Professional carers' knowledge and response to depression among their aged-care clients : the care recipients' perspective

Depression is an under-diagnosed disorder among the elderly, even in those who are in receipt of aged-care services. One factor associated with this under diagnosis has been identified as a reluctance amongst the elderly to discuss their mood and emotions with their medical practitioners. The current study focused on why depression is not recognised and acted on by those providing residential or home-based care to older people. We interviewed 15 elderly people residing in high-level or low-level aged-care facilities, and three elderly people who were receiving personal care in their homes. All participants had been identified by their care agencies as depressed. Participants reported their perceptions of their personal carers' knowledge and practices in managing the residents' depression. Although the participants described their carers in positive terms, they were critical of their knowledge and skills in recognising depression, and indicated that the communication between personal carers and care recipients about depressive symptomatology was seriously flawed. Training for personal carers in these areas, and efforts to change organisational culture are recommended.

Enhancing nutritional research within an aged care facility

Aim: The present study examined the barriers to the implementation of a nutritional intervention project and sought ways to enhance future projects.

Methods: The study, utilising a qualitative approach, included participants from key areas involved in the project and who were employed by either the university or regional aged care facility.

Results: Through analysis the themes 'successes', 'stumbling blocks' and 'solutions' emerged. Within these themes descriptive stories of what worked, what did not work and suggestions for future projects are depicted.

Conclusions: Communication was the connecting element of each theme, suggesting effective verbal and written communication that ensures ownership by all involved is essential for successful clinical research projects. Strategies to enhance this process have been included to assist future researchers.

Knowledge of late-life depression : an empirical investigation of aged care staff

Objectives: This study examined knowledge of late-life depression among staff working in residential and community aged care settings, as well as their previous training in caring for older people with depression.

Method: A sample of 320 aged care staff (mean age = 42 years) completed a survey questionnaire. Participants included direct care staff, registered nurses and Care Managers from nursing and residential homes and community aged care services.

Results: Less than half of the participating aged care staff had received any training in depression, with particularly low rates in residential care. Although aware of the importance of engaging with depressed care recipients and demonstrating moderate knowledge of the symptoms of depression, a substantial proportion of staff members saw depression as a natural consequence of bereavement, aging or relocation to aged care.

Conclusion: Experience in aged care appears to be insufficient for staff to develop high levels of knowledge of depression. Specific training in depression is recommended for staff working in aged care settings in order to improve the detection and management of late-life depression, particularly among direct carers, who demonstrated least knowledge of this common disorder.

An examination of the 'gold standard' diagnosis of major depression in aged-care settings

Objectives: Individual clinical interviews are typically viewed as the “gold standard” when diagnosing major depressive disorder (MDD) and when examining the validity of self-rated questionnaires. However, this approach may be problematic with older people, who are known to underreport depressive symptomatology. This study examined the effect of including an informant interview on prevalence estimations of MDD in an aged-care sample.

Design: The results of an individual clinical interview for MDD were compared with those obtained when an informant interview was incorporated into the assessment. Results from each diagnostic approach were compared with scores on a self-rated depression instrument.

Setting: Low-level aged-care residential facilities in Melbourne (equivalent to “residential homes,” “homes for the elderly,” or “assisted living facilities” in other countries).

Participants: One hundred and sixty-eight aged-care residents (mean age: 84.68 years; SD: 6.16 years) with normal cognitive functioning.

Measurements: Individual clinical interviews were conducted using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Axis I Disorders. This interview was modified for use with staff informants. Self-reported depression was measured using the Geriatric Depression Scale-15 (GDS-15).

Results: The estimated point prevalence of MDD rose from 16% to 22% by including an informant clinical interview in the diagnostic procedure. Overall, 27% of depressed residents failed to disclose symptoms in the clinical interview. The concordance of the GDS-15 with a diagnosis of MDD was substantially lower when an informant source was included in the diagnostic procedure.

Conclusion: Individual interviews and self-report questionnaires may be insufficient to detect depression among older adults. This study supports the use of an informant interview as an adjunct when diagnosing MDD among cognitively intact aged-care residents.

Barriers to care for depressed older people : perceptions of aged care among medical professionals

The current study evaluated barriers to detection of depression among older people. Focus groups were conducted with 21 professional carers, 4 nurses, 10 general practitioners, and 7 aged care managers. The results demonstrated that care for older people is primarily focused on physical care. Further, staff resources, a lack of continuity of care, multiple co-morbidities, reluctance by older people to discuss depression, negative attitudes among carers, as well as a lack of skills all contributed to a failure to detect and treat depression. The implications of these findings for training programs for professional carers are discussed.

