Nursing homes are residential settings that provide around the clock medical care for people who are recovering from acute health issues such as stroke or hip fracture, or for people who can no longer manage to live safely on their own because of physical or psychological debilitation (Ferrini, 2008). Long-term nursing home residents are generally elderly, frail, have multiple chronic illnesses, mobility issues, and are dependent on others for many of their daily needs. The professional care and supervision that nursing homes provide are meant to positively impact the health and well-being of the residents, but this is often overshadowed by negative factors that can compromise health and well-being. These factors detract from the quality of life of the residents and often contribute to depression, which is quite prevalent in nursing homes. Although percentages range among studies, research has shown that as much as 31% of nursing home residents have been found to have major depressive disorder and up to 75% experience significant depressive symptoms (Namkee Choi, 2008).
Depression is considered a life-long mental illness, but it is often experienced as alternating periods of wellness with reoccurring bouts of illness. The illness affects mood, thoughts, feelings, behavior, and physical health (National Alliance on Mental Illness, 2013). Sadness associated with normal grief is different from depression. A sad or grieving person can continue to carry on with regular activities. The depressed person suffers from symptoms that interfere with his or her ability to function normally for a prolonged period of time. There is no exact cause of depression, but the general professional consensus is that depression has a biological basis involving genetics and an imbalance of chemical neurotransmitters in the brain, often combined with environmental and psychological triggers (National Alliance on Mental Illness, 2013).
Any circumstance of trauma, loss, difficulty, hardship, or stress can be an environmental or psychological trigger (National Institute of Mental Health, 2013). It is highly plausible that 100% of people living in nursing homes experience one or more of these environmental or psychological circumstances not only regularly, but relentlessly. The factors specific to nursing home life that can lead to depression include, but are not limited to, 1) the preconception of the nursing home as a death sentence, 2) the profound losses experienced by residents, 3) healthcare-associated acquired infections, and 4) the organizational culture and climate within the nursing home. This paper will discuss the negative environmental and psychological factors that can lead to depression, and explore options for management of depression; particularly better assessment and detection, more proactive prevention rather than reactive treatment, and the encouragement of realistic coping options.
Negative Environmental and Psychological Factors of Nursing Homes
The Death Sentence:
Once people have lost the ability to care for themselves on their own, moving to a nursing home becomes more of a necessity than a choice because there quite often is no other available and affordable alternative (Ferrini, 2008). Although people may value and benefit from the full-time care and supervision the nursing home setting provides, the transition is wrought with ambivalence and apprehension. Many people hold the preconceived notion that the nursing home is where they will go to die. For long-term residents, the nursing home represents a one-way street with a dead end. Unlike acute-care residents who live in nursing homes to recover from surgery or illness, long-term residents are not there to recover or stabilize to the point where they can take care of themselves and go back home. These people either die in the nursing home or are transferred to acute care hospitals, where they either die, or return to the nursing home, or transfer to hospice care to die (About Nursing Homes, 2013).
Residents have described their feelings about living in a nursing home as “institutionalized”, “imprisoned”, and “trapped” (Namkee Choi, 2008). This can create feelings of hopelessness and helplessness for nursing home residents, which are both symptoms of depression (Thakur, 2008). This hopelessness is compounded by the frequent encounters with the death of others that nursing home residents must endure. The death of other residents is a regular occurrence at nursing homes that forces people to constantly face their own mortality. The grief and loss experienced on a daily basis affirms the notion that the nursing home is where people go to die. Some residents just give up and openly express that they want to die (Namkee Choi, 2008).
