Even with the recent emphasis on "home-like" environments, living in a long-term care facility is a major life change - one that's historically associated with the onset of depression.
"As much as you can tell them this is their new home, you can't ignore the restrictions," said Shirley Callahan, RN, assistant director of nursing for safety and quality at Holy Redeemer St. Joseph Manor, Meadowbrook, PA. "While they can freely walk around the facility, they can't just get in the car and go to the store. If they want to go out, a family member has to come and take them."
Add the situational burden to declining health and depression is even harder to avoid.
In Pennsylvania, a statewide depression management collaborative initiated by the Abramson Center for Jewish Life and coordinated by Scott Crespy, vice president of quality improvement, aimed to take on this problem, utilizing CMS PHQ-9 depression screener and the Abramson Center's quality improvement model of depression management and prevention. Across the state, 40 nursing homes participated in this 8-month collaborative. Callahan and her counterpart Sue Leedom, RN, at Holy Redeemer, Philadelphia, led the initiative at Holy Redeemer with guidance from the Abramson Center.
The results would impress any assisted living expert. All told, the collaborative's active group reported a 58 percent relative reduction in the number of residents with moderate-to-severe depression. Callahan and Leedom were recently lauded by state Rep. Todd Stephens for their work in leading the investigational study and addressing this industrywide issue. To their pleasant surprise, most of the collaborative measures were already a part of their everyday practice.
Though social workers and nurses have long considered a new patient's mental state upon admission, clinicians participating in the collaborative were obliged to pick up on even subtle signs during the initial assessment.
"We want to catch it very early if these residents are headed on a path to depression," said Leedom. "Sometimes a resident is listless or unmotivated. We try to identify who is at risk and connect them with the psychology resources."
Other residents in skilled nursing facilities are more obvious in their distress. When residents are crying frequently, refusing to come out of the room or acting out, nurses are trained to start them on a path toward improved mental health right away.
Oftentimes, it's not the circumstances of living in a nursing home but an earlier life event that may be at the root of a patient's depression, the colleagues said.
"The generation in nursing homes now is from a time when depression wasn't talked about, even after something like the death of a child," explained Leedom. "Depression was considered a weakness. I've cared for so many over the years who were reluctant to even consider a diagnosis of depression because they'd be considered weak."
Together with pastoral care, the multidisciplinary team schedules regular meetings to clarify a resident's life history. According to Leedom, these extra interventions with the entire team let the resident know it's acceptable to deal with their past, even decades later.
Power of Participation
One of the most important non-pharmacological interventions is simply learning a new resident's hobbies and interests at admission.
"We've always done this but we're now trying to formalize our approach where we have our activities department meet each resident upon admission," said Leedom.
Nurse aides are also encouraged to initiate games, quizzes and other group activities to engage patients.
"Our residents have all different levels of physical abilities," said Callahan. "If aides are alert to the situation, they can even sit and read magazines and just talk with a patient. Everybody likes bingo and aides can encourage participation, as well as build a sense of community."
Pastoral care is also more proactive in working with all residents, even those not associated with a church or religion.
"Before this study, pastoral care would meet with the residents upon admission," said Leedom. "Now they're trying to zero in and make a cultural difference with each resident. When they feel their day is enjoyable and their life has meaning, their quality of life is enhanced."
Quality of life is even harder to maintain when the resident has dementia. One in 20 adults over age 65 have some form of dementia and an alarming one in five individuals older than 85, according to statistics from Alzheimer's Disease International.
Admittedly, patients with dementia are harder to engage in assisted living musicals or bridge games. With this patient population, it's even more critical to apply whole person care, Leedom and Callahan said.
"Some patients with dementia can't communicate verbally," said Callahan. "We really have to key into their behaviors."
Because many of these patients can't articulate if they're sad or depressed, Leedom said it's of the utmost importance to open the communication line with families.
"Some patients with moderate-to-severe dementia become tearful when they realize they're not at home or can act out," said Leedom. "There are many ways patients with dementia can exhibit depression."
By speaking with relatives and learning the family history, clinicians can learn clues about the patient's past and triggers. It's a simple concept that's working wonders, with more than half of the participants in the collaboration's active group displaying a reduction in the instances of moderate-to-severe depression.
"The last thing we want is somebody in our facilities displaying symptoms of depression," summarized Leedom. "As an organization, one of our goals is to provide the best quality of life. If we can address these symptoms, their quality of life always improves."
Robin Hocevar is senior regional editor at ADVANCE.