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

Study protocol for ELders AT Ease (ELATE): a cluster randomised controlled trial of cognitive behaviour therapy to reduce depressive symptoms in aged care residents

BACKGROUND

This protocol describes a study of the effectiveness of cognitive behaviour therapy (CBT) for reducing depressive symptoms in older adults living in residential aged care (RAC) facilities in Australia. Depressive symptoms are highly prevalent in this population, yet the benefits of CBT for reducing such symptoms in RAC facilities have not been widely investigated. Elders at Ease (ELATE) is a 16-session CBT intervention designed for implementation in RAC facilities. The intervention includes cognitive, behavioural and reminiscence strategies and is delivered by mental health trainees (MHTs) in collaboration with RAC facility staff and residents' family.

METHODS AND ANALYSIS

ELATE will be evaluated using a cluster randomised trial comparing outcomes for residents who participate in the intervention with those living in usual care control facilities. The participants are RAC residents aged 65 years or above, with depressive symptoms (Patient Health Questionnaire-2 ≥ 3) and normal cognition or mild cognitive impairment (Standardised Mini Mental Status Examination ≥ 21). They are assessed at four time points: baseline prior to randomisation (T1), mid-treatment (T2; 2.5 months post randomisation), post-treatment (T3; 5 months post-randomisation) and 3-month follow-up (T4; 8 months post randomisation). The primary outcome is change in depressive symptoms between T1 and T3. Secondary outcomes are depressive symptoms at T4, anxiety, suicide ideation, sleep problems, quality of life, staff and family knowledge of late-life depression, stress levels and efficacy in caring for residents, and MHT levels of geropsychology competencies. Residents receiving the intervention are hypothesised to report a greater decrease in depressive symptoms between T1 and T3 compared to residents receiving usual care. The primary analysis is a regression, clustered over site to account for correlated readings, and independent variables are condition and depressive symptoms at T1. A cost-utility analysis is also undertaken.

DISCUSSION

ELATE is a comprehensive CBT intervention for reducing depressive symptoms in RAC residents. It is designed to be implemented in collaboration with facility staff and residents' families, individually tailored to residents with normal cognition to mild cognitive impairment and delivered by trainee therapists. ELATE offers a model that may be widely applicable across the RAC sector.

TRIAL REGISTRATION

Trial registered with the Australian and New Zealand Clinical Trial Registry (ANZCTR) Number ACTRN12619001037190, prospectively registered on 22 July 2019.

Perceptions and practice behaviors regarding late-life depression among private duty home care workers: a mixed-methods study

Background: This study aimed to examine personal care aides (PCAs)' knowledge, beliefs, and attitudes towards late-life depression and their experience caring for older adults with depression.Method: This study used a mixed-methods convergent parallel design involving an online survey (n = 87) and semi-structured interviews (n = 22). Survey respondents were recruited using convenience sampling and interviewees using purposive sampling from private duty home care agencies in Michigan. Qualitative data analyzed using a technique involving data reduction and open coding. Survey data were analyzed using descriptive statistics.Results: Most PCAs underestimated suicide rate among older adults, overrated self-help ability of the depressed person, underrated difficulty diagnosing depression, and attributed depression to personality flaws. PCAs favored psychotherapy and informal support and generally regarded medication as unhelpful, particularly in mild/moderate depression. Despite these discordances, PCAs' self-reported practice behaviors included strategies (i.e., communication, behavioral, cognitive, emotional regulation, relational, and external) that were largely consistent with the scientific view, particularly relating to behavioral activation. A prominent theme from PCAs' narratives was individualized care, reflected in their assessment of depressive symptoms, attitude towards depression treatment, and strategies caring for clients.Conclusions: Several areas of PCAs' perceptions regarding late-life depression were discordant with the current scientific view, although their practice behaviors were largely consistent with the principles of evidence-based practice for depression. Specialized mental health training, a standard depression care protocol, and higher training standards are essential to mobilize the large number of PCAs to improve the mental health outcomes of hard-to-reach older adults.

