Analysis of a care planning intervention for reducing depression in older people in residential care

Preventing and responding to depression, self-harm, and suicide in older people living in long term care settings: a systematic review

Objective: The well documented demographic shift to an aging population means that more people will in future be in need of long term residential care. Previous research has reported an increased risk of mental health issues and suicidal ideation among older people living in residential care settings. However, there is little information on the actual prevalence of depression, self-harm, and suicidal behavior in this population, how it is measured and how care homes respond to these issues. Method: This systematic review of international literature addressed three research questions relating to; the prevalence of mental health problems in this population; how they are identified and; how care homes try to prevent or respond to mental health issues. Results: Findings showed higher reported rates of depression and suicidal behavior in care home residents compared to matched age groups in the community, variation in the use of standardised measures across studies and, interventions almost exclusively focused on increasing staff knowledge about mental health but with an absence of involvement of older people themselves in these programmes. Conclusion: We discuss the implications of these findings in the context of addressing mental health difficulties experienced by older people in residential care and future research in this area.

‘He just gave up’: an exploratory study into the perspectives of paid carers on supporting older people living in care homes with depression, self-harm, and suicide ideation and behaviours

This study explored the concept of ‘giving up’ from the perspective of care staff working in care homes, and their everyday communication and hidden knowledge concerning what they think about this taboo topic and the context it reflects. Moving to a care home is a major transition where cumulative losses can pose risks to mental health in later life. If not recognised, this vulnerability can lead to depression which extends to suicide ideation and behaviours in the form of self-harm and self-neglect. Care homes are a significant place of care until death, yet a discourse of silence means that self-harm and suicide is under-reported or not attended to with specialist expertise. The layperson's concept of an older person ‘giving up’ on life is hardly discussed in the literature. This co-produced qualitative study used an inductive approach to explore this phenomenon through focus groups with 33 care staff across four care homes in South-East England. Findings paint a complex picture, highlighting tensions in providing the right support and creating spaces to respond to such challenging situations. ‘Giving up’ requires skilled detailed assessment to respond to risks alongside improved training and support for paid carers, to achieve a more holistic strategy which capitalises on significant relationships within a wider context.

Optimal NHS service delivery to care homes: a realist evaluation of the features and mechanisms that support effective working for the continuing care of older people in residential settings

Background

Care homes are the institutional providers of long-term care for older people. The OPTIMAL study argued that it is probable that there are key activities within different models of health-care provision that are important for residents’ health care.

Objectives

To understand ‘what works, for whom, why and in what circumstances?’. Study questions focused on how different mechanisms within the various models of service delivery act as the ‘active ingredients’ associated with positive health-related outcomes for care home residents.

Methods

Using realist methods we focused on five outcomes: (1) medication use and review; (2) use of out-of-hours services; (3) hospital admissions, including emergency department attendances and length of hospital stay; (4) resource use; and (5) user satisfaction. Phase 1: interviewed stakeholders and reviewed the evidence to develop an explanatory theory of what supported good health-care provision for further testing in phase 2. Phase 2 developed a minimum data set of resident characteristics and tracked their care for 12 months. We also interviewed residents, family and staff receiving and providing health care to residents. The 12 study care homes were located on the south coast, the Midlands and the east of England. Health-care provision to care homes was distinctive in each site.

Findings

Phase 1 found that health-care provision to care homes is reactive and inequitable. The realist review argued that incentives or sanctions, agreed protocols, clinical expertise and structured approaches to assessment and care planning could support improved health-related outcomes; however, to achieve change NHS professionals and care home staff needed to work together from the outset to identify, co-design and implement agreed approaches to health care. Phase 2 tested this further and found that, although there were few differences between the sites in residents’ use of resources, the differences in service integration between the NHS and care homes did reflect how these institutions approached activities that supported relational working. Key to this was how much time NHS staff and care home staff had had to learn how to work together and if the work was seen as legitimate, requiring ongoing investment by commissioners and engagement from practitioners. Residents appreciated the general practitioner (GP) input and, when supported by other care home-specific NHS services, GPs reported that it was sustainable and valued work. Access to dementia expertise, ongoing training and support was essential to ensure that both NHS and care home staff were equipped to provide appropriate care.

Limitations

Findings were constrained by the numbers of residents recruited and retained in phase 2 for the 12 months of data collection.

