Depression and Quality of Life in the Elderly in a Special Nursing Home

Abstract: Using a Japanese version of the Self-Rating Depression Scale by Zung (SDS) and the Quality of Life (QOL) rating scale designed by Iida et al. (QOL scale), we compared the QOL and depressive state of special nursing home residents and the elderly in the general community. The QOL scale has four categories: physical functioning, emotional adjustment, interpersonal relationships and attitudes toward life. High scores in either examination indicate a greater impairment. The SDS scores of the residents in the special nursing home were significantly lower than those of the elderly in the community, but the scores in 3 categories and the total score, except for those of physical functioning of the QOL, were significantly higher in the nursing home residents. In the nondepressed elderly rated by the SDS, the physical functioning score of the elderly in the community significantly exceeded that of the special nursing home residents. In the depressed elderly, all the scores including the total score were significantly higher than those in the special nursing home residents. Our results suggest that while the QOL of the depressed elderly in a special nursing home was poorer than that of the elderly in the community, their depression could be treated. However, the QOL cannot be improved by treatment alone.     

Nursing home suicides-a psychological autopsy study

OBJECTIVE: Older adults comprise a fifth of all suicides. Elders are the fastest growing part of the population, thus the number of persons needing nursing home care will increase dramatically in the near future. Little information has been available about suicides in nursing homes. The present study described all suicides among older adults in nursing homes in Finland during a 12-month period emphasizing the factors that have been found to be associated with suicide in the general elderly population. METHODS: Drawing on data from a psychological autopsy study of all suicides (n=1397) in Finland during one year, all suicides committed by patients in nursing homes were identified. Retrospective DSM-IV consensus diagnoses were assigned. RESULTS: Twelve elderly (aged 60 years or more) nursing home residents who died by suicide, 0.9% of all suicides, were identified. The primary finding of the present study was that nursing home residents who died by suicide had suffered from highly comorbid somatopsychiatric disorders. One or more diagnoses on Axis I were made for all who died by suicide in nursing home. Depressive syndrome was diagnosed in three-quarters of subjects. Only a third of these were identified to have suffered from depressive symptoms before their death. CONCLUSIONS: Early recognition and adequate treatment of both somatic diseases and mental disorders, particularly depression, as well as early recognition of suicide risk among nursing home residents, are needed in order to prevent suicide.     

Antiepileptic Drug Use in Nursing Home Residents: Effect of Age, Gender, and Comedication on Patterns of Use

Summary: Purpose: Examine antiepileptic drug (AED) use in nursing homes by age, gender, and use of comedication that can interact with AEDs.
Methods: Two point-prevalence evaluations of AED use from computerized medical records of nursing home residents throughout the United States (set 1, 43,757; set 2, 41,386) 65 years and older serviced by PHARMERICA.
Results: 10.5% of residents received an AED. Of the age group 65–84 years, 15% received an AED compared with 6.1% of those 85 years or older (p < 0.001). Gender differences were present; 13.4% of the male residents and 9.4% of the female residents were treated with an AED (p < 0.001). The most frequently prescribed AEDs were phenytoin, carbamazepine, clonazepam, or phenobarbital. The average number of routine medications taken by AED recipients was 5.6, greater than the average of 4.6 for other residents.
Conclusions: AEDs are extensively prescribed for elderly nursing home residents. Men and persons aged 65–85 years were more likely to receive AEDs than were women or those older than 85 years. AED recipients receive more routine medications than do other residents, including co-medications that alter hepatic metabolism and clinical response. The reasons for age and gender differences are unclear and require further study.     

The effect of integrated emotion-oriented care versus usual care on elderly persons with dementia in the nursing home and on nursing assistants: a randomized clinical trial

