View on Washington: geriatric depression beckons SNFs to act. (Frontlines).

Not long ago, weariness and sadness were viewed as normal components of aging. It was assumed that older people "naturally" became unhappy, fatigued, and distant from everyday concerns because "it comes with the territory" (nostalgic recollections of "Jenny" notwithstanding).

Researchers and clinicians in the 21st century, however, accept that these symptoms very often indicate chronic depression, one of the most common and treatable major mental health disorders. Depression appears to occur more frequently among older people, but it is not a "normal" consequence of aging. In fact, depression is now recognized as a contributor to a wide variety of health-related problems among the elderly. These range from delays in recovering from other illnesses, increased severity of pain, inability to access support services and medical care, alcohol abuse, and frequency of emergency room visits. With most healthcare expenses concentrated among the oldest fifth of the population, undiagnosed and untreated depression among the elderly could be a major source of the rising costs of Medicaid, Medicare, and private long-term care insurance.

Until recently, government policies and programs did very little to address the issue of geriatric depression. A survey of "top health issues" as perceived by state health departments ranked mental health below cancer, chronic cardiovascular disease, and arthritis. Although the survey found that state health departments report "high to moderate involvement" in responding to domestic violence, dementia, Alzheimer's, and caregiver issues, depression failed to make the list.

State units on aging responsible for distributing the largesse provided by the federal Department of Health and Human Services' Administration on Aging (AoA) did give a relatively higher rank to depression. According to Ruth Palombo, director of the Massachusetts Office of Elder Health, one reason for this disparity might be that state aging networks have a holistic approach to the needs of older people that has been lacking in the disease-focused programs of health departments. A particularly important finding for depression was that many state units on aging (44%) thought that responsibility for health promotion and disease prevention for older adults was shared between the aging-services networks and the state health departments. In contrast, state health departments most frequently reported that they lacked any responsibility for prevention and health promotion among the elderly.

That's why it's significant that the Aging States Project -- a highlight of the gerontology sessions of the 2002 annual meeting of the American Public Health Association (APHA) -- represents a first step toward bringing government units together to address depression and other geriatric health problems. The project is a cooperative effort between the Association of State and Territorial Chronic Disease Program Directors and the National Association of State Units on Aging. It was launched in spring 2001, with financial support from the Centers for Disease Control and Prevention and the AoA. The Aging States Project's goal is to promote collaboration between the scientific expertise of the state health authorities and the outreach capabilities of the aging-services networks and, in the process, upgrade care for the depressed elderly, including those in nursing homes.

The Aging States Project's initial survey, mentioned above, uncovered many institutional barriers to collaboration. Long-term care staff will not be surprised to learn that many public-health respondents simply did not understand the needs of the elderly as individuals. State health department personnel usually described the barriers to preventive care for conditions such as depression in terms of the absence of organized programs, accessible healthcare professionals, and reimbursement for preventive services. In contrast, the state unit on aging respondents tended to see barriers in terms of the lifestyle preferences of older individuals, their personal health behaviors, and a general lack of consumer awareness.

Proof that an innovative collaboration between behavioral science and lowcost outreach can make a significant difference in the mental health and quality of life of residents with both Alzheimer's and depressive symptoms was offered by Patricia Heyn, a graduate student at the University of Florida. Heyn described how she brought a music-based storytelling and role-play session into the Alzheimer's wing of a central Florida SNF. The storytelling sessions were designed to promote light physical activity and relaxation exercises, and to focus the residents' attention on creative imagery. The nine "regular" participants were occasionally joined by staff and family members in acting out such "adventures" as a trip to Ireland or a visit to the seashore, with swimming motions, walking, and other movements following the musical theme. Most of the Alzheimer's residents experienced a significant improvement in mood and functioning, Heyn reported, and the SNF continued her intervention with its own personnel.

One crucial theme repeated by several researchers at APHA was that older patients are resistant to using professional mental health services to address depression. Dr. David Oslin of the University of Pennsylvania noted, for example, that the conviction among many elderly that depression is a problem of faith rather than of health creates a significant barrier to their participation in depression screening and treatment.

Long-term care facilities have a distinct advantage in overcoming these types of barriers. Until recently, it was assumed that the 13 to 30% rate of depressive symptoms found among the elderly in institutional settings was unusually high. It now appears that the reason for this is that facilities are in a better position to identify depression, which might go unnoticed among elderly living alone. What's more, facilities are well equipped to respond--residents can be observed by nurses and other staff, medication can be monitored, and residents can be conveniently introduced to activities that might alleviate or prevent depression.

Given these advantages, SNFs should have a place in the collaborations of the Aging States Project. Alliances with university projects, such as Heyn's storytelling exercises, would further strengthen the role of SNFs in bridging the perspectives of health scientists and aging-services agencies, and thus promote the health of their residents.

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