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Gray days.

Depression isn't a natural part of aging. Here's how to combat it

Nurse Carol Shapiro asks the nurses and nursing assistants sitting before her to close their eyes and take a deep breath. "Imagine yourself aging," she says. "You are now 80. Look in the mirror. Is your hair gray? Are you wrinkled? Can you See? Can you hear people on the telephone?" For 10 minutes, Shapiro, RN, a research associate at the Hebrew Home for the Aged in Riverdale, New York, guides her audience through the imagery of old age. Some people react with anxious laughter or tears. Others start talking or want to leave. But most begin to understand how quickly anyone--like so many nursing home elderly--can descend into depression.

For many staff, the session awakens them emotionally to a fact they know only to well: as many as 50 percent of nursing home residents have some form of depression. Twelve percent of all nursing home residents experience major depression: loss of appetite, changes in sleeping patterns, and lack of interest in once appealing activities. The rate among the cognitively intact residents in nursing, homes is even higher: 20 to 25 percent suffer major depression, more than 10 times the rate of nonresident adults over 65. Statistics specific to assisted living aren't available, but experts note that the problem warrants concern in that setting as well. According to the National Depressive and Manic-Depressive Association in Chicago, untreated depression is the most common mental disorder and the number-one cause of suicide among older adults.

Despite its prevalence, depression among the elderly long term care residents often goes untreated. Assessment tools are often inadequate, and many residents are unwilling or unable to describe their feelings. Other illnesses and medications can further mask or heighten their symptoms. Pair those difficulties with a shortfall of staff trained to recognize depression, and under-detection is no surprise. Still, it's possible to improve care. Here's how a few innovative long term care providers are addressing some of the most common obstacles to the successful detection and treatment of depression.

Obstacle: Poor assessment tools

Although the minimum data set addresses some issues like mood, affect, and behavior that could help alert staff to depression, its revelatory powers are far from adequate. "Because there are so many questions on other aspects of functioning, staff may not notice that a person scored high on depression questions," says Eran Metzger, MD, associate director of psychiatry service at Boston's Hebrew Rehabilitation Center for Aged, a chronic care hospital with 725 long term care beds. Assessment tools tend to be even more inadequate for those with dementia. "Most of the protocols don't work because these residents can't self-report symptoms," says Jeanne Teresi, PhD, Senior research associate at the Hebrew Home for the Aged. "Their answers can change from minute to minute."

Solution: The Geriatric Depression Scale, developed by Stanford researchers in the late 1970s, is a far more reliable tool than the MDS, even for those with mild to moderate cognitive impairment, says Joel E. Streim, MD, associate professor of geriatric psychiatry at the University of Pennsylvania School of Medicine in Philadelphia. "It's specifically designed to omit somatic symptoms such as fatigue, diminished appetite, and sleep disturbances since those can often be attributed to medical illness other than depression," he says. Although Streim recognizes the burden of more paperwork, he points out how easy the scale is to administer. "You don't have to go to ten training sessions to use it. For residents who can circle answers themselves it doesn't take staff time except to collect and score--about a minute per test. And if a simple screening helps assess depression up front that will save staff time."

The Hebrew Home in Riverdale has addressed depression in residents with dementia by working with Robert Abrams, MD, at Cornell University to develop a protocol for assessing and diagnosing it. Included in the protocol is a "staff recognition measure," a series of questions that determine how well staff recognizes depressive symptoms. Using the new protocol, researchers were able to assess 84 percent of residents suffering from dementia compared with only a third using a standard protocol.

Obstacle: Residents' silence

It's a rare resident who says outright, "I'm depressed." The current elderly weren't raised in an era replete with psychotherapy and Prozac. "There's a generational stigma attached to mental illness and an inhibition about acknowledging psychiatric problems," says Metzger. "Rather than talk about feeling depressed, residents might say the food is bad or they may have a long list of physical symptoms." That's why Phyllis Cronin, RN, a psychiatric nurse clinical specialist at Boston's Hebrew Rehabilitation Center, suspected the constantly complaining Mrs. P. required a closer look. Says Cronin, "When I asked her about her life, she exploded with terrible sadness."

"People become incredibly focused on body parts, and it's a displacement of emotions," she adds. "Even if you ask, 'Are you depressed,' they'll say, 'Oh no.' They may focus on constipation or headaches instead."

Solution: Cronin both informally and formally teaches staff not to wait for a resident's declaration. Instead she urges them to report changes that might suggest emotional turmoil: difficult behaviors, poor appetite, reclusiveness, continuous physical complaints. "You have to have staff who can pick up the signs and who can say, 'We need a psychiatric consult,'" says Cronin. "Even if a facility has a psychiatric staff, they can't possibly detect all the depression. They count on other people to call it to their attention." Cronin also routinely visits each unit, asking charge nurses about any changes they or other staff have noticed.

Hebrew Rehabilitation Center for Aged also consults informally and formally with families, whose own feelings of guilt and pain may contribute to a resident's depression. If the family feels more comfortable with the situation, it's in a better position to be supportive through more frequent visits and phone calls. The center also holds a family day during which Metzger addresses depression. "Families often know if a loved one is acting differently," he says.

For cognitively alert residents who are depressed, Metzger holds small weekly group sessions, addressing topics such as loneliness, availability of family, and the sadness evoked by holidays.

Obstacle: Poor staff education and training

If anyone is apt to recognize a shift in mood or behavior, it's the frontline worker who sees the same resident day in, day out. Yet for staff busy with feeding, dressing, and bathing, allowing the signals of depression to register isn't easy or automatic. "If a person's not eating well, you might assume she doesn't like the food, or she can't use her hands, or she can't have salt, when in fact it might be depression," says Shapiro. "Staff are so busy that something may need to happen 15 to 20 times before the bell goes off."