OBJECTIVES: To examine the effect of integrated emotion-oriented care on nursing home residents with dementia and nursing assistants. DESIGN: A multi-site randomized clinical trial with matched groups, and measurements at baseline and after seven months. SETTING: Sixteen psychogeriatric wards in fourteen nursing homes in the Netherlands. PARTICIPANTS: One hundred and forty-six elderly residents with the diagnosis dementia of the Alzheimer (DAT) type, mixed DAT and vascular dementia, and dementia syndrome (NAO) and 99 nursing assistants. INTERVENTIONS: Integrated emotion-oriented care and usual care. MESUREMENTS: Demented elderly: Behaviour and mood related to adaptation to the illness and the institutionalization. Nursing assistants: General health as measured by feelings of stress, stress reactions, feeling of competence and illness. RESULTS: Positive effects in favour of the integrated emotion-oriented care were found in mild to moderately demented residents on two adaptive tasks: maintaining an emotional balance (less anxiety) and preserving a positive self-image (less dissatisfaction). In the trained group of nursing assistants fewer stress reactions were found only in those who perceived improvement in their emotion-oriented care skills after training. CONCLUSION: Emotion-oriented care is more effective with regard to the emotional adaptation in nursing homes of persons with a mild to moderate dementia. For the severely demented elderly we did not find this surplus value. This outcome is of clinical importance for elderly persons with dementia who are cared for in nursing homes. With respect to the nursing assistants it is concluded that emotion-oriented care has a positive influence on stress reactions in some of them.     

Comparison of the prevalence and risk factors for depressive symptoms among elderly nursing home residents in Taiwan and Hong Kong

BACKGROUND: Depression in the elderly has become a serious health care issue worldwide. However, no studies have compared the prevalence and risk factors for depressive symptoms among institutionalized Chinese elders living in different regions. OBJECTIVES: To explore and compare the prevalence and risk factors for depressive symptoms among elderly residents of nursing homes in Taiwan and Hong Kong. METHODS: Random sampling was used to recruit participants from eight nursing homes in each region. A total of 150 elders from Taiwan and 214 elders from Hong Kong participated. RESULTS: The prevalence of depressive symptoms was significantly higher in participants from Hong Kong (65.4%) than in Taiwan (43.3%). Logistic regression analysis indicated that gender, satisfaction with living situation, perceived health condition, and perceived income adequacy significantly predicted depressive symptoms in elderly nursing home residents in Taiwan. Significant predictors of depressive symptoms in the Hong Kong sample were satisfaction with living situation, cognitive status, and functional status. CONCLUSIONS: It is important to consider risk factors specific to a target population when developing depression intervention programs.     

A randomized,placebo-controlled trial of paroxetine in nursing home residents with non-major depression

Depression is common across a broad spectrum of severity among nursing home residents. Previous research has demonstrated the effectiveness of antidepressants in nursing home residents with major depression, but it is not known whether antidepressants are helpful in residents with less severe forms of depression. We conducted a randomized double-blind placebo-controlled 8-week trial comparing paroxetine and placebo in very old nursing home residents with non-major depression. The main outcome measure was the primary nurse's Clinical Impression of Change (CGI-C). Additional outcome measures were improvement on the interview-derived Hamilton Depression Rating Scale (HDRS) and Cornell Scale for Depression (CS) scores. Twenty-four subjects with a mean age of 87.9 were enrolled and twenty subjects completed the trial. Placebo response was high, and when all subjects were considered, there were no differences in improvement between the paroxetine and placebo groups. Two subjects that received paroxetine developed delirium, and subjects that received paroxetine were more likely to experience a decrease in Mini Mental State Exam scores (P =.03). There were no differences in serum anticholinergic activity between groups. In a subgroup analysis of 15 subjects with higher baseline HDRS and CS scores, there was a trend toward greater improvement in the paroxetine group in an outcome measure that combined the CGI-C and interview-based measures (P =.06). Paroxetine is not clearly superior to placebo in this small study of very old nursing home residents with non-major depression, and there is a risk of adverse cognitive effects. Because of the high placebo response and the trend towards improvement in the more severely ill patients, it is possible that a larger study would have demonstrated a significant therapeutic effect for paroxetine as compared with placebo. The study also illustrates the discordance between patient and caregiver ratings, and the difficulties in studying very elderly patients with mood disorders.     

A short-term inpatient program for agitated demented nursing home residents

OBJECTIVE: This case series describes the various contributors of disruptive behavior in demented nursing home residents and outlines the necessary steps to identify and treat them. DESIGN: Evaluation of overall clinical improvement and agitation at discharge from the hospital and at follow-up. SETTING: Nursing home residents consecutively admitted to the geriatric psychiatry service of a psychiatric university hospital in the New York metropolitan area. PATIENTS: 15 elderly demented nursing home residents with agitation. MEASURES: Overall clinical improvement was assessed with the 'global assessment of functioning scale'. Agitation was evaluated with the 'brief agitation rating scale' and the 'nursing home scale for agitation'. Medication side-effects were measured with the 'Simpson-Angus scale' and the 'abnormal involuntary movement scale'. RESULTS: The patients showed significantly more overall clinical improvement at discharge compared with admission. Additionally, agitation scores were significantly lower at discharge and at follow-up compared with admission. CONCLUSION: A comprehensive medical and neurological assessment, an accurate identification of comorbid psychopathology, evaluation of drug toxicity, and a thorough history of psychotropic medication trials are essential steps for a successful treatment.     

