20180430220215picot_articledepression_in_older_adults_in_nursing_homes__a_review_of_the_lite
PICOT FORMAT POWER-POINT PRESENTATION. YOU NEED TO SIMULATE A RESEARCH STUDY CONDUCTED ON HOW TO IMPROVE DEPRESSION ON ELDERLY PATIENT IN NURSING HOMES WITHIN 6-8 WEEKS TIME FRAME. USING THE MONTGOMERY ASBERG DEPRESSION SCALE TO COMPARE THE CONTROL AND THE DEPENDENT VARIABLE, DEVELOP THE OUTCOME AFTER IMPLEMENTING ACTIVITIES SUCH GAMES (BINGO, SCRABBLE AND OTHER), MUSIC, EXERCISE ETC.
PLEASE, COME UP WITH A TABLE CONTAINING DATA TO SUPPORT MONTGOMERY ASBERG DEPRESSION SCALE.
INCLUDE PICTURES TO SUPPORT THIS IDEA (GRAPH) ETC
Portland
State University
University Honors Theses University Honors College
2016
Depression in Older Adults in Nursing Homes: A Review of the
Literature
Isabella McCarthy-Zelaya
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Depression in Older Adults in Nursing Homes: A Review of the Literature
by
Isabella McCarthy-Zelaya
An undergraduate honors thesis submitted in partial fulfillment of the
requirements for the degree of
Bachelor of Science
in
University Honors
and
Psychology
Thesis Adviser
Dr. Diana White
Portland State University
2016
Abstract
The rates of depression are high in nursing homes and often is not treated. A systematic
literature review was conducted searching for research studies on depression interventions in
nursing homes. Nineteen studies met selection criteria, which included being published in a peer-
reviewed journal, being set in a nursing home and utilizing an experimental design. The sample
sizes of the studies ranged from 21 participants to as many as 595; the lengths of the studies
varied as well from 4 weeks to 24 weeks, with six studies also including follow-ups up to one
year post-intervention. Studies showed that interventions involving reminiscing on meaning of
life, music and dance therapy, increasing pleasant events in the nursing home, and demonstrating
goal-oriented problem-solving strategies significantly improved depressive symptoms in older
adults in nursing homes. In many cases, depressive symptoms improved even in control groups
due to increased social contact from researchers; depressive symptoms decreased significantly
when social contact was highly individualized. Interventions involving cognitive stimulation
therapy, exercise
therapy
and interventions involving reminiscence on personal life did not
improve depressive symptoms. Depressive symptoms were measured using a version of the
Geriatric Depression Scale in most of the studies. The remaining studies used the Cornell Scale
for Depression in Dementia, the Hamilton Rating Scale for Depression, or the Montgomery-
Asberg Depression Rating Scale. Review findings suggest that multiple interventions can be
used successfully to more adequately care for depressed older adults. Discussion will include
integrating pieces of these effective interventions into nursing home.
Introduction
Over one million Americans currently reside in nursing homes (U.S Census Bureau,
2010). This number can only be expected to increase as the older adult population—people aged
65 years and older—is projected to increase over the next 20-40 years. Advancements in
healthcare are keeping people alive longer, and the large baby boomer population is now
reaching old age, increasing the proportion of older adults even more (Jeste DV, Alexopoulos GS,
Bartels SJ, & et al., 1999).
The lifestyle of older adults differs from adults in younger stages of life. For example,
older adults are more likely to experience more loneliness (Luhman & Hawkley, 2016),
experience a harmful fall and have a fear of falling (Howland et al., 1998). Older adults are also
less expectant of finding purpose in life as they age, thus they will even stop seeking out new
sources of purpose. Lacking a sense of purpose is correlated with feelings of hopelessness and
symptoms of depression. Having a sense of purpose can be as simple as having goals and sense
of direction in life, and feeling needed and paid attention to by others (Pinquart, 2002).
Major depression affects an estimated 1 to 4% of the older adult population (Alexopoulos,
2005); however, major depression affects older adults living in nursing homes disproportionately.