Conclusions

NHS services work well with care homes when payments and role specification endorse the importance of this work at an institutional level as well as with individual residents. GP involvement is important but needs additional support from other services to be sustainable. A focus on strategies that promote co-design-based approaches between the NHS and care homes has the potential to improve residents’ access to and experience of health care.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

A pilot study using "apps" as a novel strategy for the management of challenging behaviors seen in people living in residential care

BACKGROUND

Many adults living in residential care will demonstrate challenging behaviors. Non-pharmacological strategies are recommended as first-line treatment. Using applications (apps) is a novel approach to managing these behaviors, and has yet to be assessed in this group. This paper describes a pilot study to test apps as a novel non-pharmacological strategy to manage challenging behaviors in adults living in residential care.

METHODS

A non-blinded, non-randomized crossover trial design was implemented which compared apps to a control situation and usual care to determine whether apps were able to decrease challenging behaviors. The primary outcome measure was the Neuropsychiatric Inventory (NPI) that measures the frequency and severity of these behaviors.

RESULTS

Fifteen residents participated whose mean age was 78.5 years. There were a range of diagnoses and comorbidities, including dementia and schizophrenia. IPads were used as the medium for delivering the apps and residential care staff implemented the interventions. There was a significant decrease in the total NPI score using the apps intervention (10.6 points) compared to the control (17.7 points) and to usual care (21.1 points). There was positive qualitative feedback from the staff who were involved in the study, but they also cited barriers such as lack of confidence using the apps and lack of time.

CONCLUSIONS

Although this was a small and limited study, results suggest that using apps may be a feasible and personalized approach to managing challenging behaviors. A more rigorous study design that includes larger sample sizes and staff training may enable further research and benefits in this area.

Exploring Individual, Family, and Extrafamilial Factors Associated With Depression Among Elderly Residents of Care Settings

This study investigated simultaneously the associations among individual, family, and extrafamilial factors and depression among elderly residents of care settings in Taiwan. The data for this study were obtained from the Vulnerability and Social Exclusion among Different Groups of Disadvantaged Elderly in an Aging Society: Phenomena and Strategies (1/2) project, which was conducted in Taipei City and Taipei County in 2007. We applied multiple regression procedures to a sample of 327 residents of care settings (48.3% women) who were mild physical impairment or physically independent and cognitively clear for determining factors associated with depression and their cumulative effects. We discovered that 24.5% of the residents were depressed. Physical mobility, number of chronic diseases, and self-assessed health status were significantly associated factors in all models. In the final model, we determined that one third of extrafamilial factors were significantly associated with depression, after controlling for all other variables. In addition, we observed an overall trend of increased mean scores of depression with an increase in the number of risk factors. The results imply that interventions aimed at preventing depression in elderly persons living in care settings, particularly persons with multiple risk conditions such as impaired physical mobility and medical comorbidities, should be designed to include extrafamilial elements. Establishing strong connections between elderly care setting residents and the institutional and neighborhood environments can help prevent depression.

Effective health care for older people living and dying in care homes: a realist review

Background

Care home residents in England have variable access to health care services. There is currently no coherent policy or consensus about the best arrangements to meet these needs. The purpose of this review was to explore the evidence for how different service delivery models for care home residents support and/or improve wellbeing and health-related outcomes in older people living and dying in care homes.

Methods

We conceptualised models of health care provision to care homes as complex interventions. We used a realist review approach to develop a preliminary understanding of what supported good health care provision to care homes. We completed a scoping of the literature and interviewed National Health Service and Local Authority commissioners, providers of services to care homes, representatives from the Regulator, care home managers, residents and their families. We used these data to develop theoretical propositions to be tested in the literature to explain why an intervention may be effective in some situations and not others. We searched electronic databases and related grey literature. Finally the findings were reviewed with an external advisory group.

Results

Strategies that support and sustain relational working between care home staff and visiting health care professionals explained the observed differences in how health care interventions were accepted and embedded into care home practice. Actions that encouraged visiting health care professionals and care home staff jointly to identify, plan and implement care home appropriate protocols for care, when supported by ongoing facilitation from visiting clinicians, were important. Contextual factors such as financial incentives or sanctions, agreed protocols, clinical expertise and structured approaches to assessment and care planning could support relational working to occur, but of themselves appeared insufficient to achieve change.