Parkinson's disease and nursing home placement: the economic impact of the need for care

Background and Purpose:  To examine the relative risk (RR) for living in nursing homes for patients with Parkinson's disease (PD) compared with the general population and to ascertain society's costs related to nursing home placement for this patient group.
Methods:  We evaluated the frequency of admission to nursing homes in a cross-sectional study and during a 12-year follow-up study of 108 patients with PD and 864 controls who were matched for age and sex. The RR for living in a nursing home was calculated at baseline and during follow-up. On the basis of 2007 prices, we estimated the costs per person year of survival for patients with PD and controls.
Results:  The RR for living in a nursing home at baseline was 5.0 for patients with PD and 4.8 during follow-up. Patients with PD caused 4.8 times higher costs for nursing home placement with euro 18 875 versus euro 3978 per individual and year. The annual costs for institutional care of patients with PD in Norway were euro 132 million.
Conclusion:  Patients with PD have a substantially higher risk for living in nursing homes than the general population. This causes high costs to society. Therapeutic interventions to prevent or delay nursing home admissions are therefore important.     

Depressive symptoms in newly admitted nursing home residents

OBJECTIVES: To study the relationship between the prevalence of depressive symptoms in newly admitted nursing home residents and their previous place of residence. METHODS: In 65 nursing homes in the Netherlands trained physicians assessed 562 residents (mean age 78.5, range 28-101, 64.6% female) within 10 days after admission. Depressive symptoms were assessed with the Minimum Data Set (MDS) Depression Rating Scale (DRS), and the MDS items: 'diagnosis of major or minor depression', 'change in depression' and 'indicators of persistent depressed, sad or anxious mood disorder present'. Previous place of residence was categorized as 'own home', 'hospital' or 'sheltered living facility'. Adjustments were performed for demographic and health related factors measured with the MDS. RESULTS: The prevalence of depressive symptoms (DRS > or = 3) for all 562 residents was 26.9%; it was higher in residents admitted from their own home (34.3%) than in residents admitted from the hospital (19.7%) (p = 0.002). Residents who were admitted from the hospital have an adjusted Odds Ratio for having many depressive symptoms of 0.54 (95% CI 0.31-0.94) compared to residents admitted from their own home. There is, after adjustment, no statistical significant difference between residents admitted from their own home, or residents admitted from a sheltered living facility. CONCLUSIONS: Depressive symptoms are very prevalent in nursing homes. Residents who are admitted from their own home, or from a residential facility, have more depressive symptoms than residents admitted from the hospital. This may reflect different conceptualizations or different adjustment patterns for those groups. For a better understanding of the factors associated with nursing home depression, future studies in detection, prevention and management of depressive symptoms should start prior to or directly after admission, especially for those who have no prior institutional history.     

Prevalence and predictors of depressive symptoms in a nursing home

The aim of the study was to identify the prevalence of depressive symptoms (GDS score) and predictors of mood changes over a 12-month period in 56 nursing home residents (13 males and 43 females; mean age 81.1 ± 8.6). At baseline, 48.2% of the residents who scores above 11 on the MMSE had a GDS score > 15. GDS score was associated with pain, disabling diseases and self-evaluation of health, and independently with dissatisfaction with the nursing home environment, low level of nursing home social activities and younger age. Five depressed residents became non-depressed, eight non-depressed became depressed and 14 residents remained persistently depressed 12 months after baseline. After controlling for potential confounders, increasing GDS score was independently associated with decreasing basic activities of daily living, increasing number of clinical problems and younger age. Our data support the hypothesis that specific emotional adjustments can be found even in the apparently static environment of the nursing home.     

