy, and relationships, should also be completed in conjunction with a depression screening.
Feasibility. Attrition of consented ALF residents (32%) within 1 week of recruitment and prior to data collection was unexpected. Due to time constraints during the current pilot study, the PI planned to begin data collection the week following residents' recruitment and consent process. For future research, data collection will begin immediately after receiving consent from residents. One possible reason for attrition is that residents withdrew due to the social stigma of depression (NIMH, 2012). During the consent process, residents were informed that confidentiality could not be guaranteed as required by an IRB. In a small facility, it is possible that study participation was discussed in residents' general conversations. One strategy is to present resident and family programs about the myths regarding depression to alleviate these stigma concerns, facilitate recruitment, and decrease attrition.
The training significantly increased staff's knowledge about depression. McCabe et al. (2009) reported similar findings from their evaluation of a training program for direct care staff of older adults in community and residential care settings in Australia. Also noteworthy in the current study is that the nurse supervisor's scores were similar to personal care providers' scores, suggesting depression training is needed at all care staff levels to provide quality care for ALF residents. This point reiterates the concern of other geriatric nursing leaders (Beck, Buckwalter, Dudzik, & Evans, 2011). Future research should include additional training for nurse managers to improve their assessment skills, communication with health care providers, and development of nursing care strategies that will benefit residents with depression (McCabe et al., 2009).
A major finding of the current pilot study was the staff's inability to accurately recognize depressive symptoms in specific residents. One possible explanation is that staff had increased sensitivity to recognize depressive symptoms because of the emphasis on the training; however, they lacked the necessary skills to identify symptoms among residents. According to Sheikh and Yesavage (1986), the GDS-15 relates to mood rather than physical symptoms. Perhaps staff based their decisions from observations rather than their discussions with the residents about depression. This point highlights the needs for further training and experience to improve staff–resident communication skills, which will be incorporated in the succeeding study. Furthermore, Mellor et al. (2008) posited that staff are often busy with tasks and may not take time to develop a trusting rapport with residents. Therefore, residents may not feel comfortable discussing their personal concerns with staff because they do not want to burden them or they try to conceal symptoms due to the stigma of mental illness. Future studies will identify staff's confidence levels and skills to recognize depressive symptoms and perceived barriers to care for residents with depression to address the aforementioned points (McCabe et al., 2009).
From the staff's perspective, the training was helpful to understand depression and provide resident care for those with depression. Staff were engaging during the training sessions review games, role-playing exercise, and case study discussion, suggesting the training format was well-received. The current study also received enthusiastic support from the ALF administration, suggesting they recognized a need for staff depression training.
Feasibility. Staff participation dwindled after the third week of training because of competing “duty obligations” despite the available additional training sessions and administrative support for this training time. This issue has important implications for future research. Strategies to resolve this issue include working with the administrator to provide staff relief for training, the administrator's promotion of the study and weekly encouragement to the staff, and formal recognition of those staff who complete the training.
The current pilot study focused on feasibility issues of depression training for ALF direct care staff. The findings suggest training emphasis should be placed on staff–resident communication skills with practice training. Further research is also needed to identify staff confidence in recognizing depressive symptoms and any perceived barriers to communicating with residents. Trained direct care staff may play an essential role in recognition and identification of residents with depressive symptoms who need treatment or better symptom management.
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Depression Training for Assisted Living Direct Care Staff
|Modules||Module Learning Objectives||Handouts||Exercise|
Myths and Truths about Late-Life Depression|
Explain the risk factors of depression in older adults.
Contrast grief from depression symptoms/behaviors.
Describe common attitudes about depression.
Myths and Truths About Depression
Review: “Myth or Truth” game
Signs and Symptoms of Depression|
Identify signs and symptoms of depression.
Explain the symptom overlap of anxiety and depression, and dementia and depression.
Word puzzle with review questions
Case study focused on identifying depressive symptoms (for next session's discussion)
Review: Depressive symptoms scrambled word puzzle
Staff Responsibility to Report Symptoms|
Explain the risk of undetected depression.
Explain the direct care staff's responsibility to report symptoms to the nursing supervisor.
Session content review questions
Review: Tic-Tac-Toe (2 teams, team that correctly answers review questions selects location of X or O)
Discussion of case study focused on identifying depressive symptoms
How to Interact Effectively with Residents with Depression|
Demonstrate effective communication with residents.
Identify risk factors for suicide and depression.
Demonstrate how to ask resident about any thoughts of harming him/herself.
Staff Resident Communication Tips (what to say when talking to a depressed individual, what not to say)
Suicide Prevention Fact Sheet
Suicide Prevention Network contact number
Role-play scenario of effective communication with resident about self-harm thoughts
Review: Name five things you have learned about depression (group discussion and responses)
Comparison of Pre- to Post-Training Staff (N = 7) Knowledge of Depression Scores
|Variable||Median Total Depression Statements Scorea (Range)|
|Pre-program score||56 (34 to 69)|
|Post-program score||64 (55 to 73)|
|Wilcoxon signed-rank test||p = 0.018|