Besides facing their own impending demise and the death of other residents, people in nursing homes experience a plethora of other losses. These losses have been shown to significantly affect the mental health of nursing home residents (Namkee Choi, 2008). First, people move to nursing homes because they have lost the physical ability to care for themselves due to chronic illness or increasing immobility, or they have lost the psychological ability to function on their own due to dementia or mental illness. Economic and sentimental losses are incurred because people sell their homes to pay for nursing home care. With their homes go lifelong memories and personal belongings. Because of limited space, cherished keepsakes, a familiar bed, a favorite desk, artwork, pictures, and beloved pets are only some of the things a person may never see again after entering the nursing home. Social losses are experienced when people move out of their community and away from friends and family to live in a nursing home. The inabilities to live in their own homes and communities and continue with their past lifestyles are the most powerful losses for people who have had to move into nursing homes (Namkee Choi, 2008). They miss out on life-affirming activities like the church choir, social engagements, gardening, and volunteering. Even seemingly mundane activities like cooking, cleaning, and shopping are longed for but lost forever.
Rules, regulations, and strict routines disconnect residents even further from any semblance of their past lives. As residents, people experience a profound loss of privacy, autonomy, independence, and self-determination. At the very onset of nursing home life, a new resident may be forced to share a room and a restroom with a complete stranger (Namkee Choi, 2008). The most intimate daily activities like dressing, sleeping, and using the bathroom are done in the very close vicinity of strangers. When receiving invasive medical treatments, like catheterization, or receiving highly personal daily care, like bathing or even diaper-changing, usually just a curtain is pulled for privacy. This may protect the resident from others seeing what is going on, but not from hearing what is going on. The perception of privacy is not only about not being seen, but also about not being heard. Doors to the rooms are often kept open, so that the nursing staff can keep an eye on the residents. It is not possible for many residents to close doors when they choose because of immobility issues, and even when doors are closed, staff members may walk in without knocking.
Bed checks, meal times, bathing times, and wake times are held to tight schedules. Residents do not have the flexibility to sleep in if they want or the option of family members staying the night, as they would in their own homes (Namkee Choi, 2008). Residents usually do not have their choice of roommates and compatibility is not considered. Many times cognitively intact individuals must room with people with severe cognitive impairments, making communication and companionship impossible. These many losses experienced are not just inconvenient, but devastating to the mental health and quality of life for nursing home residents (Namkee Choi, 2008).
Healthcare Acquired Infections:
Healthcare-associated or healthcare-acquired infections (HAIs) are infections that patients acquire while in a healthcare facility receiving treatment for other conditions (Healthcare Associated Infections, 2010). The age and already-compromised health and immune systems of the nursing home population, the close proximity of residents and staff, and environmental contamination are all factors that foster the development and transmission of infection within the nursing home (L.E. Nicolle, 1996). HAI’s significantly impact the physical health and mortality of the residents, and multiple illnesses are associated with greater risk of depression (Thakur, 2008).
One of the most common infections among nursing home residents are lower respiratory infections. Pneumonia and bronchitis are lower respiratory infections. Among all infections, they have the highest frequency and the worst consequences. Pneumonia is a leading cause of death among infectious diseases (L.E. Nicolle, 1996). Gastrointestinal infections are also deadly for nursing home residents. A gastrointestinal infection from Clostridium difficile, which causes diarrhea, has been connected to 14,000 deaths each year in the United States with nursing home residents being the most at-risk (Healthcare Associated Infections, 2010). This adds to the number of deaths of others that nursing home residents are forced to endure.
If they do not cause death, these diseases can lead to functional impairments such as immobility and incontinence. Conditions such as these tend to increase the need for hygiene while at the same time limiting the ability to perform the necessary hygiene on one’s own (L.E. Nicolle, 1996). This means more loss, trauma, hardship, and stress for the residents. These are all psychological triggers for depression. HAI’s can also lead to malnourishment because people are too sick to want to eat, can’t keep the food down, cannot feed themselves, or have trouble swallowing. Malnourishment has been found to be prevalent in nursing home residents (L.E. Nicolle, 1996). Malnourishment leads to nutritional deficiencies. Vitamin D deficiencies have been specifically linked to depression (Cherniack, 2011).
