A cluster randomised trial of the program to enhance adjustment to residential living (PEARL): a novel psychological intervention to reduce depression in newly admitted aged care residents

Psychological interventions designed to reduce relocation stress for older people transitioning into permanent residential aged care: a systematic scoping review

OBJECTIVES

This study aimed to identify and evaluate psychological interventions or strategies designed to reduce relocation stress in older people making the permanent transition into residential aged care.

METHOD

A scoping review following the Joanna Briggs Institute methodology for scoping reviews and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) was conducted. An electronic search of nine databases and the search engine google scholar was completed in December 2022. Article screening and quality appraisal was undertaken independently by at least two reviewers.

RESULTS

Eight full-text articles were included for review, from which four psychological interventions were identified: 1) Resident peer support; 2) Life review; 3) Mental Health Service for Older Adults; 4) The Program to Enhance Adjustment to Residential Living. No interventions were implemented before transitioning into care; all were implemented within three months of resident relocation into an aged care facility.

CONCLUSION

The transition to residential aged care is an inherently distressing experience. The absence of interventions implemented during the pre- and mid-transition phases presents a gap in the literature and suggests an opportunity for early intervention. As population ageing continues to increase, there is a pressing need for the development and implementation of interventions aimed at reducing symptoms of depression and anxiety for older people undertaking this major life transition.

Adverse impacts in residential aged care facilities: The resident perspective

OBJECTIVES

Inclusion of consumer perspectives is a key component to person-centred health-care approaches. While current residential aged care systems focus on recording adverse events to meet the requirements of regulatory reporting, little is known about the views of residents. The aim of this research was to explore residents' responses on the types of incidents that have an adverse impact on them and how they are affected by these incidents.

METHODS

The study used a qualitative, inductive approach to derive themes from interviews with 20 permanent residents of aged care facilities in New South Wales and the Australian Capital Territory.

RESULTS

Four main themes surrounding adverse incidents emerged: (i) social relationships and the adverse impacts of lack of meaningful interactions, (ii) adjustment to life in the residential aged care facility and the loss of residents' former life and self-determination, (iii) the impact of COVID-19 lockdowns which meant that residents were not able to go out or interact with others and (iv) acceptance, resignation and resilience in coping with adverse incidents.

CONCLUSIONS

This research highlights the difference between health-care definition, used for incident management reporting and quality indicators, and the way residents respond when asked to describe an incident that has affected them. Resident responses discuss situations having an adverse effect on them in contrast to the way adverse events and incidents are reported and monitored. The findings suggest that within adverse event and incident management systems and resident governance systems, there is scope for incorporating periods of transitions and well-being measures that capture elements that matter to older people.

Factors associated with adaptation level in the older adult residential care facilities: a path analysis

Background

It has become very common for older adults to relocate to residential care facilities. Yet whether older adults adapt to life in a long-term care residential facility through perception, reflection, and conscious behavioral choices is a challenging social issue. Previous research has shown that adaptation is influenced by physical, mental, psychological, social systems, and other debris factors. However, existing knowledge is often based on unidirectional relationships between these factors and adaptation. Few studies have formally examined bivariate relationships between these factors, and the influence of adaptation between these factors internally remains unclear. Therefore, there is a need to examine the structural causality of adaptation in residential care facilities influenced by a combination of physical, emotional, social and psychological factors, life satisfaction, and social support.

Methods

The present cross-sectional study recruited older adults from three residential care facilities in Henan province, China, through convenience sampling. The Chinese Nursing Home Adjustment Scale (NHAS), Geriatric Depression Scale-15 (GDS-15) and Social Support Scale (SSRS), Satisfaction with Life Scale (SWLS), and Barthel Index were employed to measure the older adult' adjustment level, depression level, social support, satisfaction with life, and self-care ability of the BMC, respectively. The relationships between depression, social support, self-care, satisfaction with life, and adaptation were analyzed and a structural equation model was developed.