Barriers to the Recognition of Geriatric Depression in Residential Care Facilities in Alberta

This study explored the barriers that regulated nurse professionals encountered in recognizing and assessing geriatric depression in residential care facilities in the Canadian province of Alberta. The study used a convergent parallel mixed methods design, including a cross-sectional survey (N = 635) and qualitative interviews (N = 14) with regulated nurse professionals. Findings revealed six major barriers to the recognition of geriatric depression in Alberta, including 1) insufficient clinical knowledge and training in geriatric depression; 2) misconceived beliefs about geriatric depression; 3) limited access to resources; 4) unclear depression assessment protocol and procedures in facilities; 5) characteristics of models of care and organizational culture in facilities; and 6) communication difficulties among all stakeholders in the process. Socio-cultural values and beliefs about geriatric depression played a key role in the complex interaction of the various structural and agential barriers to the effective recognition and assessment of depression in residential care facilities in Alberta.

How Do Regulated Nurse Professionals in Alberta Assess Geriatric Depression in Residential Care Facilities?

Although geriatric depression is a prevalent, serious, and under-recognized mental health condition in residential care facilities, there is a dearth of related research in Canada. This exploratory mixed methods study examines the perspectives and practices of regulated nurse professionals on assessment of geriatric depression in residential care facilities in Alberta. Findings from the quantitative surveys (n = 635) and qualitative interviews (n = 14) suggest that geriatric depression is not systematically assessed in these care settings due to multiple challenges, including confusing assessment protocol, inconsistent use and contested clinical utility of current assessment methods in facilities, limited availability of mental health professionals in facilities, and the varied views of regulated nurse professionals on who is responsible for depression assessment in facilities. Implications and future research directions are discussed.

Nurses' perceptions regarding providing psychological care for older residents in long-term care facilities: A qualitative study

AIMS AND OBJECTIVES

To explore nurses' perceptions regarding providing psychological health care for older residents in long-term care facilities (LTCFs).

BACKGROUND

Loneliness and depressive symptoms are commonly observed among older residents living in LTCFs. Nurses are expected to provide holistic care including physical, psychological and social care for older residents in LTCFs to fulfil their needs. Therefore, understanding nurses' feelings and thoughts regarding providing care for older residents who feel lonely, sad, unhappy or depressed is important for delivering better care.

DESIGN

A qualitative research design was employed. The Standards for Reporting Qualitative Research (SRQR) was used to enhance for reporting quality.

METHODS

Purposive sampling and snowball sampling were applied in Northern Taiwan. One-to-one in-depth interviews were conducted using a semi-structured interview guide. Twenty-one nurses with a mean age of 38.4 years were interviewed. Content analysis was performed for data analysis.

FINDINGS

Four themes were generated from the data: "insufficient psychological healthcare competency," "having a willing heart but not adequate support," "families playing an essential role in residents' mood" and "physical-oriented care model."

CONCLUSIONS

Long-term care facilitie nurses felt that they were not adequately prepared for taking care of older adults' psychological problems before their nursing career or during their practice. Unreasonable nurse-to-resident ratios and an absence of care consensus among healthcare providers can make nurses feel that they have a willing heart but not adequate support. Family members are essential in older residents' emotional status within the Taiwanese cultural context. Physical care evaluation indicators emphasised by LTCF accreditation resulted in the current care practice model.

IMPLICATIONS FOR PRACTICE

This study provides valuable information for LTCF nurses, managers and directors to develop appropriate strategies to assist nurses in providing better psychological health care for older residents. Evaluation indicators required by LTCF accreditation in Taiwan must be re-examined at the earliest stage.

Organizational factors related to the confidence of workers in working with residents with dementia or depression in aged care facilities

OBJECTIVES

There has been limited research examining how organizational factors are associated with the level of confidence of residential aged care staff in managing both residents' depression and the behavioural and psychological symptoms of residents with dementia (BPSD). This study investigated this issue.

METHOD

A cross-sectional study design was employed. In total, 255 aged care staff (131 senior staff, 124 junior staff) from 21 residential care facilities participated in the study. All staff completed measures of self-efficacy in managing BPSD as well as confidence in working with older people with depression. They also completed measures of organizational climate (autonomy, cohesion, trust, pressure, support, recognition, fairness and encouragement of innovation) and measures of workplace experience (job role, number of years working in aged care facilities), job stress and satisfaction, and knowledge of depression.

