|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
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.
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
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.
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.
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).
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
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
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