An estimated 20.3% of older adults in nursing homes are affected by major depression. The rate
is likely even higher when subsyndromal depression is factored in. Subsyndromal depression is
when depression symptoms are present, yet the symptoms are not severe or numerous enough to
be considered major or even minor depression. Even though the rate is so high, depression is still
incredibly under-recognized in nursing homes leaving many older adults untreated. For older
adults in nursing homes, depression is not a normal part of life and is very treatable. The
treatment of depression is a serious topic, as it does not only mean personal suffering but can
also contribute to the promotion of disability, a worsened outcome of diseases, and decreased
cognitive and social functioning, which are all associated with increased mortality (Jones,
Marcantonio & Rabinowitz, 2003).
Many theories on combating depression without the use of medication exist. Jongenelis et
al. suggests receiving “instruction on body-mind relations, relaxation techniques, cognitive
restructuring, problem solving, communication, and behavioral management of insomnia,
nutrition, and exercise” can reduce symptoms of depression.
One theory of combating depression in older adults is the behavioral activity therapy
(Meeks and Depp, 2002). This therapy could reduce depression symptoms through the
implementation of pleasant events in the nursing home. This looks like assessing events that are
found to be pleasant to older adults and then implementing these activities. This is based on the
theory that positive reinforcement for older adults in nursing homes does not exist. Because their
environments have been so disrupted in transitioning to nursing home life, depression symptoms
occur. As such, integrating events that these older adults rate as pleasant events could be an
effective way of lowering depression symptoms.
Reminiscence therapies are another common intervention for depression in older adults.
The theory of integrative reminiscence therapy is based in the hypothesis that negative thoughts
about the self, the world and the future that are not true are contributing to depression; and so, by
older adults directly dealing with these negative thoughts, incorrect causal attributions can be
disconfirmed (Walt & Cappliez, 2000). Instrumental reminiscence therapy is grounded in a
somewhat different theory: the assumption that depression symptoms arise from an inability to
cope with stressors in the environment, and suggests that by calling upon memories of past
coping strategies, these strategies can subsequently be used to better deal with stressors in the
current environment.
It is also theorized that music therapy is helpful in reducing depression symptoms by
using goal-directed and evidence-based practices (Hanser & Thompson, 1994). Music therapies
fall into two groups, active and receptive therapy. Receptive music therapy uses the
psychological, emotional and physiological effects of music to treat illness. Active music therapy
uses learning how to play instruments (Guètin et al, 2009). Exercise interventions are also
thought to reduce depression symptoms. Exercise activity is correlated with improved moods and
cognitive function (Blumenthal et al., 1999), along with inactivity being correlated with
depression and anxiety symptoms (Ströhle, 2008).
Cognitive stimulation therapy (CST) is commonly used as preventative measure against
dementia in older adults. Apostolo et al., (2014) theorize that the skills learned in CST that
promote the capacity for self-care will also aid in combating depression symptoms by the
subsequent increase in an older adult’s ability for self-care. Pet therapy has historically played a
positive role in physical and psychological rehabilitation (Moretti et al., 2010). Depression in
older adults has been shown to be very affective in nature, thus it is theorized that pet therapy
can be helpful in reducing depression symptoms in older adults.
The aim of the following literature review is to further investigate interventions for
depression in older adults in nursing homes, in search of patterns that may arise. The
interventions will be investigated via studies that were experimentally designed.
Methods
Search Strategy
To find relevant articles, the keywords and phrases used for search were ‘depression
treatment’, ‘aging’ and ‘nursing home’. These key words and phrases were searched in various
databases and journals; these included Google Scholar, PsychInfo, AgeLine, MedLine, The
Journal of Gerontology, The Gerontologist and Aging and Mental Health. Additional sources
were discovered through viewing bibliographies of studies already found.
Criteria for Inclusion and Exclusion
To be included, an intervention had to take place in a nursing home and use experimental
or quasi-experimental methodologies. The study also required to be published in peer-reviewed
journal articles. Dissertations, books, and papers that could not be accessed through the Portland
State University Library were all excluded from the review.