Some medications may also increase the likelihood of infection, and unfortunately, the average nursing home resident takes 5 to 10 different medications at any given time (L.E. Nicolle, 1996). Fluoroquinolones are broad-spectrum antibiotics that have been used to treat hospital-acquired infections such as pneumonia and urinary tract infections caused by cathaterization, but these medications tend to encourage the development of Clostridium difficile infections. Fluoroquinolones may also lead to depression as a side effect (Goldberg, 2012). In fact, many medications used to treat the chronic conditions prevalent in nursing homes cause symptoms of depression. They include the following:
• Beta-blockers and calcium channel blockers for high blood pressure, heart failure and angina,
• Estrogens to prevent or treat osteoporosis,
• Statins to lower cholesterol, protect against damage from coronary artery disease, and prevent heart attacks,
• Opioids to relieve moderate to severe pain,
• Bromocriptin for Parkinson’s disease,
• Benzodiazepines for anxiety and insomnia,
• Interferons for cancer (Goldberg, 2012).
With every increase in medication usage, there is an increased possibility of depression symptoms (Vann, 2010). When depression-inducing medications are added to the onslaught of psychological and environmental triggers of depression that nursing home residents must endure, they become particularly vulnerable to depression.
Organizational Culture and Climate:
There has also been found to be a connection between depression in residents and the organizational culture and climate within nursing homes. Organizational culture is defined as “the expectations that govern the way things are done in an organization” (Cassie, 2012). The three aspects of organizational culture include:
1) Rigidity- characterized by requiring employees to follow strict policies and procedures and seeking permission from a supervisor before acting independently
2) Proficiency- characterized by employees who are responsive to client needs and competent in their actions
3) Resistance- characterized by employees who are resistant to change or efforts to improve the organization (Cassie, 2012)
Organizational climate is defined as “the shared perceptions of the psychological impact of the work environment on the employee’s own well-being” (Cassie, 2012). The three aspects of organizational climate include:
1) Engaged- characterized by employees who connect with residents and view them as individuals, making their job important and worthwhile
2) Functional- characterized by employee perceptions that the organizations offers growth and opportunities for advancement, role clarity, and cooperation
3) Stressful- characterized by employees who feel emotionally exhausted in an organization with role conflicts and role overload (Cassie, 2012)
Research results show that organizational cultures with lower levels of proficiency and higher levels of resistance were associated with more depressive symptoms. This is evidence that a more negative culture and/or climate within the nursing home is associated with depression. In highly proficient cultures, residents experienced a decrease in depressive symptoms over time. This may be due to the fact that proficient cultures respond to resident’s needs promptly and competently making residents feel valued and protected, which may minimize depressive symptoms.
Dealing with Depression in Nursing Homes
Depression has been found to be “the most common cause of morbidity and decreased quality of life” in older people (Thakur, 2008). Given the plethora of psychological and environmental triggers of depression found in nursing homes, it is not surprising that long-term nursing home residents have the highest rates of depression (Cassie, 2012). The disease has detrimental effects on the elderly as it is associated with cognitive and physical decline, malnutrition, falls, hospitalizations, and longer nursing home admissions. As the older population continues to expand significantly with the aging of the baby boomers, the prevalence of depression is expected to grow and contribute to increased health care costs. It has become a major health issue, which has sparked much research on the subject (Cassie, 2012).
Because there are so many environmental and psychological triggers of depression present in the nursing home setting, the high rate of depression within nursing homes is a multidimensional issue. A systemic change in current nursing home practices is warranted to make any substantial difference in the rates of depression. These changes involve better assessment and detection, more proactive prevention rather than reactive treatment, and the encouragement of realistic coping options.