RESULTS

The results demonstrated that autonomy, trust, support, and job stress were associated with confidence in managing BPSD, while the factors related to confidence in managing depression were autonomy, support, job stress, job satisfaction, and knowledge of depression.

CONCLUSION

These findings highlight that organizational climate factors need to be addressed in order to increase staff confidence in managing BPSD and depression. In particular, the findings demonstrate the importance of fostering organizational environments in which autonomy is promoted and there is support and cooperation among aged care staff. Attention to these factors is likely to increase the confidence of staff as they carry out their carer role.

Prevalence of depression among recently admitted long-term care patients in Norwegian nursing homes: associations with diagnostic workup and use of antidepressants

AIMS

We aimed to establish the prevalence of depression among recently admitted long-term care patients and to examine associations with diagnostic initiatives and treatment as recorded in patients' medical records.

MATERIALS AND METHODS

Eighty-eight long-term care patients were included. Depression was diagnosed according to the ICD-10 criteria; patients were screened for depression using the Cornell Scale for Depression in Dementia (CSDD) and for dementia with the Clinical Dementia Rating (CDR) scale.

RESULTS

Depression was found in 25% of the patients according to the ICD-10 criteria and in 31% according to a CSDD sum score of ≥ 8. Diagnostic initiatives were documented in the medical records of half of the patients with depression. Forty-four percent of the patients were prescribed antidepressants and 23% actually received them for the treatment of depression.

CONCLUSION

Depression was prevalent among recently admitted long-term care patients, but diagnostic initiatives were too rarely used. Antidepressants were commonly prescribed, but depression was the indication for treatment in only half of the cases. Screening for depression should be mandatory on admission.

A study protocol to investigate the management of depression and challenging behaviors associated with dementia in aged care settings

BACKGROUND

The high occurrence and under-treatment of clinical depression and behavioral and psychological symptoms of dementia (BPSD) within aged care settings is concerning, yet training programs aimed at improving the detection and management of these problems have generally been ineffective. This article presents a study protocol to evaluate a training intervention for facility managers/registered nurses working in aged care facilities that focuses on organisational processes and culture as well as knowledge, skills and self-efficacy.

METHODS

A Randomised Control Trial (RCT) will be implemented across 18 aged care facilities (divided into three conditions). Participants will be senior registered nurses and personal care attendants employed in the aged care facility. The first condition will receive the training program (Staff as Change Agents - Enhancing and Sustaining Mental Health in Aged Care), the second condition will receive the training program and clinical support, and the third condition will receive no intervention.

RESULTS

Pre-, post-, 6-month and 12-month follow-up measures of staff and residents will be used to demonstrate how upskilling clinical leaders using our transformational training approach, as well as the use of a structured screening, referral and monitoring protocol, can address the mental health needs of older people in residential care.

CONCLUSIONS

The expected outcome of this study is the validation of an evidence-based training program to improve the management of depression and BPSD among older people in residential care settings by establishing routine practices related to mental health. This relatively brief but highly focussed training package will be readily rolled out to a larger number of residential care facilities at a relatively low cost.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Register (ANZCTR): The Universal Trial Number (UTN) is U1111-1141-0109.

Staff-focused interventions to increase referrals for depression in aged care facilities: a cluster randomized controlled trial

OBJECTIVE

While there is evidence that depression training can improve the knowledge of staff in residential care facilities, there is an absence of research determining whether such training translates into practice change. This study aimed to evaluate the impact of staff training and the introduction of a protocol for routine screening and referral for depression on the numbers of residents detected and referred by care staff for further assessment.

METHOD

A cluster randomized controlled design was used to compare the referral rates for residents in seven facilities randomly allocated into one of three conditions: staff training, staff training plus a screening and referral protocol and wait-list control. Participants were 216 aged care residents (M age = 87 years), who agreed to a 12-month audit of their facility file.