Conclusion

How relational working is structured between health and care home staff is key to whether health service interventions achieve health related outcomes for residents and their respective organisations. The belief that either paying clinicians to do more in care homes and/or investing in training of care home staff is sufficient for better outcomes was not supported.

Enjoying the front-line of dementia care: an integrative analysis of what care home staff report makes them happy at work

Purpose

– High turnover of staff in the long-term dementia care sector contributes to poor quality care and lack of continuity of care in the UK and many other countries. The purpose of this paper is to explore the research evidence on what care assistants report they enjoy when working in front-line dementia care jobs in long-term care facilities.

Design/methodology/approach

– An integrative analysis was used to study research findings focusing on the front-line workforce in care homes. The literature review sought to capture key findings, including overviews of research, from studies from 1990 to mid-2014 that have considered the positive experiences of front-line care home staff working with people with dementia.

Findings

– There is a great deal of research investigating care home staff's job satisfaction. Much of this highlights the importance of personal, social and managerial relationships. Common themes continue to be reported. There is potential for work on improving care assistant experiences in care homes but also a need to address long-standing inequities affecting the care home sector.

Research limitations/implications

– Some studies are not precise about which staff groups they are investigating in studies about care homes and many concentrate on the problems staff report. Measures of job satisfaction vary. When exploring dementia-related care not all studies are clear if care home residents have dementia or not.

Practical implications

– Many studies have investigated the views of care assistants working with people with dementia in care homes that address happiness in their work, often reported as job or work satisfaction, and these should be consulted when developing dementia services or managing care homes. As with other parts of the social care workforce, employers and managers need to be aware of effective and acceptable workforce reforms and ways to reduce turnover.

Originality/value

– This review suggests the value of investigating positive aspects of care work with people with dementia living in care homes. Greater attention could be paid to job satisfaction in social care more widely.

National trends and local delivery in old age mental health services: towards an evidence base. A mixed-methodology study of the balance of care approach, community mental health teams and specialist mental health outreach to care homes

Background

The rising number of older people with mental health problems makes the effective use of mental health resources imperative. Little is known about the clinical effectiveness and/or cost-effectiveness of different service models.

Aims

The programme aimed to (1) refine and apply an existing planning tool [‘balance of care’ (BoC)] to this client group; (2) identify whether, how and at what cost the mix of institutional and community services could be improved; (3) enable decision-makers to apply the BoC framework independently; (4) identify variation in the structure, organisation and processes of community mental health teams for older people (CMHTsOP); (5) examine whether or not different community mental health teams (CMHTs) models are associated with different costs/outcomes; (6) identify variation in mental health outreach services for older care home residents; (7) scope the evidence on the association between different outreach models and resident outcomes; and (8) disseminate the research findings to multiple stakeholder groups.

Methods

The programme employed a mixed-methods approach including three systematic literature reviews; a BoC study, which used a systematic framework for choosing between alternative patterns of support by identifying people whose needs could be met in more than one setting and comparing their costs/outcomes; a national survey of CMHTs’ organisation, structure and processes; a multiple case study of CMHTs exhibiting different levels of integration encompassing staff interviews, an observational study of user outcomes and a staff survey; national surveys of CMHTs’ outreach activities and care homes. A planned randomised trial of depression management in care homes was removed at the review stage by the National Institute for Health Research (NIHR) prior to funding award.

Results

BoC: Past studies exhibited several methodological limitations, and just two related to older people with mental health problems. The current study suggested that if enhanced community services were available, a substantial proportion of care home and inpatient admissions could be diverted, although only the latter would release significant monies. CMHTsOP: 60% of teams were considered multidisciplinary. Most were colocated, had a single point of access (SPA) and standardised assessment documentation. Evidence of the impact of particular CMHT features was limited. Although staff spoke positively about integration, no evidence was found that more integrated teams produced better user outcomes. Working in high-integration teams was associated with poor job outcomes, but other factors negated the statistical significance of this. Care home outreach: Typical services in the literature undertook some combination of screening (less common), assessment, medication review, behaviour management and training, and evidence suggested intervention can benefit depressed residents. Care home staff were perceived to lack necessary skills, but relatively few CMHTs provided formal training.