The Minimum Data Set (MDS) is a federally mandated standardized assessment completed on all residents in nursing homes that receive Medicare or Medicaid funding, regardless of how the resident pays for services. It is completed upon admission, quarterly, annually, and at various other intervals as necessary (Cassie, 2012). Its primary purpose is to identify resident care problems that can be addressed in an individualized care plan (CMS 2012 Nursing Home Action Plan). There are many scales within the MDS such as the Depression Rating Scale (DRS), which is a seven-item scale that rates the presence of depressive symptoms in residents in the past 30 days. However, using the MDSDRS to screen for depression has been found in at least three separate major studies to have poor validity in comparison to other standard screening methods (Thakur, 2008). Despite its shortcomings, the MDSDRS is the most readily and widely available comprehensive data to researchers (Thakur, 2008).
Also, recognizing depression in the elderly is not always easy. Older Americans do not readily admit feelings of depression because of the stoicism characteristic of their generation or the perceived stigma of mental illness. They worry about being labeled as crazy or that complaining about their problems will be seen as a character weakness (Namkee Choi, 2008). Depression may also go unnoticed because many depression symptoms overlap with the symptoms of other illnesses, which may mask the depression (Thakur, 2008). Researchers have noted that when compared to the Geriatric Depression Scale, the MDSDRS underestimates depression, “particularly in facilities reporting no or very low levels of depressive symptoms among their residents” (Cassie, 2012). Since the MDSDRS is completed by nursing home staff, these reported zero levels or low levels may be more of a result of the staff’s inability to recognize depressive symptoms rather than the actual absence of depressive symptoms (Cassie, 2012).
In response to these concerns, the Center for Medicaid and Medicare Services (CMS) contracted with Harvard University and the RAND Corporation in 2006 to revise and nationally test the new version, which was implemented in October 2010. The goals were “to introduce advances in assessment measures, increase clinical relevance of items, improve the accuracy and validity of the tool, increase user satisfaction, and increase the resident’s voice by introducing more resident interview items” (CMS 2012 Nursing Home Action Plan). The goals represent a four-year-long collaborative effort to improve individualized care and the overall health of residents in the nursing home population through quality improvement across the board. These quality improvements could certainly bring about culture changes in many facilities.
Proactive Prevention of Depression
Meaningful Activities and Exercise:
Antidepressants are the most common treatment for depression, and data from the CMS shows that 43.3% of nursing home residents take these medications (Suzanne Meeks, 2008). Antidepressants are effective in the treatment of depression, but are often under-prescribed because of detection issues. When prescribed, antidepressants are more poorly tolerated in the elderly, especially in the very old and frail who have multiple chronic illnesses (Nalin A Singh, 2000). Also, elderly patients are more likely to be taking several medications simultaneously, increasing the potential for adverse drug interactions.
Electroconvulsive therapy (ECT) is a depression treatment reserved for people who have severe or psychotic depression that is not responding to antidepressant medication or for people who cannot tolerate the medication. It is highly effective and considered safe, even in the elderly population (Thakur, 2008). However, both ECT and antidepressants are therapies that are reactive rather than proactive. Their focus is on treating depression rather than preventing depression.
Many researchers, however, have researched methods to prevent depression by decreasing the negative factors associated with depression that are prevalent in nursing homes. Meeks et al recognized that the negative events surrounding nursing home placement are not generally counteracted by positive experiences which, thus, compounds the risk of depression in nursing home residents. The Meeks et al research team created a non-pharmocological approach for the prevention and treatment of depression called BE ACTIV. This program involved 1) individual sessions with residents to identify positive events, 2) a person-centered plan tailored toward increased involvement in such events, 3) a system-wide assessment to increase the availability and frequency of such events, and 4) the assessment and removal of both individual barriers and institutional barriers that prevent access to any such positive reinforcements. Positive events are pleasant activities as defined by each individual and could be anything from a cup of coffee in the morning to having books on tape delivered. They could be as simple as getting a compliment to as challenging as going on an outing (Suzanne Meeks, 2008).