Nor is depression a single, easy diagnosis. Staff must wrestle the illness in multiple guises including major depression; minor depression, a less severe form of major depression that includes only some of the classic characteristics of major depression; dysthyma disorder, a less severe but chronic and difficult to treat depression; and bipolar or manic depression, which is characterized by alternating periods of elation and depression.

Solution: Shapiro approaches staff training through 3 30- to 40-minute training modules developed as part of the Hebrew Home/Cornell protocol. The first addresses recognition. Shapiro stresses not only how common depression is but also the many ways residents may express it. "It's not uncommon for residents to be agitated, and one of the many causes may be depression. Or depression can be evidenced by anger. When people feel great sadness, they can strike out verbally or physically."

Shapiro also addresses common myths about depression, for example, that residents can just snap out of it. "We don't ask diabetics to snap out of it without insulin," she says. "So why would we ask a depressed person to snap out of it without help also?" The module also stresses how crucial staff, especially CNAs, are in recognizing and reporting changes. "Sometimes CNAs may not feel they have the knowledge to make that contribution," says Shapiro, "but many times their observations are what trigger comprehensive evalualions. Just offering the resident support won't do it. Staff have to talk to the charge nurse or the physician or the team about what they observe."

Module two addresses the distinctions and overlap between dementia and depression, and stresses ways to communicate with troubled residents. For example, Shapiro teaches staff to avoid asking "why" questions that residents may not be able to answer. Instead she encourages questions that elicit yes and no responses: Are you sad today? Did the food taste bad?

Module three addresses intervention. Shapiro familiarizes staff with the different kinds of antidepressants--and with methods of approaching residents with sensitivity. For instance, she notes the temptation of some to address residents as children or to use the first person plural, we. "Residents hear the tone as well as the words, and it's disheartening," says Shapiro.

Obstacle: The masks of other illnesses and medications

Another tricky aspect of depression in the elderly is that it can be masked by other illnesses. "Most people in nursing homes have medical illnesses, and it's very difficult for a physician to separate symptoms," says Metzger. "Just think back to your last cold: you didn't sleep, your appetite was poor, you lost energy--all symptoms of depression. And if you have a chronic illness, those symptoms go on from day to day."

Parkinson's disease, multiple sclerosis, Huntington's disease, and stroke, for example, all carry with them high rates of depression. And certain medications, including antipsychotics, beta-blockers, and steroids, can create depressive symptoms as well.

Solution: One way to sort depression from illness and medication, says Metzger, is to exclude all symptoms but those related to depression, such as ideas of suicide, extreme hopelessness, or guilt. And sometimes, depending on severity, the depression needs to be treated regardless of cause. Of course, no one wants to dose a resident with antidepressants if a change of medication could lift the depression. "We start by running down the medication list or asking the consulting pharmacist, 'Is Mrs. X on a medication that could cause depression?'" says Maggie Donius, a gerontology clinical nurse specialist at Providence Benedictine Nursing Center, a 106-bed long term care facility in Mount Angel, Oregon. "If she is, we consult with the primary care provider about changing the medication."

Obstacle: Limited studies on treatment options

Physicians are sometimes hesitant to treat residents with depressive symptoms unless they can make a clinical diagnosis of depression. That hesitancy is compounded by the lack of treatment studies on long term care resident populations. Some nursing homes, sensitive to excessive drug use, worry about adding yet another medication to a resident's roster.

Solution: Obviously, more studies need to be done but, according to Streim, the relative few that exist do show that residents respond to treatment.

But treating depression goes beyond drugs. Those at the Hebrew Home also stress recreational and creative arts therapy. Says Metzger, "People who are stimulated artistically and intellectually are less likely to become depressed and if they are depressed, they recover more quickly."

In part, the failure to recognize and treat depression adequately may be a failure of imagination. Our society--and even nursing home staff--expects the elderly to be depressed. After all, they're sick, they're old, they face terrible losses. But as Streim emphasizes, good cause or no, residents respond to treatment. "Even minor depression affects quality of life," he says. "Those with symptoms need attention."

Dorothy Foltz-Gray is a contributing writer to Contemporary Long Term Care.


Achieving Mental Health of Nursing Home Residents: Overcoming Barriers to Mental Health Care by Nancy B. Emerson Lombardo, et al (Hebrew Rehabilitation Center for Aged and Mental Health Policy Resource Center, 1996). This booklet assesses treatment difficulties and offers examples of model programs. To order contact the HRCA Research and Training Institute, 1200 Centre Street, Boston, MA 02131. You may also fax your order to 617-327-7639 or call 617-325-8000, extension 391 (cost: $5 per copy).

Depression in the Nursing Home: Training and Intervention Designed for the Depressed and Cognitively Impaired Resident in Three Modules by Carol Shapiro, RN, MSN, and Danielle Butin, MPH, OTR. This guide is prepared by and available from the National Alzheimer Center of the Hebrew Home for the Aged at Riverdale, 5901 Palisade Avenue, Riverdale, NY 10471; for telephone orders, call 718-432-7420.

The Protocol for Assessment, Diagnosis and Recognition of Depression in Dementia was developed by Hebrew Home for the Aged at Riverdale in collaboration with Weill Medical College at Cornell University, with funding by the National Institute of Nursing Research and the New York Department of Health. For more information, contact Dr. Jeanne Teresi, Research Division, Hebrew Home for the Aged at Riverdale, Riverdale, New York, 10471.

The National Depressive and Manic-Depressive Association in Chicago offers free educational materials. Call 800-826-3632 or visit the group's Web site at [less than][greater than].
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Author:Foltz-Gray, Dorothy
Publication:Contemporary Long Term Care
Date:Dec 1, 1999
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