Fighting elder depression: a battle that can be won. (Feature Article).
Although entering a nursing home leads to improved quality of life for many seniors, the transition from a private home can be a stressful, grief-laden process exacerbated by medical conditions Perhaps it's no surprise to learn that some residents develop depression, although providers might be shocked to learn that up to half of residents have some form of it, according to Peter A. Lichtenberg, PhD, the director of the Institute of Gerontology and an associate professor of psychology at Wayne State University in Detroit.
In fact, depression has been identified as one of the biggest risk factors for increased disability and mortality in frail elders, says Dr. Lichtenberg, noting that "depression in frail elders becomes quite a killer." But this is not a hopeless situation; Dr. Lichtenberg points out that depression in the elderly can be alleviated in 65% of cases. To provide insight on this issue, Dr. Lichtenberg, coauthor of Depression in Geriatric Medical and Nursing Home Patients: A Treatment Manual, recently shared his thoughts with Nursing Homes/Long Term Care Management Assistant Editor Douglas J. Edwards.
Edwards: What is the prevalence of depression among the general geriatric population in the United States?
Dr. Lichtenberg: Among community samples the prevalence of major depression is about 1%, but an additional 15% have minor depression or adjustment disorder.
Edwards: Are these figures different for elderly in long-term care facilities?
Dr. Lichtenberg: The figures are dramatically different for both hospitalized elders and those in long-term care. About 25% of these seniors have major depression, and another 20 to 25% have minor depression.
Edwards: Why do the elderly in long-term care and hospitals have a higher rate of depression?
Dr. Lichtenberg: Depression is a syndrome that has a constellation of symptoms with multiple etiologies. For example, there is a lack of serotonin in people with depression. Serotonin is a chemical in the brain that has been associated with mood states. No one knows for certain how serotonin is reduced and thereby is linked to depressive disorders, but it appears to be linked to overall health of the brain and to physical functioning. Strokes and vascular risk factors-such as diabetes, heart disease, high blood pressure, smoking and obesity-can play a role in lowering serotonin.
We know that decreases in physical and social functioning can lead to depression, as well, and nursing home residents often have a higher risk for disruptions in their physical and social functioning than the elderly in the community. There is also a very strong link between different forms of dementia and depression. For example, people with Alzheimer's disease in both inpatient and outpatient settings have depression at about a rate of 30 to 40%. The grief and sense of loss associated with moving into a nursing home play a role in depression in this population, too.
Edwards: How does one recognize depression in residents who cannot communicate well?
Dr. Lichtenberg: Some nonverbal ways of assessing depression have been developed for the stroke/aphasia population. These are called "visual analogues"; for example, a resident who cannot communicate verbally might point to either a picture of a smiling or a frowning face to indicate her mood. This has been shown to relate highly to the ratings of mood made by professional psychiatric observers.
Another thing we have found is that although people with dementia--especially as they advance into the moderate stages--can't perhaps accurately answer a lot of open-ended questions, they can tell us something about their mood if we ask the question in a closed-ended way, such as, "Do you often feel blue? Yes or no?"
Edwards: Should drug side effects be considered as possible causes of depressive symptoms in nursing home residents?
Dr. Lichtenberg: Absolutely. There are a number of medications people take for chronic diseases that might be contributing to depression, such as drugs for heart conditions, sleep medications and antianxiety drugs.
Edwards: How does one communicate to a resident that he/she has depression, considering that many of today's residents were not reared in the time of mental health awareness that we are living in now?
Dr. Lichtenberg: I point out to residents that depression is a health problem that goes along with lots of other health conditions. I tell the resident that to improve his/her health, depression has to be treated, as well. Viewing depression as a health problem also eases the concerns of families, because depression is a condition that can be treated.
Edwards: Besides dispensing medication, what role can the nursing staff play in helping residents with depression?
Dr. Lichtenberg: All staff can play a very important role in helping to reduce depression or, unfortunately, to help perpetuate it. Staff need to connect with residents on a personal level and not just view them as patients. Depression shouldn't just be left for mental health practitioners. Staff need to spend time connecting with residents in pleasurable ways.
Edwards: Are there specific activities geared toward helping residents with depression?
Dr. Lichtenberg: The basis behind the behavioral theory of depression is that depression is preceded and continued by a drop in pleasurable activities and that mood therefore follows. We try to get residents to begin doing things they enjoyed before, even if there are new limitations to what they can do. For example, if a person enjoyed writing to family and friends but has lost the use of her hands, we might transcribe a letter for her. For a resident who loves to travel, we'll ask the family to bring in photos of past trips so the resident can describe them to us. Listening to favorite music, reading out of the Bible, doing a crossword puzzle together over a cup of coffee-it's about reintroducing pleasure to residents' lives.
Edwards: What are the roles of occupational therapists, physical therapists and speech pathologists in working with depressed nursing home residents?
Dr. Lichtenberg: These caregivers should tie what they do functionally into reintroducing pleasurable events into residents' lives, as I just discussed. Another thing is that people with depression often don't recognize the gains they make in therapy. We found that using visual graphs of improvement really meant a lot to residents and made them feel proud about their work in therapy. For example, a speech pathologist could chart the percent of words comprehended, the number of words spoken or problems solved, etc. A physical therapist could document how many feet walked or independence with transfer.
Edwards: If a resident were to need psychotherapy or psychological counseling, how would the facility handle this?
Dr. Lichtenberg: All non-mental-health professionals should know how to access psychological/psychiatric consultation if residents can't participate in the activities I mentioned earlier because they are crying too much, they are too withdrawn or they are having hallucinations. If there is talk of harming oneself or taking one's life, that should be taken very seriously, as well.
If a resident is cognitively intact but physically disabled and clearly has interpersonal conflicts, or if she questions the reasons and meaning behind her nursing home stay, more traditional psychotherapy can be useful. Psychologists and psychiatrists are available to work with Medicare residents in nursing homes and can bill independently for those services. As far as Medicare is concerned, all physicians--or psychologists in this case--are independent providers and don't actually need an order to provide care, but most facilities require an order from the medical director. Medicaid often pays part or all of what Medicare does not pay--this varies by state.
Dr. Peter A. Lichten berg can be reached at the Institute of Gerontology, Wayne State University, 87 E. Ferry St., Detroit, MI 48202, or by e-mail at p.Lichtenberg@wayne.edu. To order Depression in Geriatric Medical and Nursing Home Patient: A Treatment Manual, phone (800) 978-7323 or visit http://wsupress.wayne.edu.
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|Date:||Jun 1, 2002|
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