Data Compilation
An evidence table was constructed to facilitate comparisons across the studies. Elements
of interest included the type and description of the intervention, how the study was designed,
sample size, study length, if there was a follow-up measurement, the outcomes of the study and
what measures and statistical analyses were used.
Data
The literature search resulted in eighteen studies of depression interventions in nursing
homes. The sample sizes of the studies ranged in size from 21 participants to as many as 793.
The studies also varied greatly in length of interventions; some interventions were studied for as
little four weeks, while others were as extensive 12-17 months. Six studies also had follow-up
check-ins six months post-test.
All the interventions in the articles were studied using an experimental design, and all
used statistical analyses of the changes in measure scores to assess the efficacy of the
interventions. Ten of the eighteen studies used T-Test for statistical significance, one studied
used Pearson’s r, and the remaining studies used ANOVA or ANCOVA.
Study Design Intervention Type Sample
Size
Study
Length
Follow Up Intervention Description Outcome
Measures of
Depression
Experimental Control Statistical
Analysis
1 Meeks et al.
(2008)
Randomized
Control Trial
Behavioral Activity
Intervention
(psychosocial)
82 10 weeks Yes; 3-
month and
6-month
Weekly meetings with MHT,
and staff intervention
(activities department), and
increase in pleasant events
More likely to be remitted at
end of trial (45.2% vs 15.0%).
at 3-month more likely to be
improved/remitted. Effects no
longer seen at 6-month.
Often improved but not
remitted
MMSE, GDS,
SCID-IV
T-test, Chi
Square
2 Teri et al.
(1997)
Randomized
Control Trial
Behavioral Activity
Intervention
88 9 weeks Yes; 6-
month
Two treatments: patient
pleasant events and caregiver
problem solving along with
behavior therapy
Significant improvement in
depression scores in both
treatment groups. Most
improvement in PS group
Some members of the control
groups saw improvement in
depression scores
HDRS, CSDD MANOVA
3Gellis et al.
(2014)
Randomized
Control Trial
Telehealth
Education and
Activation of
Mood (I-TEAM)
102 8 weeks Yes. 3, 6, &
12-month
Telehealth nurse providing
problem solving treatment for
depression.
I-TEAM mean HAM-D, PHQ-9
scores fell by half at 3-months
Slight decrease in scores at 3-
month, slight increase in
following 3-month
HAM-D, PHQ-
9,
T-test
4Szczepanska,
Kowalska,
Pawik, &
Rymaszewska
(2014)
Randomized
Control Trial
Group
Psychotherapy
28 4 weeks
No goal-focused group
psychotherapy was used;
building social connections,
focus on things in life that can
be changed, focus directed
onto the future
All members of treatment
group no longer had severe
depression symptoms
Some reduction in depression
symptoms
GDS-15 T-test
5Hyer et al.
(2008)
Stepped-
wedge,
Randomized
Control Trial
Cognitive
Behavioral
Therapy
25 15 weeks No. Group, individual and staff
therapy (GIST). 15 sessions.
Group sessions are focused on
goal-setting and attainment
with social support
Depression scores reduced by
more than 50%
Depression scores increased GDS-S T-test
6 Underwood
et al. (2013)
Cluster
Randomized
Control Trial
Exercise Therapy 595 12 months No twice-weekly physiotherapist-
led 45 min exercise sessions
No significant changes in GDS
scores
No significant changes in GDS
scores
GDS-15 T-test
7Vankova et
al.
(2014)
Randomized
Control Trial
Dance Therapy 162 3 months No. Exercise dance for seniors for
60min/week
Significant improvement in
depression scores
Non-significant worsening of
depression scores
GDS T-test
8Williams and
Tappen.