Limitations

Limitations include a necessary reliance on observational rather than experimental methods, which were not feasible given the nature of the services explored.

Conclusions

BoC: Shifting care towards the community would require the growth of support services; clarification of extra care housing’s (ECH) role; timely responses to people at risk of psychiatric admission; and improved hospital discharge planning. However, the promotion of care at home will not necessarily reduce public expenditure. CMHTsOP: Although practitioners favoured integration, its goals need clarification. Occupational therapists (OTs) and social workers faced difficulties identifying optimal roles, and support workers’ career structures needed delineating. Care home outreach: Further CMHT input to build care home staff skills and screen for depression may be beneficial. Priority areas for further study include the costs and benefits for older people of age inclusive mental health services and the relative cost-effectiveness of different models of mental health outreach for older care home residents.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Choosing treatment for depression in older adults and evaluating response

An update is provided on the current information regarding late life depression with regard to assessment, clinical implications, and treatment recommendations. Several treatments are considered evidence-based, but when deployed into field trials, the efficacy of these treatments falls short. It is thought that the lower impact in community trials is due in large part to patient, clinical, environmental, socio-economic, and cognitive correlates that influence treatment response. The aim is to assist providers in making decisions about what type of treatment to recommend based on a sound assessment of these clinical correlates.

A systematic review of staff training interventions to reduce the behavioural and psychological symptoms of dementia

Behavioural and psychological symptoms of dementia (BPSD) are highly prevalent and problematic in care settings. Given the limited effectiveness of medical treatments, training care staff to understand and manage these symptoms is essential for the safety and quality of life of people with dementia. This review evaluated the effectiveness of staff training interventions for reducing BPSD. A systematic literature search identified 273 studies. Twenty studies, published between 1998 and 2010, were found to meet the inclusion criteria. Overall, there was some evidence that staff training interventions can impact on BPSD: twelve studies resulted in significant symptom reductions, four studies found positive trends and four studies found no impact on symptoms. No links were found between the theoretical orientation of training programmes and their effectiveness. Training was also found to impact on the way staff behaved towards residents. A quality screening, using pre-specified criteria, revealed numerous methodological weaknesses and many studies did not adhere to the recommended guidelines for the conduct of cluster randomised controlled trials. There is an urgent need for more high quality research and evidence-based practice in BPSD.

Specialist mental health consultation for depression in Australian aged care residents with dementia: a cluster randomized trial

OBJECTIVE

This cluster randomized controlled trial sought to determine whether multidisciplinary specialist mental health consultation was more effective than care as usual in treating the depression of aged care residents with dementia.

METHODS

Three hundred and eighty nine aged care residents were screened for dementia and major depression. Forty four were ultimately included in the intervention sample, selected from 20 aged care facilities located in Melbourne, Australia. Facilities were randomly allocated to an intervention condition involving the provision of multidisciplinary specialist consultation regarding the best-practice management of depression in dementia, or to a care as usual condition. Consultations involved individually tailored medical and psychosocial recommendations provided to care staff and general practitioners. All residents participated in a comprehensive pre-intervention diagnostic assessment, including the administration of the Cornell Scale for Depression in Dementia. This assessment was repeated approximately 15 weeks post-intervention by a rater blind to study condition.

RESULTS

Multidisciplinary specialist mental health consultation was significantly more effective than care as usual in treating the clinical depression of aged care residents with dementia (p < 0.05, partial η(2)  = 0.16). At follow-up, the mean Cornell Scale for Depression in Dementia score for the intervention group was 9.47, compared with 14.23 for the control group. In addition, 77% of the intervention group no longer met criteria for major depression.

CONCLUSIONS

The results of this study suggest that the psychosocial and medical management of depressed aged care residents can be improved by increasing access to specialist mental health consultation.

'There's a hell of a noise': living with a hearing loss in residential care

BACKGROUND

Hearing loss is common in older age. Research with older people in residential care settings has identified high prevalence of hearing loss and low uptake of hearing aids. Hearing loss in these settings is associated with reduced social engagement. Although hearing aids remain the default treatment for presbyacusic hearing loss, these are not well used. We do not know what other modifiable factors contribute to communication problems for older people with hearing loss living in residential care.

OBJECTIVES

To explore the factors affecting communicating with a hearing loss in residential care.

