Long-term care residents who have serious depression may hesitate to seek help because they attribute their feelings to age, changing life circumstances or health issues. Caregivers can play a vital role in identifying the illness and ensuring that residents’ mental healthcare needs are addressed. Depression, after all, is a treatable medical condition that should be not accepted as an inevitable part of aging.
Douglas Lefton, MD, a family physician in Fairlawn, Ohio, who visits two nursing homes as part of his regular schedule, says that nurses, nursing aides and other hands-on caregivers are an important first line of defense for recognizing and alerting him if a resident under his care has serious depression.
“Their insights are very helpful, because they are the ones who are with the [residents] all day,” he says. “They are like the surrogate family members.”
Older adults who do visit a physician may believe they need to put on a happy face, or they do not feel comfortable discussing their emotions with the physician, says Tamara Shoemaker, PhD, a licensed psychologist who has a private practice in Fredericksburg, Md. That reluctance makes staff members’ role in speaking up for residents even more important, adds Shoemaker, who also works with behavioral health services provider MedOptions as a clinician specializing in geriatric psychology.
Look for these signs
Anyone can have a bad day and exhibit depressive behaviors occasionally, Shoemaker says. Caregivers, however, she adds, should take notice when they see these traits in a resident every day for two weeks or more:
- A sad face or a flat tone to the voice;
- Lack of enjoyment in activities that previously brought happiness, such as reading the newspaper;
- Irritability or short-temperedness;
- An increase in physical complaints, such as nausea, insomnia or headaches. Also, unexplained weight loss (more than five pounds in a month) or a significant increase in sleep time; and
- Enhanced pessimism or negativity, such as saying he or she did not accomplish anything in life.
“A depressed person might exhibit behaviors that look a lot like anxiety, such as restlessness, hand-wringing or pulling their hair,” Shoemaker says. “Alternatively, you also can see a slowing of speech or movement. It almost could seem as if they are underwater.”
Some of these behaviors commonly emerge at times of transition, such as when a resident moves into a new facility, she adds. “I wouldn’t worry about it for a good four to six weeks as they adjust,” Shoemaker says. “But I would [worry] if it persists after that.”
Depression sometimes is mistaken for dementia, Lefton notes. “Someone asks you what day it is, and you don’t care what day it is, so you don’t answer,” he says.
Take these actions
Lefton says that although he appreciates when staff members alert him in person, some may not see him regularly, perhaps because of their schedules, so he appreciates them leaving him a note describing concerns they have about a resident’s mental health.
Shoemaker suggests that caregivers keep a log of when the new behavior started and how often it happens so they can present the physician with a complete picture. In the meantime, she says, caregivers can try to help residents fight depression “naturally,” for instance by encouraging them to enjoy time outdoors when the weather is nice—walking if they are able. “A lot of research shows that exercise can be equally effective to an anti-depressant in some patients,” she says.
A resident’s inclination may be to sit alone and withdraw, but try to nudge him or her out of the room, Shoemaker suggests. “Make a specific effort to invite them to things. Encourage them to ‘just try it,’ and tell them they can return to their room if they really want to after five minutes. Sometimes, it’s just getting over the hump of going.”
Lefton says that prescribing medications such as serotonin reuptake inhibitors can help, but he cautioned that dramatic turnarounds in mood do not always occur in older adults.
“It can be hard to reach some people. There is no pill that can change people who feel achy, lonely and in poor health, but it is something the doctor should consider,” he says. Sometimes, he adds, he will order a psychiatric evaluation on a resident if he or she has enough cognitive function to participate and is willing to do so.
Make a connection
Jeanne Segal, PhD, who with her husband, Robert, co-founded the non-profit self-help website Helpguide.org, says she believes one of the most important things caregivers can do for a depressed resident is give him or her strong nonverbal reassurances.
“People need eye contact. They need to feel safe. They need to be given a look that says, ‘I am here, and I care,’ ” she says. “Words mean less to people than the tone of voice in which they are said.”
Segal believes that depression in skilled nursing residents largely is driven by fear. Residents may feel isolated, alone and scared about their future.
“Make sure they see the compassion that you are sending to them,” she says. It takes effort to make a connection, Segal adds, “but it feels great to help [people] this way.”
Thoughts versus plans
If a resident tells you that he or she feels like killing themselves, Shoemaker recommends that you ask how he or she is thinking of doing it. If the resident describes a plan, then alert the medical staff immediately.
“Do not be afraid that, by asking, you will be pushing them into actually committing suicide. It is normal for people to have occasional thoughts, but most people never would do it,” she says. “Having a plan is not normal.”