Recognizing and Treating Resident Depression

Depression is perhaps the most misunderstood illnesses in today's nursing homes, often overlooked by staff or simply seen as a natural consequence of the aging process. Too often, staff have not been trained to recognize the symptoms of depression. Many do not realize that depression is indeed a disease, one that is highly treatable among the elderly. By recognizing the symptoms of depression and taking corrective action, staff have the potential to greatly reduce the effects of depression within their resident populations.

Depression not only affects a person's mental health, but often impacts on a person's physical health. In a one year study by psychiatrists at Johns Hopkins University, nursing home residents with depressive disorder were 59% more likely to die than residents who were not depressed. The researchers attributed this result due to some of the common symptoms of the disease: nutritional deficits due to lack of appetite, insufficient rest due to insomnia, and immobility due to despondency.

Depression is often unrecognized by staff, because it can be masked by other physical and mental illnesses. Many times, the presence of depression interferes with the effective treatment of these illnesses. Also, there is a societal stigma with depression which inhibits its adequate diagnosis and treatment.

Nursing home caregivers can greatly improve resident quality of life by becoming more knowledgeable about the causes and symptoms of depression. They can use simple but effective caregiving strategies to improve a resident's emotional well-being. Many antidepressant medications have also proven to be highly effective in treating this disease, along with some of the traditional verbal therapy approaches. The following article, reflecting information delivered at a meeting of the Psychosocial Forum by Licensed Clinical Social Worker Carol Gordon, outlines many of the important facts about the symptoms and treatment of depression that should be understood by all nursing home staff.

Understanding the Symptoms of Depression

Everybody has times in their lives when they feel sad or depressed. These reactions are perfectly normal. However, with the disease of depression, these feelings persist and deepen over several weeks, months, or years. Diagnosed as having depression, persons often require medications and psychological treatments.

Situational depression most of the time is a reaction to losses, and generally responds well to therapeutic interventions. Much of the depression observed in nursing home residents is situational depression. On the other hand, chronic depression can continue for years and often reflects a more in-depth character trait of the individual and may involve more intensive clinical and pharmacological interventions.

Caregivers can begin to assess if residents are suffering from depression by looking at the residents' behaviors, to see if they reflect the following symptoms:

• expression of feelings of guilt, worthlessness, or inability to improve the situation
• frequent crying
• persistently sad or anxious; feelings of pessimism
• loss of interest or pleasure in daily activities; poor personal hygiene
• easily fatigued; decreased energy
• loss of appetite; significant weight loss; sometimes increase in appetite
• difficulty in concentrating; inability to make decisions
• sleep problems such as inability to fall asleep, or early awakening
• irritability and anger
• suicidal thoughts, statements, attempts
• recurrent aches and pains that are not responsive to treatment

According to Carol Gordon, if a resident exhibits three or more of the above symptoms persistently for more than a week, the resident may be suffering from depression. After carefully documenting the specific behaviors exhibited, the facility should then recommend to the resident's primary physician the need for a psychiatric evaluation.

Psychological Causes of Depression

There are many psychological factors which can lead to feelings of depression. Depression is generally a reaction to feelings of loss. With the aging process, elderly people face a variety of losses which can eventually build up and decrease their ability to cope. They may feel that their lives lack control, purpose, or meaning. Caregivers can look at the residents' histories and listen to the issues that they address on a daily basis to understand the psychological origins of their depressive symptoms.

Persons in nursing homes particularly have faced many losses, of which the most obvious and important one is the loss of health. Other losses may include the loss of a spouse, friends, job, home, financial security and community.

The adjustment in being admitted to a nursing home can produce feelings of depression and emotional distress. Moving from one's home and family to a more institutional atmosphere can be a traumatic experience, leading to feelings of fear, loneliness, and confusion. Societal attitudes about the elderly and of nursing homes can also effect depressive symptoms. Our youth-oriented culture can lead older persons to question their value and role.

Physical Causes of Depression

While many people think solely of psychological factors which provoke depression, there are many physical causes related to the aging process, effects of chronic illnesses, and side effects of medications which must also be considered.

As people get older, their bodies slow down and they may become less flexible in coping with stress. Dramatic changes in their lives become more of a challenge. The aging process may also lead to decreases in nerve transmitters in the brain, relating to many commonly seen cognitive deficits. These cognitive challenges can impair residents' ability to deal with stressful situations. Researchers point out that even residents with Alzheimer's disease and related dementias can suffer from depression.

