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Depression, including major and minor is one of the most prevalent mental illness among the elderly in nursing home around the world with up to 78% being affected(Brown and Luisi, 2002; Blazer, 2003; Achterberg et al., 2006; Mcdougall et al., 2006; Davison et al., 2007; Levin et al., 2007; Lin et al, 2007; Mc Sweeney and O’Connor, 2008), which can result in higher costs, functional problem, malnutrition, bad quality of life and death(AGS/AAGP, 2003; Blazer, 2003) It is no doubt that the care providers should be capable of recognizing and dealing with depressive symptoms. According to rate of depression in agreed care rather than in community, However, it is found that the rate of detection and appropriate intervention of depressed residents is low (Cohen et al., 2003; Gruber-Baldini et al., 2005). Therefore, proper actions should be taken to improve the undertreating situation to gain the better quality of life of the residents. According to Katz & Parmelee in 2001, depression is a reversible illness with timely interventions in residential care. Through this time, it will be covered what risk factors of depression of the elderly in residential care are, how nurses can recognize and take care of the depressed residents.
Residential care depression risk factors
The most easily recognized sign of depression of residents in residential care is their withdrawal and isolated behaviors from other residents and care staff. Then, what makes them into depressed state?
Being labeled by relatives as being depressed before admission can make a person in depression (Fleming, 2001, 2004). Most of all, sense of loss and grief is one of the most major factors to bring out anxiety and sadness to them. Firstly, fitting into new lifestyle after leaving their house and their belongings is a big challenge causing grief feeling. The socially isolated lifestyle can cause loneliness. Especially, it will give abandoned feeling when relatives and friends not visit them as frequently as they expect. Although there are activities for helping them, it can be other risk factors when attending but not taking part in (Fleming, 2001, 2004). Secondly, the residents confront loss of physical and functional control of their body everyday and are dependant partially and totally on others, while there is less autonomy in institutional care, lack of caring due to staff shortage. Thirdly, sudden loss of relationships with staff members due to staff turnover, loss of spouse, other families or friends is another big issue for them to become in depression. However, there are few studies about whether long-term residential care stay itself is one of risk factors for the high rate of depression (Payne et al., 2002; Boyle et al., 2004) or depression is the reason the elderly are admitted into the facilities (Webber e al., 2005; Fullerton et al., 2009).
Depression detection and intervention
Elderly depression is treatable with pharmacological (Alexopoulos et al., 2002; Katona and Livingstone, 2002) and psychological therapies (Lebowitz et al., 1997; Gatz and Fiske, 2003). Therefore, considering that nurses contact the clients more frequently and close than any other health care providers, their roles of detecting depressive symptoms of residents are very important (Lee, 2005). Then how can nurses recognize and help residents’ depression?
Active care to recognition and intervention
The U.S. Preventive Task Force advises that all elderly aged 65 and over should be assessed periodically for depression and “evidence-based nursing practice guidelines” require “nurse depression screening”. Therefore, firstly, nurses should try to recognize depression actively because normally depressed elderly people are not willing to seek help first. Unfortunately, despite the high occurrence of depression among nursing home residents, focused and effective interventions seems to be difficult (Bagley et al., 2000). However,it is studied the ability and initiative of detecting depression can be improved by staff education program on depression (Moxon et al., 2001; Eisses et al., 2005).
Need for training
Mentioning the need for nurses to be trained on depression to gain more awareness and concerns about it, education on depression medically, functionally and mentally should be a priority. Most nurses knew the problem of depression in the elderly but were not sure about whether they are capable of recognizing depressive symptoms (Ellen et al., 2009).
Providing emotional support
Nurses can be an advocate of them providing emotional support. Having a meaning relationship with residents provides a therapeutic relief (Audit Commission, 2000) and opportunities to detect any abnormal behaviors. However, shortage of staff and heavy workload can make nurses concentrate on basic nursing care rather than making intimate relationship (Lindeman et al., 2004).
Encouraging to take part in activities
Mild-to-moderate depression could be effectively treated behavioral and psychosocial such as, recreational therapy and exercise program (Snowden et al., 2003).
Providing health education and health promotion to clients
Considering that clients also take one of important roles in treating, increasing their knowledge and understanding about the disease is important as well as introducing some ways to improve the symptoms (Robert et al, 2001)
Through this essay, it is found that institutionalized older adults’ depressions are not properly recognized and treated due to lack of knowledge, understaffing, and lack of funding. Furthermore, it seems evident residential care facilities have some risk factors to trigger and deteriorate depression. Therefore, to obtain their quality of life, most of all, nurses should be sensitive to mental health to try to actively approach to this issue. In addition, nursing education program on depression should be prioritized.