(2008)
Random, 3-
group,
repeated
measure
design
Exercise Therapy 45 16 weeks program of three groups:
exercise, supervised walking,
social conversation
More improvements in exercise
patients than control patients
Social conversation group
improved slightly
CSDD T-test
9Chueh and
Chang (2014)
Quasi-
Experimental
Reminiscence
Therapy
22 2-weekly
sessions
for 4
weeks
Yes; 3 & 6-
month
Group reminiscence therapy. Mean GDS score decreased by
7 points post-test. Increased by
~2 points every 3-months post-
test
Mean GDS score increased over
6-month period
Taiwan GDS T-test
10 Melendez
et al. (2013)
3 group, pre-
post test
experimental
design
Reminiscence
Therapy
34 6 weeks Yes. 3-
month
ve reattribution therapy
All groups showed
improvement, integrative
treatment group showing most
improvement.
Control group showed some
improvements
GDS-15 ANCOVA
11Karimi et al.
(2010)
Randomized,
pre-post test
design
Reminiscence 29 6 weeks No 3-groups: instrumental
reminiscence (discussion of
past experiences to solve
present problems), active
discussion (placebo) control
group
Integrative reminiscence
intervention provided
significant decrease in
depression scores
Integrative and placebo groups
did not have significant
changes in depression scores
GDS-15 ANCOVA
12 Stinson and
Kirk
(2006)
Two-group
comparison
of Treatment
vs. Activity
Group
Reminiscence
Therapy
24 6 weeks No Group reminiscence on
depression and self-
transcendence. Twice weekly
60-min sessions.
No significant changes in
depression scores
No significant changes in
depression scores
GDS Pearson’s r.
13 Tsai et al. Quasi- Self-worth 63 4 weeks Yes; 2- All participants met with a Statistically significant decrease Statistically significant decrease GDS T-test
Group reminiscence
therapy
(2008) experimental Therapy month research 1day/week. Only
experimental group received
self-worth therapy. Involved
teaching strategies for
managing depression and
dignity therapy
in depressive symptoms. More
than control group at 2 months
in depressive symptoms. Less
than experimental at 2 months
14Buettener
and
Fitzsimmons
(2002)
Randomized
Control Trial
One-to-one
bicycle/wheelchair
therapy
70 10 weeks No Small group therapy and
bicycle rides. (individualized
social contact)
Significant decrease in
depression scores (almost 50%)
Slight increase in depression
scores
GDS T-test
15McCurren et
al.
(1999)
Randomized
Control Trial
Trained gero-
psychiatric Nurse
+ trained
volunteer contact
85 24 weeks No. Twice weekly visits of
volunteers, and weekly visit
from nurse. Study of efficacy
of individualized social support
interventions.
Significant improvement.
“quality not frequency”
No change measured GDS, MMSE ANOVA,
ANCOVA
16 Werner,
Wosch and
Gold
(2015)
Randomized
Intervention
Trial
Group music
therapy vs. group
singing
117 12 weeks No. Groups were assigned to
either music therapy or group
singing
Music Therapy Group had a
significant decrease in
depression scores. (more
decrease in dementia patients)
Group Singing increased
depression scores significantly
MADRS T-test
17Apostolo,
Cardoso,
Rosa, Paul
(2014)
Randomized
Control Trial
Cognitive
Stimulation
Therapy
56 7 weeks No Intervention was 14 CST
sessions in groups of six to
eight older adults
No significant changes in
depression scores
No significant changes in
depression scores
GDS-15 ANOVA
18Moretti et
al.
(2011)
Pre-post
Control,
Experimental
Design
Pet Therapy 21 6 weeks No. 90-min, once a week of pet
interaction for intervention
group. Control group only
viewed the pets
Mean depression scores
decreased by half.
Some improvement. 2-poing
decrease in scores
MMSE, GDS T-test
Results
Interventions
The most common intervention applied in the nursing home trials was reminiscence
therapy; this was seen in five studies (Chueh & Chang, 2014; Mendelez et al., 2013; Karimi et al.,
2010; Stinson & Kirk, 2006; Tsai et al., 2008). Reminiscence therapies can vary in how they are
implemented. The reminiscence therapies seen in this review were instrumental and integrative
reminiscence therapies. Integrative reminiscence is a group intervention involving reflection on
the continuity and meaning of life along with disconfirmation of negative self-worth and
renewing sources of self-worth. Instrumental reminiscence therapy involves reflecting on past
experiences and using those experiences to solve current problems.
