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Managing Depression in the Skilled Nursing Home

Categorised as: General

Basic Principles Upcoming Changes

Is it Depression?

Skilled nursing home professionals should be aware of the symptoms of a common malady among residents-major depression. It is manifested as a depressed mood or loss of interest in previously enjoyed activities, plus any five or more of the following symptoms, lasting for at least two weeks:

  • Weight loss or gain
  • Insomnia or hypersomnia
  • Psychomotor retardation or agitation
  • Decreased energy
  • Guilt feelings
  • Inability to concentrate
  • Thoughts of suicide

When depression is present, these symptoms almost always produce social impairment that is not related to substance abuse or bereavement. The many complications inherent in assessing, managing, and preventing depression are further complicated when they occur in the skilled nursing home setting with its own set of physical, emotional, and environmental variables.

Skilled nursing home caregivers must be able to recognize depressive symptoms so they can make a referral to the psychologist or psychiatrist. The evaluating professional will then assess them and do a root-cause analysis and diagnosis, so that not only the symptom, but the cause can be treated.

Physical conditions such as hypothyroidism, cardiovascular disease, pulmonary pathology, anemia, and stroke can all cause depressive symptoms that, if not recognized, may lead to profound physical effects.

If a resident has had a heart attack, treatment of his/her post-recovery depression can be almost as important as treatment of the heart itself because of the inhibiting effect depression can have on the recovery process. However, skilled nursing home workers don’t pay the same attention to these very important risk factors of depression.

There are some common triggers for depression in long-term care which makes its population particularly vulnerable. They include chronic illnesses and losses. Consequently, residents with more severe cases should be monitored for depressive symptoms.

Sadness is a normal response to uncomfortable changes. However, referral for an evaluation must be made when the symptoms become serious, not transitional and go from normal mood variations to a chronic persistent state that lasts for months.

The skilled nursing home professional should be aware that medication side effects from many drugs such as long-acting benzodiazepines, steroids, non-steroidal anti-inflammatories, digitalis, cardiac antiarrhythmics, antihypertensive medications, seizure medications, beta blockers and antihistamines can mimic depressive symptoms.

Mental status is another possible trigger. A patient who is chronically confused should be evaluated to be sure that the confusion is not being misdiagnosed as dementia. This is common in Alzheimer’s or stroke-related dementia, hypertension, and with diabetes related depressive symptoms.

Apathy is common in individuals with dementia; however, it is a cognitive problem, not a mood dysfunction and is not equivalent to depression. Distinguishing apathy from depression has important treatment implications because these disorders respond to different interventions.

Differential Diagnosis

In older patients, the presentation of depression is often nonspecific–confusion, loss of appetite, anorexia, weight loss, or fatigue. There is apt to be a sense of loss. Some realize they’ve lost their independence and understand they’re near the end of life. These emotions factor into it.

In older adults, depression often doesn’t look like sadness, and so it is harder to identify than in younger people. This is especially so for people who have cognitive impairment.

Because these individuals often can’t articulate their feelings, one has to look at changes in their behavior, such as more agitation, wandering, hitting, biting, and acting-out. It’s a complex situation requiring that the skilled nursing home population receive skillful individualization in its assessments..

One of the Resident Assessment Protocol issues in the skilled nursing home is mood state. But physical functions, nutrition, and hydration are clinically linked to depression, so it should be considered as a possible cause of changes in such status as weight loss or activity level.

Apathy, certain medications, lethargy due to medical illnesses, adverse drug reactions, and self-destructive dementia-related behaviors can mimic depression. Therefore, before concluding that someone is depressed, it is important that skilled nursing home professionals rule out these other possible reasons for any non-specific symptoms.

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