METHODS

An ethnographic study in two residential care homes comprised 19 sessions of observation, and in-depth interviews with 18 residents. Observations explored communication behaviour in everyday interactions, including mealtimes, structured groups and informal group activities. Interviews were informed by the observations and identified reasons for these behaviours and communication preferences. Observational data were recorded in field notes and interviews were audio-recorded and transcribed. Analysis was conducted using constant comparison methods.

RESULTS

Hearing loss affected whether residents were able to access social opportunities. Two key themes influenced this (i) contextual issues compounded communication difficulties and (ii) environmental noise restricted the residents' communication choices. Problems were observed at every mealtime and during formal and informal group activities. The use of hearing aids and access to hearing services did not improve social engagement.

CONCLUSIONS

Environmental and social factors are key to maximising communication opportunities. Improvements to communication in residential care settings could be based on changes in these with input from residents and staff. Further work is needed to develop effective communication strategies in residential care.

Identification of depressive disorder among older people in care homes - a feasibility study

BACKGROUND

Depression is common among older people but more common among those living in care homes. Depression is not easily detected among older adults because of the presentation, and the tendency for older people not to complain of depression, particularly those living in care homes. In general, care home staff have limited training in recognising depression. Depression is undertreated and residents may not receive a therapeutic dose of antidepressant. The true prevalence of depression among care home residents is uncertain.

METHOD

This feasibility study aimed to explore the level of depression among older people in care homes by comparing the outcome of an assessment by care home staff with the outcome of a diagnostic clinical interview, using ICD-10 criteria and the 30-item Geriatric Depression Scale (GDS), conducted by a psychiatrist.

RESULTS

In all, 47 older people from four care homes were interviewed by a psychiatrist. Of them, 39.1% (18/46) of residents were prescribed an antidepressant and were no longer depressed; 8.7% (4/46) were prescribed an antidepressant and remained depressed; and 6.5% (3/46) of residents assessed as being depressed, had not been prescribed an antidepressant. That is, 54% (25/46) of residents had been or were currently depressed. Using ICD-10 criteria, the sensitivity of the GDS at a threshold of 10 and 11 was 100%. In total, 89.4% of residents received a correct diagnosis (presence or absence of depression) using the GDS at the 11 threshold.

SUMMARY

The prevalence of depression in these homes was 54%. Of the residents with depression, 72% (18/25) were managed with an antidepressant and 28% (7/25) were receiving ineffective or no treatment. The 30-item GDS can provide more useful information than a home care staff assessment for identifying depression. More research should explore the value of training home care staff to administer the 30-item GDS to optimise the management of depression in older people in care homes.

The center for epidemiological studies depression scale (CES-D) is an adequate screening instrument for depressive and anxiety disorders in a very old population living in residential homes

OBJECTIVE

The CES-D is an instrument that is commonly used to screen for depression in community-based studies of the elderly, but the characteristics of the CES-D in a residential home population have not yet been studied. The aim of this study was to investigate the criterion validity and the predictive power of the CES-D for both depressive and anxiety disorders in a vulnerable, very old population living in residential homes.

METHODS

Two hundred seventy seven residents were screened with the CES-D, and subsequently interviewed with a diagnostic instrument, the Mini International Neuropsychiatric Instrument (MINI). The sensitivity, specificity, and positive and negative predictive value of the CES-D were calculated by cross-tabulation at different cut-off scores. Receiver Operating Characteristics (ROC) curves were used to assess the optimal cut-off point for each disorder and to asses the predictive power of the instrument.

RESULTS

In a residential home population the CES-D had satisfactory criterion validity for depressive disorders and for any combination of depressive and/or anxiety disorders. With a desired sensitivity of at least 80%, the optimal cut-off scores varied between 18 and 22. The predictive power of the CES-D in this population was best for major depression and dysthymia (Area Under the Curve, AUC 0.87), closely followed by the score for any combination of depressive and/or anxiety disorder (AUC 0.86).

CONCLUSION

The use of one single instrument to screen for both depression and anxiety disorders at the same time has obvious advantages in this very old population. The CES-D seems to be a suitable instrument for this purpose.