Overall results showed clinically significant reductions in depressive symptoms in the treatment group and a 75% recovery rate by the time of follow-up. There was a 50% recovery rate from depressive symptoms in the control group which received treatment as usual. The treatment group gained in activity participation whereas the control group declined. A positive affect was self-reported in the treatment group, it increased over time, and the affect was related to amount of activity participation. Positive affect in the control group decreased over time. Feedback from staff was positive as well. They appreciated the additional training they received and found it to be helpful in their ongoing relationship with their clients and assessing their needs appropriately (Suzanne Meeks, 2008).
There is a monumental amount of research about the effects of exercise on overall psychological well-being., which overwhelmingly shows that consistent physical activity is associated with better psychological well-being. Well-being is characterized as the presence of positive traits such as life satisfaction and hardiness, and the absence of negative traits like anxiety, anger, fatigue, and depression. Further research regarding depression, specifically, in relation to exercise have shown that there is a strong, cross-sectional relationship between depressive symptoms and physical activity with less active individuals experiencing the highest levels of depression. Also, those who were not depressed initially, but were active, had lower rates of depression over time than those who were not depressed initially, but were sedentary. This suggests that increasing physical activity may prevent the onset of depression as well (Fiatarone, 2000).
In regards to the older population, resistance training, or weight-lifting, has more benefits than aerobic exercise because 1) it specifically addresses the loss of lean muscle mass and strength, 2) it has fewer contraindications than aerobic exercise, 3) it is proven safe and feasible with high compliance in the frailest of elderly, and 4) it may directly counteract falls and hip-fracture risks. Aside from these benefits, exercise also offers additional benefits in the treatment of depression in older people. First, it is better tolerated than pharmacological treatments. Second, pharmaceuticals meant for depression do not treat comorbid diseases and they do not offer the potential benefit of improved fitness. Exercise, however, is an effective treatment for many comorbid diseases such as obesity, hypertension, cardiovascular disease, diabetes, osteoporosis, and arthritis to name a few, and exercise has the likelihood to improve fitness. Third, because of the evidence in research that depression in older people is being seriously under-diagnosed and under-treated, the adoption of exercise programs within nursing homes could potentially serve to treat depression that has yet to be diagnosed and even prevent the onset of depression in the first place (Fiatarone, 2000).
Although more research is being devoted to system-wide prevention methods that counteract the negative factors within the nursing home; admittedly, not all negative factors can be removed from nursing home life. Despite our greatest efforts, nursing home residents will always feel the trauma and stress of the many losses and environmental limitations they experience as a result of the nursing home setting. Therefore, it is logical to research viable coping strategies for nursing home residents. Since long-term nursing home residents are often the frailest of the elderly population with the most chronic illnesses, they tend to recognize that their situation is not likely to change. Therefore, coping with their problems becomes more of the focus than solving their problems (Joseph Z.T. Pieper, 2012).
Religious coping is “the most widely used spiritual resource that older people utilize to deal with illness and stressful life events” (Reyes-Ortiz, 2006). It is especially important for people who are living in nursing homes. In one study of 65 nursing home residents, 59 described themselves as religious by reading the Bible and praying on a regular basis. Many also attended weekly religious services at the nursing home. (Namkee Choi, 2008). Another study found that 86% of people either hospitalized in the geriatric unit or institutionalized in a nursing home used religion to cope with their illnesses and disabilities (Reyes-Ortiz, 2006).
Religious behavior includes intrinsic religious activities such as having faith in God, reading the Bible, and praying, as well as organizational religious activities such as attending church and participating in other religious group activities (Reyes-Ortiz, 2006). Religious attitudes and beliefs offer hope that exceeds beyond the hope of getting better. Many nursing home residents are no longer active members of the community, feel they have outlived their productivity, and are dependent on others for survival. Since their exterior lives can no longer be cultivated, religion allows people to cultivate their “interior” lives. It gives them meaning and significance in a world that may view them as useless members of society (Fahey, 1997).