Results

A total of 210 participants completed the questionnaire. The model demonstrated an acceptable fit of the data. The results showed that the difference between life satisfaction and depression on the level of adaptation was 60 and 23%, respectively. Social support and life satisfaction had a positive direct effect on the level of adaptation, both showing a positive correlation with the level of adaptation. Depression, on the other hand, have a direct effect on the level of adaptation and showed a negative correlation with the level of adaptation. Self-care ability indirectly influenced adaptation mediated by social support.

Conclusion

Social support has a positive impact on both life satisfaction and depression, which in turn promotes adaptation. As a major source of social support, family members and nursing home staff in residential care facilities can enhance social support for older people through improved interaction, which can have a meaningful and positive impact on levels of adjustment. The model demonstrates the strengthening and weakening of social support, self-care, life satisfaction, and depression levels, which can help inform the development of relevant care health strategies for older people to promote levels of adjustment and improve quality of life.

Trajectory and Predictors of Mental Health Symptoms and Wellbeing in Newly Admitted Nursing Home Residents

OBJECTIVES

This study determined changes in multiple aspects of mental health and wellbeing in newly admitted nursing home residents, and identified risk and protective factors.

METHODS

Participants were 204 residents recently admitted to one of 42 nursing homes in Melbourne, Australia. A subgroup of 82 participants were followed up eight months post-admission. Depression, anxiety, stress, adjustment, and quality of life were assessed at baseline and follow-up. Predictive factors (demographics, health, transition factors, nursing home characteristics) were examined in multiple regression analyses.

RESULTS

Rates of depression and anxiety were high at both baseline and follow-up. Low self-rated health and medical comorbidity predicted poor wellbeing at baseline. Higher perceived control in the relocation to the nursing home and engagement in meaningful activities were associated with better post-admission outcomes. Baseline psychotropic medication use predicted lower anxiety at follow-up but did not impact depressive symptoms.

CONCLUSIONS

There were no significant changes in mental health and wellbeing from one to eight months post-admission. The negative effect of residing in a for-profit nursing home requires further investigation.

CLINICAL IMPLICATIONS

Individual activity scheduling and an opportunity to participate in relocation decision-making and planning may support resident wellbeing post-admission.

Program to Enhance Adjustment to Residential Living (PEARL): Effect on Adjustment, Anxiety, Quality of Life, and Stress

OBJECTIVES

The Program to Enhance Adjustment to Residential Living (PEARL) is a five session intervention primarily designed to address high rates of depression in newly admitted residents. This study reports the efficacy of PEARL on secondary outcomes of resident adjustment, symptoms of anxiety, quality of life, and stress.

METHODS

A cluster randomized controlled trial was conducted with 219 newly admitted nursing home residents (M age = 85.5 years) from 42 nursing homes. Outcomes were assessed at baseline, post-intervention, and at two and six month post-intervention follow-up, compared to a standard care condition.

RESULTS

There was a significant overall condition by time interaction for adjustment (p = .027) and quality of life (p = .015), but not for stress (p = .309). While the overall condition by time interaction was not significant for anxiety (p = .221), there was a significant interaction contrast six-month post-intervention, indicating a greater decrease in anxiety scores in the intervention group relative to control (p = .039).

CONCLUSIONS

This study demonstrates the broad effects of PEARL on the wellbeing of newly admitted residents.

CLINICAL IMPLICATIONS

PEARL is a brief intervention that may be feasible for routine use in nursing homes to facilitate adjustment and improve residents' quality of life.

The Course of Depressive Symptoms Over 36 Months in 696 Newly Admitted Nursing Home Residents

OBJECTIVES

To investigate the course of depressive symptoms in newly admitted nursing home (NH) residents and how resident characteristics were associated with the symptoms. To identify groups of residents following the same symptom trajectory.

DESIGN

An observational, multicenter, longitudinal study over 36 months with 7 biannual assessments.