Combating Heightened Social Isolation of Nursing Home Elders: The Telephone Outreach in the COVID-19 Outbreak Program

ObjectiveSocial isolation and loneliness—common concerns in older adults—are exacerbated by the COVID-19 pandemic. To address social isolation in nursing home residents, the Yale School of Medicine Geriatrics Student Interest Group initiated a Telephone Outreach in the COVID-19 Outbreak (TOCO) Program that implements weekly phone calls with student volunteers.MethodsLocal nursing homes were contacted; recreation directors identified appropriate and interested elderly residents. Student volunteers were paired with elderly residents and provided phone call instructions.ResultsThree nursing homes opted to participate in the program. Thirty elderly residents were paired with student volunteers. Initial reports from recreation directors and student volunteers were positive: elderly residents look forward to weekly phone calls and express gratitude for social connectedness.ConclusionsThe TOCO program achieved initial success and promotes the social wellbeing of nursing home residents. We hope to continue this program beyond the COVID-19 pandemic in order to address this persistent need in a notably vulnerable patient population.     

Family members'perception of the quality of nursing home care

This study investigated the extent to which factors not directly related to the caregiving situation predicted family members' perceptions of the quality of nursing home care their elderly relative received. A conceptual model based on consumer satisfaction theory was used to test the extent to which factors associated with family members' expectations for care and their emotional response to the nursing home placement predicted perceptions of quality among 452 relatives representing the residents of two skilled care facilities. The entire model accounted for 27% of the variation in quality assessments. Attitudes towards nursing homes in general, length of resident stay and emotional responses to the placement (concern about the race/ethnicity of caregivers, caregiver burden and caregiver emotional distress) were found to be significant predictors of perceptions of quality.     

‘Negative symptoms’, health,depression, and level of functioning among nursing home residents

A six-month longitudinal design was used to assess the relations among functinal ability, medically disabling conditions, cognitive function, depression, and negative psychiatric symptoms in a nursing home sample. Seventy intermediate and skilled care residents were interviewed, with 51 completing the six-month follow-up. Negative symptoms were found to be related approximately equally to physical disability, boredom, and depression, but were not strongly predicted by any study variables. The most stable relationship observed was that between negative symptoms and functioning in the realm of activities of daily living (ADL). Negative symptoms predicted change in ADL functioning across the six-month period of the study. The findings have possible implications for predicting mortality and focusing interventions on what appears to be a general decline syndrome in nursing home elderly.     

Geriatric care on a ward without nurses

The Multiphasic Environmental Assessment Procedure (MEAP; Moos and Lemke, 1984) was used to assess three long-stay settings within a geriatric hospital, one of which is a non-nursing unit committed to the philosophy of residents viewing the setting as their own home. Findings suggest positive outcomes for residents on the nonnursing unit, and support the view that types of care fostering independence and personal responsibility of elderly residents in their setting may be associated with increased mental functioning and activity. The lack of trained nursing staff had no detrimental effect on any measure of resident life, and some specific caring practices on the unit may be interpreted as having a positive outcome for residents.     

Factors contributing to nursing home admission because of disruptive behaviour

The key relative of 417 nursing home residents was interviewed to determine reasons for admission and patient behaviour before admission using the Psychogeriatric Dependency Rating Scale (PGDRS). Families stated that 25% of new nursing home admissions were due to disruptive behaviour but there were nearly always other reasons for admission as well. A receiver operating characteristic curve and cluster analysis showed that a greater amount of generalized behaviour problems predicted admission in the 74% of new residents. Admission because of disruptive behaviour was associated with greater cognitive impairment, possible Alzheimer’s disease, delusions or hallucinations, a psychiatric diagnosis, admission from home, requiring help from others before admission and a permanent move to a nursing home. Both psychiatric and social factors are important determinants of nursing home admission for disruptive behaviour.     

Psychosis, depression and behavioural disturbances in Sydney nursing home residents: prevalence and predictors

BACKGROUND: There is wide variation in the rates of behavioural and psychological symptoms of dementia (BPSD) reported in nursing homes. AIMS: This study aimed to investigate: (1) the prevalence of BPSD in nursing home residents using the BEHAVE-AD; (2) the relationships of BPSD with (a) demographic, (b) dementia, (c) diurnal and (d) nursing home variables; and (3) the inter-relationships between different types of BPSD, as measured by subscales of the BEHAVE-AD. RESULTS: Over 90% of residents exhibited at least one behavioural disturbance. Specifically, there was evidence of psychosis in 60%, depressed mood in 42% and activity disturbances or aggression in 82% of residents. Younger, more functionally impaired residents with a chart diagnosis of psychosis had higher BPSD rates, as did those residing in larger nursing homes. Individual BPSD were significantly intercorrelated. CONCLUSIONS: BPSD are ubiquitous in nursing home residents. Behavioural disturbances are frequently associated with psychosis and/or depression. The findings suggest the need for psychogeriatric services to nursing homes and smaller facilities.     