RESULTS

Staff training on its own did not increase the rate of referrals for depression; however, staff training plus the screening protocol and referral guidelines did lead to a significant increase in the number of residents who were referred to a medical practitioner for further assessment. However, this increase in care staff referrals did not result in substantial changes in the treatment prescribed for residents.

CONCLUSION

Staff training in depression, supplemented with a protocol for routine screening and guidelines on referring residents, can improve pathways to care. However, strategies to overcome barriers to appropriate subsequent treatment of depression are required for staff-focused initiatives to translate into better outcomes for depressed older adults. Methodological limitations of this study are discussed.

A preliminary study of aged care facility staff indicates limitations in awareness of the link between depression and physical morbidity

Background

It is important to understand the complex inter-relationship between depression and physical illness in order to plan and provide quality health care services for older persons and reduce suffering and early mortality. This study assessed the awareness and knowledge of age-care staff of the link between physical morbidity and depression.

Methods

One hundred and nineteen staff from both residential (high and low care) and community aged care facilities were surveyed on their awareness and knowledge of the relationship between physical morbidity and symptoms of depression. Predictors of levels of knowledge were assessed using multiple regression analysis.

Results

Awareness of the link between physical morbidity and symptoms of depression was generally high. However, while nearly eighty percent of respondents said they had had training in mental health, they were only able to answer an average of six out of ten of the knowledge questions correctly. Predictors of knowledge were: higher age, higher educational status and working in a high care facility.

Conclusions

Responses to the survey questions demonstrated gaps in knowledge about the relationship between depression and physical health. The need for regular ongoing training to improve knowledge and awareness of this relationship is indicated. Treatment of physical health issues which is essential in reducing the risk for depression in older persons in aged care environments could be optimized by improved staff training.

More age-care staff report helping care recipients following a brief depression awareness raising intervention

Background

Those working with elderly care recipients require a good working knowledge of depression and appropriate help giving responses. While it is important for age-care staff to recognize depression in care recipients it is also critical that they know the appropriate course of action to assist a care recipient who may be depressed. This study aims to determine the knowledge of age-care staff of appropriate help giving responses, their confidence in knowing what kind of assistance to provide and their actual likelihood of providing help to potentially depressed care recipients and to examine if these measures improve following an intervention training program.

Methods

One hundred and two age-care staff were surveyed on their confidence in helping age-care recipients and on their knowledge of appropriate ways to provide assistance. Staff then participated in a two hour depression awareness raising intervention. The survey was repeated immediately following the training and again six months later.

Results

Staff confidence in knowing how to provide assistance increased significantly subsequent to training and remained significantly improved at the six month follow up. In addition, a significantly higher proportion of staff reported helping care recipients at the six month follow up.

Conclusions

This study highlights the potential of a brief staff training program to provide a cost effective means to improve staff self-confidence and increase the likelihood of staff providing assistance to depressed care recipients.

Measuring carers' knowledge of depression in aged care settings: the Knowledge of Late Life Depression Scale-Revised

BACKGROUND

Aged care staff is increasingly relied upon to assist with the recognition and treatment of depression in older care recipients. However, there exist few reliable and comprehensive measures that assess aged care staffs' knowledge about late life depression. The Knowledge of Late-Life Depression Scale is one such scale. In this study we modified this measure in an attempt to improve its psychometric properties so that it can be used with confidence in research and practise. Our modifications to the original measure resulted in the Knowledge of Late-Life Depression Scale-Revised.

METHOD

Aged care staff (N=149) from 20 low level care facilities and community care facilities in Melbourne, Australia, completed the Knowledge of Late-Life Depression Scale-Revised.

RESULTS

Using Confirmatory Factor Analysis and reliability analysis, the Knowledge of Late-Life Depression Scale-Revised was found to demonstrate three robust and internally consistent factors. These factors were: symptoms of depression, facts about depression, and myths of depression. The revised measure was found to yield superior psychometric properties compared to the original measure.

LIMITATIONS

Replication studies are required, especially with other aged carer samples to ensure that the factor structure and internal consistency of the measure are supported across different aged care contexts in Australia and elsewhere.