End of life care
Approximately 18 million people worldwide have dementia, which is predicted to be double by 2025(WHO, 2009). In Australia, majority of elder people with dementia are admitted into residential aged care facilities to spend the rest of their lives. However, palliative care is not always available in the facility (Volicer et al.,2008). Therefore, through this essay, it will be first referred to what advanced dementia and palliative care are, then how currently advanced dementia is treated and how the palliative care is applied to the elderly with the severe dementia.
‘Advanced dementia’ is the end stage of progressive, irreversible illness severely deteriorating quality of life with loss of ambulation, incontinence, and inability of speech and almost total dependence of ADLs. In addition, ‘End stage’ dementia means the severe condition before death from comorbidities.
A palliative care is firstly helping to have an ‘open and positive’ attitude to death and dying, Secondly, reducing pain by regular pain assessment and management, thirdly considering the clients’ individual and specific ‘ cultural, social, psychological and spiritual’ needs, and lastly focusing on communicating skill with the clients and their family to achieve effective care. Recently, Australian Government suggested that a palliative care be introduced and practiced for residents with incurable illness.
Current problem with advanced dementia
It has been reported that a high per cent of people with advanced dementia are suffering more and more as they approach to death. Franks said “64% of people dying with dementia experience pain, 83% weakness, 59% appetite disturbance and 61% depression”. In addition, with poor quality of care in residential aged care [3-5], in the case of acute illness, demented residents are usually admitted again to hospitals to get aggressive interventions and inadequate care, which are causing burdensome to them with delirium, anxiety, constipation and pressure ulcers [6, 7]. Health professionals face due to difficulty of communication, which can be a big barrier in bring out better outcomes as well as assessment and management (Shuster, 2000). Additionally, lack of knowledge about a palliative care approach becomes a barrier as well as lack of funding, shortage of staff.
Special care issues for the person with advanced dementia
With difficulty of expressing what a client exactly wants and needs, nurses need to be trained and have enough knowledge in understanding and communicating with the clients for effective and efficient care.
Pain is not always a symptom along with advanced dementia, but the clients may have pain from comorbid chronic diseases. Therefore, a pain history should be collected from the person with dementia and their caregiver before admission. The clients may be unable to recognize pain due to cognitive impairment caused by the dementia, thus care givers should carefully look at non-verbal behaviors, like facial expression. When they show agitated behavior, it should be considered whether it is from any pain. There are a few pain assessment tools such as ‘The Assessment of Discomfort in Dementia’ protocol (Kovach, 2003), ‘The Abbey Pain Scale’ (Abbey et al, 2004), and ‘The Royal College of Physicians et al (2007) have published comprehensive guideline on the assessment of pain in older people with severe cognitive impairment, communication difficulties or language and cultural barriers. Analgesic can be used to alleviate pain starting with a simple drug, moving up to morphine, but this may cause confusion (National Council for Palliative Care and Alzheimer’s Society, 2006).
Eating and drinking
Approximately 70% people with advanced dementia suffer from dysphasia leading to nutrition problem (Feinberg et al, 1992). Declining in appetite loss of hunger feeling, dyspraxia are other factors of malnutrition (Hughes et al, 2007). Hand-feeding can help to take food and antidepressants or ‘appetite stimulants’ can be used when refusing to eat. Furthermore, swallowing problem can be helped changing texture and size of food (Treloar, 2007). In practice, artificial hydration and nutrition such as nasogastric tubes are commonly practiced. However, it is not evident whether artificial hydration and feeding is beneficial compared to hand-feeding (Meir et al, 2001). Artificial feeding may cause infections, pressure sores (Finucane et al, 1999). Despite little or no benefit, up to 44% people with dementia are fed until before death (Gillick, 2000).
Inability to recognize and report infectious symptoms, weak immune system to infections and loss of ability to move make people with dementia vulnerable to infection (Robinson et al, 2005). In addition, antibiotic use is limited by the recurrent nature of infections and on an individual basis (NICE, 2006).
Depression and psychosis
Depressive symptoms are prevalent (National Council for Palliative Care, 2006), and antidepressants are found effective in advanced dementia (Doody et al, 2001). Approximately, 40% of people with dementia show psychosis symptoms (National Council for Palliative Care and Alzheimer’s Society, 2006). Despite side effects, antipsychotics are the only effective treatment (Treloar, 2007).
Special needs for the person with advanced dementia
Spiritual needs do not just mean religious practice, but include all kinds of beliefs seeking meaning from suffering and death. Therefore, nurses should not ignore the spiritual need.
Psychological need is tremendous with advanced dementia with experiences of being transferred from one environment to another or being in institution for long term, which can be traumatizing and declining a person’s symptom.
Although there is increasing awareness about palliative
Care of advanced dementia, there are still a lot of limitations such as communication difficulty between practitioners and clients, deficit of knowledge about a palliative care about dementia, and lack of financial investment and staff. As being mentioned above, considering that treatment people with advanced dementia need special care and needs, consistent multidisciplinary team approach including nutritionist, psychologist should be established.
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