This meaning and significance derived from religious beliefs has positive effects on health and well-being, according to several research studies. One study showed that being involved in organizational religious activities is strongly associated with improvements in functional ability and depression (Pierre, 1994). Other studies have found that deriving strength from religion is the best predictor of longetivity (Pierre, 1994). Research in the Netherlands showed that 74% of the 106 residents of a nursing home reported that religion was a positive resource for coping with their problems, and this positive influence tended to manifest itself as decreased anxiety and increased well-being ( (Joseph Z.T. Pieper, 2012). Also, studies on religion and aging at Duke University noted that people with a history of religion were better at coping with the stresses of aging (Fahey, 1997).
Other types of coping strategies have not been as well-received among the nursing home elderly. There are several studies on the effectiveness of Cognitive Behavioral Therapy (CBT) for the treatment of depression. CBT, also known as psychotherapy, is based on the idea that “our thoughts cause our feelings and behaviors, not external things, like people, situations, and events”. The premise of this is that we can change the way we think in order to feel and act better even if the situation does not change (What is Cognitive Behavioral Therapy?, 2013). The problem is that this requires older people to talk about their feelings. The current population of older Americans was raised during a time when people did not talk openly about their feelings and not much was understood about mental illness. Talking about problems was regarded as feeling sorry for oneself. As older adults, many of these same people are still more comfortable with being stoic and not complaining about their situation (Namkee Choi, 2008). Even if older people of this generation were more accepting of CBT, three-quarters of nursing homes are unable to access the psychiatric, consultation, or educational services to implement such therapies (Namkee Choi, 2008).
Physical illness, pain, disability, immobility, cognitive impairment, nutritional deficits, comorbidity, heavy medication use, death, loss of privacy, autonomy, self-determination, and independence are all real-life situations associated with depression and experienced by most if not all nursing home residents. Depression is an appropriate reaction to this conglomeration of negative experiences. Therefore, any treatments for depression such as pharmacology, CBT, ECT, exercise therapy, or other treatments not discussed in this text such as light therapy or reminiscence therapy, should be accompanied by noticeable and thoughtful efforts within the organization to decrease the negative experiences within the setting that lead to depression in the first place. Since research has shown that depression can be triggered by negative situations and circumstances, it follows that decreasing these negatives should decrease depression in nursing homes. Treating depression without any meaningful effort to prevent depression is illogical from both a practical and ethical perspective.
Great efforts have been made over the years to manage and improve the care that people receive in nursing homes for their physical and medical needs. For example, organizational changes and new protocols have been put in place to better control healthcare acquired infections, to minimize elder abuse, and to decrease the risk of falls. However, equal importance should be placed on protecting the mental health of residents as is placed on protecting their physical health. The exponential growth of the senior population, the projected increase in nursing home residents over the next several years, the high rate of depression found in residents, and the increased costs of healthcare resulting from the detrimental effects of depression are fair warning that grand efforts must also be made to manage and improve the psychological and environmental negatives of the nursing home setting that lead to depression.
Hopefully this research paper has given you some insight into what to expect if you have a loved one preparing to move to a nursing facility or is already living in one. Educating yourself is the first step in helping your loved one have a positive experience within the nursing home setting and possibly preventing the onset of depression. Key things to remember are:
1) Follow the BE ACTIV model by identifying what your loved one considers to be positive events or activities. (These can be anything whatsoever; for example, watching the news each morning, tea in the afternoon, getting a compliment, getting hair brushed, holding a baby, eating dessert, wearing an eye mask at bedtime, etc.) 2) Help to devise a game plan with staff and other family members to allow for as much availability and frequency of these events as possible in your loved one’s daily life.
3) Help to make sure your loved one has a variety of religious outlets such as a bible in the room, assistance or reminders in attending church services within the facility, and arranging for a pastor to visit with your loved one regularly.
4) Help to assure that your loved one engages in regular physical activity, especially resistance training as appropriate.
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