SETTING AND PARTICIPANTS

Representing 47 Norwegian NHs, 696 residents were included at admission to a NH.

METHODS

Depressive symptoms were assessed with the Cornell Scale for Depression in Dementia (CSDD). We selected severity of dementia, functional impairment, physical health, pain, use of antidepressants, age, and sex as covariates. Time trend in CSDD score was assessed by a linear mixed model adjusting for covariates. Next, a growth mixture model was estimated to investigate whether there were groups of residents following distinct trajectories in CSDD scores. We estimated a nominal regression model to assess whether the covariates at admission were associated to group membership.

RESULTS

There was a nonlinear trend in CSDD score. More severe dementia, a lower level of functioning, poorer physical health, more pain, use of antidepressants, and younger age at admission were associated with higher CSDD scores. Growth mixture model identified 4 groups: (1) persistent mild symptoms (32.6%), (2) persistent moderate symptoms (50.8%), (3) increasing symptoms (5.1%), and (4) severe but decreasing symptoms (11.6%). A lower level of functioning, poorer physical health, more pain, use of antidepressants, and younger age at admission were associated with higher odds for belonging to the severe but decreasing symptoms group compared with the persistent mild symptoms group.

CONCLUSIONS AND IMPLICATIONS

Most NH residents were in trajectory groups with persistent mild or moderate depressive symptoms. Residents with more severe dementia, lower levels of functioning, poor physical health, severe pain, younger age at admittance, and who are using antidepressants should be monitored closely and systematically with respect to depression. Taking actions toward a more personalized treatment for depression in NHs is a priority and should be investigated in future studies.

General practitioners' perspectives on discontinuation of long-term antidepressants in nursing homes

Background

Long-term use of antidepressant drugs (AD), much longer than recommended by guidelines, in nursing homes (NH) is common. NH home residents may have a relatively higher risk of adverse events. Moreover, in an NH setting nursing staff and relatives are intensively involved in the decision-making process. In many countries, General Practitioners’ (GPs) provide care for residents in NHs. Little is known about GPs’ perspectives on discontinuation of long-term AD in NH residents.

Objectives

To explore GPs’ views of discontinuing long-term AD in NH residents.

Methods

An exploratory qualitative study, with semi-structured interviews, was conducted with a purposive sample of 20 Belgian GPs. Interviews, conducted over six months in 2019, were analysed by thematic analysis.

Results

Twenty interviews were conducted until data saturation. The first theme, ‘reluctance to rock the boat: not worth taking the risk’, describes that GPs perceive discontinuation as an unpredictable risk without clear benefits. GPs’ main concern was the risk of destabilising the fragile balance in an older patient. Second, ‘it takes at least three to tango’, captures the unspoken alliance between GPs, nursing staff and relatives and suggests that agreement of at least these three partners is required. The third, ‘Opening the door: triggers to discontinue’, points to severe health problems and dementia as strong facilitators for discontinuation.

Conclusion

Discontinuation of long-term AD in NHs is a complex process for GPs. More evidence and attention to the role nursing staff and relatives play are needed to better guide the discontinuation of AD in older NH patients.

Views of Greenery and Psychological Well-Being in Residential Aged Care Facilities: Longitudinal Associations

OBJECTIVES

This study examined associations of objectively measured views of greenery in residential aged care facilities (RACFs) with changes in multiple psychological well-being measures among residents who were newly admitted to RACFs.

METHODS

Data were collected from 52 residents (mean age: 84, 73% women) of 13 RACFs, located in Melbourne, Australia. The outcomes were changes in depression, stress, anxiety, and quality of life (QoL) between baseline and 8-week follow-up. The exposure measures were the amount and presence of greenery visible from participant's bedroom and common areas (lounge, dining). Greenery was categorized as being either within or beyond the RACF perimeter.