The loss of organ functions, such as liver, kidneys, brain, heart, and muscles may precipitate the development of depressive symptoms. Many chronic illnesses such as stroke, heart disease, lung disease, diabetes, cancer, and Parkinson's disease are also linked with a change in a person's emotional state, such as feeling sad, useless, or out of control.

One of the most important areas to consider with persons exhibiting depressive symptoms are the prescriptions that they are taking. Staff must realize that medications or the combinations thereof can directly cause depression. Caregivers should particularly consider the side effects of prescriptives in the following categories: antihypertensives (to decrease blood pressure); anti-Parkinson's (to treat Parkinson's disease); cardiovasculars (to treat heart and circulation); hypoglycemics (to regulate diabetes); anti-microbials (to fight infection); and steroids (for inflammation).

Strategies for Helping the Depressed Resident

Generally, the treatment of depression involves psychotropic drug treatments, verbal therapies, or a combination of both. Psychiatrists are the most qualified professionals to prescribe medications to treat this illness. They are more experienced than general physicians in the wide repertoire of medications available for treatment.

In their daily care activities, caregivers can play a very important role in improving the well-being of depressed residents. The most important thing that they can do is to allow residents with depression to express their feelings. This intervention sounds simple, but often it is not done enough or in the correct manner.

Nursing home staff must be very aware of their communication strategies with depressed residents. They must always talk to them in a caring tone of voice. Often, the vocal tone is more important to these residents than the words that are said.

Active listening techniques are very effective. This strategy involves reflecting back to residents what they have said. One can summarize and show empathy resident's feelings by making a statement such as "I'm sorry that you're so sad about the death of your husband. I know your life has been hard without him." This type of reply provides residents support and reassurance.

Trying to cheer residents without recognizing and validating their feelings is very inappropriate. For instance, saying for the above example, "Let's not talk about your wife's death. You're still alive and you can still enjoy life" would be improper and often counterproductive. This answer doesn't acknowledge the resident's emotions. Depressed residents don't need cheerleaders; they need people to truly listen to their feelings and provide acknowledgment without judgment.

With depression comes a feeling of being out of control. Caregivers can benefit depressed residents by offering them choices whenever possible to increase their self esteem. Even basic choices such as "Would you like to sit by the window or by the bed?" can make a difference.

Caregivers should make every effort to encourage and praise the residents' efforts. As depression can lead to feelings of worthlessness, offering compliments can have a profound effect, even something simple as, "That sweater you're wearing is very pretty." It also may be helpful to encourage good grooming and hygiene, as depressed residents often do not feel a need to take good care of themselves. Looking better may help residents to feel better about themselves.

Depression causes many residents to withdraw from people and events. Caregivers should slowly encourage these residents to become involved in activity programs through a step by step process. At first, the residents may only feel comfortable in having visits with favorite staff members. Eventually, they may become comfortable in participating in a small group activity. Caregivers should gently encourage but not push depressed residents to become more involved in facility life.

Psychosocial programs can play a key role in rehabilitation. In particular, life review and the sharing of meaningful experiences can benefit residents' mental well-being. Carol advises that residents with milder levels of depression respond better to group programs, while residents with higher levels should be involved in one-on-one visits.

Depression is a frequently overlooked and misunderstood illness affecting many residents in long term care. In recognizing the symptoms of this disease and making appropriate interventions, nursing home staff can effectively enhance not only the residents' emotional health, but overcome many obstacles in treating their physical health conditions as well.

References

Burns, David D. Feeling Good: The New Mood Therapy. New York: Morrow, 1980.

Deakin, J.F.W. (Ed.) The Biology of Depression. Washington, D.C.: American Psychiatric Press, Inc., 1986.

Greist, John H., M.D. and Jefferson, James W. Depression and Its Treatment. Washington, D.C.: American Psychiatric Press, Inc., 1992.

Parmelee, Patricia A. et al. "The Relation of Pain to Depression Among Institutionalized Aged." Journal of Gerontology. Vol. 46: 15-21, 1991.

Rovner, Barry W. et al. "Depression and Mortality in Nursing Homes." Journal of the American Medical Association. Vol. 265: 993-996, 1991.

Sargent, M. Depressive Illnesses: Treatments Bring New Hope. U.S. Department of Health and Human Services (ADM 89-1491), 1989.

Winokur, G. Depression: The Facts. New York: Oxford University Press, 1981.