Following reminiscence therapy, the next most common intervention was exercise
therapy; this was seen in three studies (Underwood et al, 2013; Vankova et al. 2014; Williams &
Tappen, 2008). The exercise interventions varied and included dance, walking or organized
exercise therapy. Three studies utilized interventions that taught goal-oriented, problem-solving
strategies to depressed older adults (Gellis et al., 2014; Szczepanska, Kowalska, Pawik, &
Rymaszewska, 2014; Hyer et al., 2008). This group intervention encouraged social connections
between group members to provide support to each other while working through problems, while
providing techniques for problem solving that focused on future goals.
Two studies focused on increasing pleasant events in nursing homes; these pleasant
events were activities that were shown to be enjoyed by older adults (Meeks et al., 2008; Teri et
al., 1997). Two studies focused on the effects individualized social interactions with older adults,
either by spending one-on-one time with the older adult participating in an activity or in
conversation (Buettener & Fitzsimmons, 2002; McCurren et al., 1999).
The remaining studies focused on a type of intervention not reported in other studies. One
study employed cognitive stimulation therapy—a group intervention that aims to advance
cognitive and social functioning through number and word games (Apostolo, Cardoso, Rosa &
Paul, 2014). One study used a pet therapy intervention (Moretti et al., 2011), and one study used
a music therapy intervention (Werner, Wosch & Gold, 2015).
Measures
The Geriatric Depression Scale (GDS) is an extensively used instrument for assessing
depression symptoms in older adults. The long-form GDS is a 30-item measure consisting of
yes-or-no answer questions. The GDS-15 is a shorter version consisting of the most relevant
items for assessment of depression symptoms. This scale was used in 15 of the 19 studies; six of
these studies employed the short form, the remaining studies employed the long form (Yesevage
et al., 1982).
The Hamilton Rating Scale for Depression (HAM-D) is a questionnaire administered by a
healthcare professional to assess depression symptoms. The questionnaire contains 21 items with
answers on scale of either 0-2 or 0-4; 0 being the absence of a symptom, and 4 being a very
severe symptom. This measure was used in three studies (Yesevage et al., 1982).
The Cornell Scale for Depression in Dementia (CSDD) measures depression via two
interviews: one with the older adult, and the other with an informant who knows the older adult
well. The items in the interviews are rated on scale from 0-2. A score of above 10 indicates
probable major depression. This measure was used in two studies (Alexopoulos, 2005).
The Montgomery-Åsberg Depression Rating Scale (MADRS) is a questionnaire that rates
ten symptoms of depression on scale of 0-6. This measure is used upon the diagnosis of
depression to measure the severity of the symptoms and depression episodes, and was only used
in one study (Muller, 2003).
Outcomes of Interventions
Reminiscence therapy was shown to be effective in some cases. The instrumental
reminiscence interventions were not effective across three studies, according to GDS and CSDD
scores. Integrative studies, however, were effective across two studies according to GDS
scores.
Only one of the exercise therapy interventions, exercise dance therapy, produced significant
improvements as measured by GDS or CSDD. Three studies opted for teaching problem-solving
techniques. These interventions were successful in all three trials according to GDS and HAM-D
scores.
Two more studies tested interventions involving increasing pleasant events in the nursing
home, which decreased depression symptoms according to GDS and CSDD measures. Two
studies with highly individualized social interaction interventions showed significantly reduced
GDS scores. In one study, cognitive stimulation therapy was shown to be ineffective at reducing
depression symptoms, and in one other study, pet therapy was shown to be effective in reducing
depression symptoms according to GDS scores. The control groups of eight studies also
demonstrated some improvement in depression symptoms.
Group-style interventions that were successful were those that used the group for social
connections and support. One-on-one style interventions that were successful were those that
made the personal interactions highly individualized. Although many of the studies did not
include follow-up measures, those that did all demonstrated that within six months post-test, the
positive effects of the interventions were no longer seen.