CONCLUSIONS

The Knowledge of Late-Life Depression-Revised is a measure that can be used by researchers and agencies to assess the knowledge of depression among professional care staff. The measure is expected to be especially useful as an assessment tool for training and educational purposes.

An evaluation of a national program to implement the Cornell Scale for Depression in Dementia into routine practice in aged care facilities

BACKGROUND

Screening tools have been recommended for use in aged care to improve the detection and treatment of depression. This study aimed to evaluate the impact of a program for the routine implementation of the Cornell Scale for Depression in Dementia in Australian facilities, to determine whether use of the instrument by nurses led to further monitoring of depressive symptoms, medical referral, and changes in treatments prescribed for depression.

METHODS

A file review was completed for 412 participants out of a total of 867 older people (47.5%) who resided in ten aged care facilities. The review examined Cornell Scale assessment data, medication charts, medical history, nursing progress notes, and resident care plans. Nursing staff who administered the Cornell Scale to each participant were also interviewed, and ten facility managers took part in an interview to determine barriers to the effective implementation of the instrument.

RESULTS

The Cornell Scale had been administered to 46.8% of the sample in the previous 12 months, with 25% of these participants scoring 9-13 and 27% scoring 14 and above. Less than one third of the residents with high scores were monitored by the staff following the assessment. Only 18% of residents with high scores were referred for further assessment of depression, while 10% received a treatment change.

CONCLUSIONS

The absence of a protocol for responding to high Cornell Scale scores limited the potential of this program to result in widespread improved treatment of depressed older people. The use of the Cornell Scale by aged care nurses with limited training raised concern.

Depression training program for eye health and rehabilitation professionals

PURPOSE

Depression often remains undetected in people with vision impairment. This study aimed to determine the effectiveness of a depression training program on practitioners' confidence, perceived barriers, and their likelihood of responding to depression in patients with vision impairment.

METHODS

This study was a pre and post single group evaluation involving 36 eye health and rehabilitation practitioners. Three 1.5-h group training sessions were held once a week for 3 consecutive weeks. The modules covered (1) understanding depression, (2) detecting depressive symptoms, and (3) developing and implementing referral pathways. Three main outcome measures were assessed: confidence in working with patients who may be depressed; perceived barriers to the recognition and management of depression; and likelihood of responding to depression.

RESULTS

The training significantly improved practitioners' confidence and reduced perceived barriers to managing depression (p < 0.001). After training, participants were significantly more likely to respond to depression in their patients (p < 0.001).

CONCLUSIONS

This preliminary study found that a brief training program is effective in increasing practitioners' ability to respond to depression in patients with vision impairment. Further work is required to determine whether these effects are sustained over time and result in improved recognition and management of depression in people with vision impairment.

Managing depression in patients with vision impairment: a descriptive study of practitioners' beliefs and confidence

AIM

Depression is common in older adults with vision impairment yet it often remains unidentified and untreated. Eye health professionals (EHPs) and rehabilitation workers (RWs) may be able to assist in detecting depression. This study identified EHPs' and RWs' beliefs about depression and confidence in working with patients with vision impairment and depression.

METHODS

A self-administered cross-sectional survey of 94 EHPs and RWs assessed beliefs about the symptoms and treatment for depression, and confidence in working with depressed people with vision impairment.

RESULTS

Participants showed awareness of both the symptoms and treatment options for depression. However, some important misconceptions were identified and many symptoms of depression were commonly attributed to vision loss. Participants lacked confidence in communicating about depression with patients and their families.

CONCLUSIONS

Training programs are needed to enable EHPs and RWs to confidently identify depression and discuss appropriate treatment and referral options with their patients.

An evaluation of the beyondblue Depression Training Program for aged care workers

BACKGROUND

The prevalence of depression among older people receiving care is high, yet the rate of treatment of this disorder is low. One way to improve the pathway to care is to train care staff to recognize the symptoms of depression and raise their confidence in responding to them. In this study we evaluated the efficacy of the beyondblue Depression Training Program to achieve this aim.

METHODS

Staff (N = 148) from low level care facilities and community care facilities in metropolitan Melbourne completed the beyondblue Depression Training Program, while staff in other facilities (N = 96) acted as controls. Pre-program, post-program and follow-up questionnaire data were collected and referrals for depression by staff were recorded.