Assessment of Competency to Contract for Care Insurance in Aichi Prefecture

Background : A nursing care insurance system went into effect in April 2000 in Japan. Under the new system, the user (person requiring care) enters a contract directly with the service provider. Hence a pertinent issue is whether or not the user has the decision-making capacity to enter a contract (competency to contract) and the degree of that capacity. The aim of the present study was to gain an understanding of the competency to contract under the new system.
Methods : The subjects were elderly residents who entered a care insurance facility after April 2000. Ten institutions from among the care insurance facilities in Aichi Prefecture cooperated in this study. The study was sufficiently explained to the elderly residents and their families, and written informed consent was obtained from both. Respective municipalities were requested to allow access to the results of the nursing care certification process of the subjects, with their consent and the consent of their families. In addition, the care manager of the facility gave the residents a Mini-Test that we had prepared to determine competency to contract.
Results : The results revealed that most subjects had little understanding of the care system, and surprisingly, that they were not in the care insurance facility of their own volition. The competency to contract in the dementia group was significantly lower than in the non-dementia group.
Conclusion : It may be unreasonable to believe that all such people are competent to enter a contract, especially those with dementia. However, the results suggest that people with a mild care grade, even if they have dementia, may have such competency. Further study including psychiatric assessment and diagnosis of the capacity to contract is necessary.     

Blunted affect,blunted lives? negative symptoms,ADL functioning,and mental health among older adults

With the growing numbers of elderly chronically mentally ill individuals, there is increasing need for evaluation of assessment procedures relevant to this population. The assessment of negative symptoms among older patients may be especially problematic if expression of affect, poverty of speech, and social withdrawal are affected by normal ageing processes. The present study was intended to establish normative levels of negative symptoms for older adults. A sample of 127 elderly community residents was compared to smaller samples of elderly schizophrenics, nursing home residents without psychiatric disorder, and young schizophrenics, using the Scale for the Assessment of Negative Symptoms. The results support the validity of this scale for elderly individuals. Negative symptoms appeared rarely among community-residing elders without psychiatric histories, so that a low cutting score on the scale identifies symptoms for this age group. For all groups negative symptoms were significantly related to competence in activities of daily living and ratings of mental health. Findings support the importance of assessing negative symptoms among the elderly chronically mentally ill. Further research is recommended to explore the relationship between asymptomatic levels of negative symptoms and functioning among non-psychiatric elders.     

Temporal patterns of agitated nursing home residents.

Twenty-four highly agitated, cognitively impaired nursing home residents were studied in depth to determine whether they manifested temporal patterns of agitation. Results demonstrated that agitated behaviors were significantly associated with temporal factors. For instance, residents made more requests for attention during lunch than other time periods, and residents screamed most often during the night. Some agitated behaviors (e.g., aggression) were manifested more frequently in the evening than in the day, consistent with the notion of sundowning in the nursing home. Implications of temporal patterns of agitation for caregivers of severely cognitively impaired and agitated nursing home residents are discussed.     

Parkinsonism in a nursing home: underrecognition

Parkinsonism is a very common condition in the elderly, particularly the elderly demented. The authors' experience in both the in-and outpatient settings suggested that parkinsonism was generally underdiagnosed in the elderly. They evaluated the residents at a local nursing home to assess for parkinsonian signs. They then compared the findings to those noted in the charts. Blinded assessment of all nursing home residents for signs of parkinsonism was performed. A standardized evaluation instrument was used, followed by a chart review to determine if patients were taking medications that might induce the parkinsonism and whether the parkinsonism had been recognized. The authors looked separately at those patients receiving antipsychotics because of their increased risk. Twenty-seven out of 100 residents had "probable" parkinsonism, 12 of whom were severe, and 33 had "possible" parkinsonism. Of 27 residents on antipsychotics, 23 showed parkinsonian features versus 43 of 73 not on such drugs (P<.02). Only 1 patient with drug-induced parkinsonism and 3 residents with previously diagnosed Parkinson's disease had chart notes indicating that parkinsonism had been recognized.