Discussion
Themes in the literature
All of the interventions in the reviewed studies fell into one of two categories: group-
style and individualized-style interventions. Both of these intervention types were shown to have
positive effects on depression symptoms. In the successful interventions that used group-type
interventions, the groups were connected socially and used these social connections for support.
However, group effects alone were not enough to improve depression symptoms–the
interventions themselves were also necessary for the improvement. This is seen in the control
groups of these interventions; even though the group effects were present, it was not enough to
reduce depression symptoms significantly.
A similar trend is seen in the studies using one-on-one type interventions. The successful
interventions were those that made interactions highly individualized, and catered to fit the needs
of each individual older adult. This was seen in interventions such as music therapy and the
individualized social interaction
intervention.
Interventions with a focus on setting goals were effective. The use of goals is an effective
way to keep focus on the future. Teaching new skills allows for goal-setting and provides older
adults the opportunity to focus on the future. This can explain why Exercise Dance Therapy
(EXDASE) was an effective intervention where the other exercise interventions were not.
EXDASE taught the skill of dance to the older adults in addition to being an exercise
intervention.
Differences in the frequency of an intervention did not appear to be a factor in these
studies. Essentially, the interventions did not need to take place daily for effects on depression to
take place. With the exception of one study in which the intervention took place four times per
week, the successful interventions occurred no more than twice a week. However, continuity
appeared to play an important role. In the studies that did have a follow-up measurement, by six-
months post-test, the progress made from the interventions could no longer be seen. So, it is
important that interventions are lasting, not just temporary.
Implications for practice
Any of the interventions that were found to be effective could be potentially integrated
into a nursing home. The key implications are that effective interventions occurred once to twice
a week, and the more time that passed after the intervention, the less the positive effects are seen.
Therefore, when integrating an intervention, the intervention does not need to take place daily to
have a positive effect on depression symptoms. However, since the effects interventions have
been shown to lessen after the intervention period ends, the intervention being on-going is
important.
Implications for Research
Based on the themes that were identified in the literature review, some suggestions can be
made for further research: would an intervention that integrated the common themes identified in
successful the interventions be the most helpful in combating nursing home depression?
Pinquart (2002) suggested that a person’s sense of purpose in life lies in having goals and a
direction in life, as well as feeling wanted and needed by others. The common themes identified
by the effective interventions all supported one of these factors of a sense of purpose. The
interventions that were highly individualized—the intervention with volunteers that have
individual interactions with the older adults, and the intervention with the wheelchair-bicycle—
allowed the older adults to feel wanted by others. The interventions that encouraged group
interaction and social support, like the integrative reminiscence and problem-solving
interventions allowed the older adults to feel needed by others. The interventions that taught
skills or encouraged goal-setting, like EXDASE and goal-setting interventions, allowed the older
adults to have a direction in life. This would suggest that depression symptoms could be best
combated by an intervention that encourages providing older adults in nursing homes with a
sense of purpose.
An example of this could be giving older adults in nursing homes weekly group sewing
lessons and teaching them how to make hats or scarves that could then be given to homeless
people in need. Through the process of learning the skill, the participants would have goals they
are trying to reach which would aid in having a sense direction. The fact the products would be
used for people in need would aid in feeling needed by others. The group setting would be
encouraging for the older adults to have social interaction to help and support each other in
learning the skill.
Biases
Although the data has provided strong evidence for the efficacy of some of these
interventions, a bias in the literature exists that may be hindering the accuracy of the results. This
is due to the fact that often studies that do not have significant findings will not publish the data.
This could mean that there has been research done disproving the efficacy of the interventions
here that has not been published. Another source of missing information could be that the limited
resources of the Portland State University library limited the collection of data.
Conclusion
This literature review demonstrated that there are effective interventions for depression in
older adults in nursing homes, and that there are solutions to combating the issue of the high
rates of depression seen in nursing homes as long as the interventions are on-going after
implementation. Relationships were also drawn between the need for a sense of purpose in life
and depression that suggest that if older adults can find a sense of purpose in their lives,
depression could be reduced.
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Depression in Older Adults in Nursing Homes: A Review of the Literature
Isabella McCarthy-Zelaya
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