RESULTS

Training improved carers' knowledge about depression, their self-efficacy in responding to signs of depression and their attitudes towards working with depressed aged care recipients. In addition, training increased the number of referrals for depression made by carers.

CONCLUSION

Training aged care staff in depression can improve the pathways to care for depressed care recipients, and has the potential to improve the quality of life of older people.

Ability of nurses to identify depression in primary care, secondary care and nursing homes--a meta-analysis of routine clinical accuracy

PURPOSE

To clarify the ability of nurses and nursing assistants working in primary care, secondary care and nursing homes to identify depressed individuals using their clinical skills using meta-analysis of published studies.

METHODS

Literature search, appraisal and meta-analysis. We located 22 studies reporting on the detection of depression, 4 involving primary care or community nurses; 7 involving hospital nurses and 11 from nursing homes.17 of 22 studies had specificity data.

RESULTS

Across all 22 studies involving 7061 individuals, and a prevalence of 28.1% (95% CI=22.6-33.9%), practice and community nurses correctly identified 26.3% (95% CI=16.2-37.8%) of people with depression. They also correctly identified 94.8% (95% CI=91.3-97.4%) of the non-depressed. Nurses working in hospital settings correctly identified 43.1% (95% CI=31.9-54.8%) of people with depression and 79.6% (95% CI=71.5-86.7%) of the non-depressed. Those working in nursing homes correctly identified 45.8% (95% CI=38.1-53.6%) of people with depression and 80.0% (95% CI=68.6-88.7%) of the non-depressed.

CONCLUSIONS

Nurses have considerable difficulty accurately identifying depression but are probably at least as accurate as medical staff.

Depression in nursing homes: prevalence, recognition, and treatment

OBJECTIVE

Depression is very common in people above 65 years living in long-term care. However, little is known about how well depression is recognized and how adequately it is treated. Therefore, the present study aimed at assessing accuracy of the unaided clinical diagnosis of the attending physicians, and the medical treatment situation in nursing home residents.

METHODS

A random sample of 97 residents of 10 nursing homes in Munich was examined with the Section A "Affective Syndrome" of the Structured Clinical Interview (SCID) for DSM-IV to detect depression. Information concerning clinical diagnosis and medication was obtained from the subjects' medical records.

RESULTS

14.4% suffered acutely from major depression, 14.4% suffered from minor depression, and 18.6% were diagnosed as depressive according to the physician and nursing records. In total, 27.8% received antidepressants. Merely 42.9% of the subjects with acute major depression were diagnosed by their attending physicians as depressive, and only half of them received an antidepressant; 17.5% received antidepressants without a diagnosis of depression in their physician and nursing records. In accordance with the guidelines, 73.3% of the antidepressants prescribed were SSRIs or newer antidepressants. Only 20.0% were tricyclic antidepressants.

CONCLUSIONS

Findings show that depression is relatively frequent in residents of nursing homes. Moreover, it is insufficiently recognized by physicians and is even more seldom adequately treated. Also, a significant proportion of residents receive antidepressants without a documented associated indication. Therefore, the recognition and guideline-based treatment of depression should be improved in this high-risk group.

Professional carers' knowledge and response to depression among their aged-care clients: the care recipients' perspective

Depression is an under-diagnosed disorder among the elderly, even in those who are in receipt of aged-care services. One factor associated with this under diagnosis has been identified as a reluctance amongst the elderly to discuss their mood and emotions with their medical practitioners. The current study focused on why depression is not recognised and acted on by those providing residential or home-based care to older people. We interviewed 15 elderly people residing in high-level or low-level aged-care facilities, and three elderly people who were receiving personal care in their homes. All participants had been identified by their care agencies as depressed. Participants reported their perceptions of their personal carers' knowledge and practices in managing the residents' depression. Although the participants described their carers in positive terms, they were critical of their knowledge and skills in recognising depression, and indicated that the communication between personal carers and care recipients about depressive symptomatology was seriously flawed. Training for personal carers in these areas, and efforts to change organisational culture are recommended.