RESULTS

Regression analyses found that greenery visible from participant's bedroom was not associated with any outcomes. The amount of greenery visible from common areas within the RACF perimeter was adversely related to stress, unexpectedly: Each additional 1 m² of greenery was associated with a greater increase in stress (b = 0.05; 95% CI [0.07, 0.94]). However, greenery visible from common areas beyond the perimeter contributed favorably to stress and QoL. The presence of such greenery was associated with a lower increase in stress (b = -3.99; 95% CI [-7.75, -0.23]; reference: no greenery), and a 1 m² increment was associated with a greater increase in QoL (b = 0.07; 95% CI [0.02, 0.11]).

CONCLUSION

Views of greenery outside of the RACF from lounge and dining areas may be protective against residents' stress increase and improve their QoL. Locating residents in areas with such outdoor views may prevent their psychological condition from worsening.

Assessing Residents' Perceptions of Their Relocation to Long-Term Care: Psychometric Validation of the View of Relocation Scale

OBJECTIVES

Relocation to long-term care is a major challenge for older people. The View of Relocation Scale (VRS) was developed to address the need for a brief instrument to assess residents' perceptions of the relocation.

DESIGN

Secondary analysis of data collected in a cluster randomized trial. The psychometric properties of the VRS examined in this study included factorial structure (using exploratory factor analysis), unidimensionality (Rasch modeling), internal consistency reliability (Kuder-Richardson Formula 20, squared multiple correlations, and item-total correlations), and known groups validity (analysis of variance). The results were used to identify the psychometrically most robust items for inclusion into the final version of the instrument.

SETTING AND PARTICIPANTS

Participants were 202 long-term care residents in Melbourne, Australia (mean age = 85.52 years, standard deviation = 7.33), who had relocated to the facility a mean of 4.4 weeks previously. Residents with moderately severe and severe dementia were excluded.

MEASURES

The VRS was developed following a review of the literature describing residents' views of relocation and was designed for administration shortly after their relocation.

RESULTS

There was support for a 2-factor, 10-item solution, with separate subscales assessing Perceived Control (degree of control in the decision making and planning for the relocation) and Perceived Need (perceived need for the relocation to long-term care). Participants who were admitted directly from hospital reported higher perceived need but lower perceived control than those admitted to the facility from home.

CONCLUSION AND IMPLICATIONS

The VRS can be used to understand the impact of older people's perceptions of relocation to long-term care on their subsequent adjustment and well-being, and to identify those who may benefit from tailored support.

The effectiveness of the Program to Enhance Adjustment to Residential Living (PEARL) in reducing depression in newly admitted nursing home residents

BACKGROUND

Depression is common in nursing homes, particularly among newly admitted residents. This cluster randomised controlled trial evaluated the effectiveness of the Program to Enhance Adjustment to Residential Living (PEARL) in reducing depression in this group.

METHODS

Participants were 219 newly-admitted residents (mean of 4.4 weeks since admission) in 42 nursing homes in Melbourne, Australia, with a mean age of 85.5 years (SD = 7.3). Nursing homes were randomly allocated to the intervention or standard care condition. Level of depressive symptoms was evaluated at baseline (T1), one week post- intervention (T2), 2 months post-intervention (T3, primary end point), and 6 months post-intervention (T4). Changes in depressive symptoms in the intervention and control groups over time were compared using a multilevel model, with nursing homes modelled as random intercept.

RESULTS

In intention to treat analyses, depressive symptoms reduced from T1 to T3 to a greater degree in the intervention condition (M_change=2.56, SD_change=5.71) than in the control (M_change=0.63, SD_change=5.25), with a significant, small-medium treatment effect size (p=.035; Cohen's d=0.36). The reduction in depressive symptoms from T1 to T4 was not significant (p=.369; Cohen's d=0.32).

LIMITATIONS

The findings require replication, particularly comparing PEARL with an active control condition.

CONCLUSIONS

PEARL is a simple, brief program that was effective in reducing symptoms of depression in newly admitted nursing home residents.