Improving care in care homes: a qualitative evaluation of the Croydon care home support team

OBJECTIVES

The Croydon care home support team (CHST) was developed in response to reports of patient abuse within long-term care. It presents a novel strategy for improving standards of care within care homes. A qualitative methodology was used to assess the perceived impact of the CHST.

METHOD

In-depth interviews were conducted with 14 care home managers and 24 members of care home staff across 14 care homes. Grounded theory principles guided the collection and analysis of the data.

RESULTS

Reports of improved communication between staff, improved staff development and confidence, and improved quality of care point towards the effectiveness of the CHST model. The collaborative approach of the CHST was considered pivotal to its success and presented as an effective method of engaging care home managers and staff. The CHST adopted a systemic approach that placed an equal emphasis on the social, mental health and nursing needs of residents and aimed to address the whole culture of care within the individual homes.

CONCLUSIONS

The data demonstrate the potential for specialist multi-disciplinary teams to raise standards of care across long-term care settings. Increased awareness of safeguarding issues, improved staff morale and communication and ongoing opportunities for discussion and problem solving promised to sustain improvements. Such services could be instrumental in meeting the government priority of preventing abuse among vulnerable adults.

Dementia care and labour market: the role of job satisfaction

OBJECTIVES

A labour shortage in the dementia care sector is to be expected in the near future in the Netherlands and in many other European states. The objective of this study is to analyse why people quit or avoid jobs in dementia care.

METHOD

An integrative analysis was used to study reports, articles, and Website information on the dementia care labour market.

RESULTS

The main reason for quitting a (dementia) care job was the lack of job satisfaction. Job satisfaction was reduced by a lack of appreciation and professionals' own dissatisfaction about the quality of care they were able to provide. Effects of staff training on job satisfaction, quality of dementia care, and patient functioning are promising.

CONCLUSION

Job satisfaction is the main cause of quitting (dementia) care jobs. It might also be the key to solving problems in the dementia care labour market. Considering health-care workers as precious capital and taking adequate measures to enhance job satisfaction might contribute to a better image of dementia care. The following hypothesis has been derived from our results: enhancement of job satisfaction will prevent professional caregivers from quitting jobs and improve the quality of care and patient outcomes.

Knowledge and skills of professional carers working with older people with depression

OBJECTIVES

The current study was designed to evaluate the knowledge, skills and self-efficacy of care providers from the perspective of professionals working in the aged-care industry.

METHOD

Participants were 21 professional carers, 10 General Practitioners and 7 aged-care managers. Focus groups, which involved the completion of a semi-structured interview related to knowledge, recognition, confidence, referral procedures and use of screening tools for the detection of depression, were conducted.

RESULTS

The results showed that all groups of respondents recognised significant gap in the knowledge and awareness of depression among professional care staff working with older people in both the community and residential care-settings. Skills in the detection and monitoring of depression and the self-efficacy of these care staff were also seen to be a problem.

DISCUSSION

The implications of these findings in terms of training programmes for professional carers working in the aged health care sector are discussed.

Effects of psychotherapy and other behavioral interventions on clinically depressed older adults: a meta-analysis

OBJECTIVES

The goal of the present study was to assess the effects of psychotherapy and other behavioral interventions on depressive symptoms in clinically depressed older patients.

METHODS

We used meta-analysis to examine the effects of 57 controlled intervention studies.

RESULTS

On average, self-rated depression improved by d=0.84 standard deviation units and clinician-rated depression improved by d=0.93. Effect sizes were large for cognitive and behavioral therapy (CBT) and reminiscence; and medium for psychodynamic therapy, psychoeducation, physical exercise and supportive interventions. Age differences in treatment effects were not observed. Weaker effects were found in studies that used an active control group and in studies of physically ill or cognitively impaired patients. Studies of samples comprised exclusively of patients suffering from major depression (versus other mood disorders) also yielded weaker intervention effects. On average, 18.9% of participants did not complete the intervention, with higher dropout rates reported in group (versus individual) interventions and in longer interventions.

CONCLUSIONS

We conclude that cognitive-behavioral therapy and reminiscence are particularly well-established and acceptable forms of depression treatment. Interventions with 7-12 sessions may optimize effectiveness while minimizing dropout rates. For physically and cognitively impaired patients, modifications in treatment format and/or content might be useful, such as combining psychotherapy with social work interventions and pharmacotherapy.