Multivitamin supplementation improves nutritional status and bone quality in aged care residents

Objectives: To assess the effectiveness of a multivitamin (MV) tablet on nutritional status, quantitative heel ultrasound (QUS), mobility, muscle strength and falls. The design comprised two groups matched on mobility levels, randomized to receive a daily MV or placebo (P) tablet for 6 months. The setting was an Australian residential care facility.

Subjects: A total of 92 aged care residents. Serum micronutrients, body weight, QUS, rate of falls, hand grip strength, and the timed up and go test were assessed at baseline and 6 months.

Results: A total of 49 participants consumed a MV and 43, a matched P for 6 months. There was a greater increase in the MV vs P group for serum 25(OH)D (mean differencestandard error, 33.42.6 nmol l-1), folate (13.42.8 nmol l-1), and vitamin B12 (178.040.3 pmol l-1) (all P<0.001). Adequate 25(OH)D concentrations (50 nmol l-1) were found among 77% of participants in the MV group vs 10% taking P (P<0.001). Adjusting for baseline levels, the increase in QUS was greater in the MV vs P group (3.02.0 dB MHz-1 vs -2.92.1 dB MHz-1, respectively, P=0.041). There was a trend towards a 63% lower mean number of falls in the MV vs P group (0.30.1 falls vs 0.80.3 falls, P=0.078).

Conclusions: MV supplementation raised serum vitamin B12 and folate concentrations and increased serum 25(OH)D, which was accompanied by an apparent positive effect on bone density. We also found a trend towards a reduction in falls and this could contribute to a reduction in fractures.

Predictors of the attitudinal and health outcomes of aged care nurses

This study examines the predictive capacity of the Demand-Control-Support (DCS) model in combination with organizational justice variables on attitudinal- and health-related outcomes for aged care nurses. Multiple regression analyses of aged care nurses (n=168) from a medium to large Australian healthcare organization. The DCS model explains the largest amount of variance across both the attitudinal and health outcomes with 27% of job satisfaction and 44% of organizational commitment, and 33% of psychological distress and 35% of wellbeing, respectively. Additional variance was explained by the justice variables for job satisfaction, organizational commitment and psychological distress. The addition of the organizational justice variables to the DCS model proved to be a valuable step in understanding the work conditions of aged care nurses. The inclusion of curvilinear effects clarified the potentially artefactual nature of certain interaction variables. The results provide practical implications for managers of aged care nurses in developing and maintaining levels of job control, support and fairness, as well as monitoring levels of job demands. The results particularly highlight the importance of the nurses’ supervisor.

Use of calcium, folate and vitamin D3-fortified milk for 6 months improves nutritional status but not bone mass or turnover, in a group of Australia aged care

In residential care, inadequate calcium and folate intakes and low serum vitamin D (25(OH)D) concentrations are common. We assessed whether daily provision of calcium, folate, and vitamin D3-fortified milk for 6 months improved nutritional status (serum micronutrients), bone quality (heel ultrasound), bone turnover markers (parathyroid hormone, C-terminal collagen I telopeptide, terminal propeptide of type I procollagen), and/or muscle strength and mobility in a group of Australian aged care residents. One hundred and seven residents completed the study (mean (SD) age: 79.9 (10.1) years; body weight: 68.4 (15.4) kg). The median (inter-quartile range) volume of fortified milk consumed was 160 (149) ml/day. At the end of the study, the median daily vitamin D intake increased to 10.4 (8.7) μg (P < .001), which is 70% of the adequate intake (15 μg); and calcium density (mg/MJ) was higher over the study period compared with baseline (161 ± 5 mg/MJ vs. 142 ± 4 mg/MJ, P < .001). Serum 25(OH)D concentrations increased by 23 ± 2 nmol/L (83 (107)%, P < .001), yet remained in the insufficient range (mean 45 ± 2 nmol/L). Consumption of greater than the median intake of milk (160 ml/day) (n = 54, 50%) increased serum 25(OH)D levels into the adequate range (53 ± 2 nmol/L) and reduced serum parathyroid hormone by 24% (P = .045). There was no effect on bone quality, bone turnover markers, muscle strength, or mobility. Consumption of fortified milk increased dietary vitamin D intake and raised serum 25(OH)D concentrations, but not to the level thought to reduce fracture risk. If calcium-fortified milk also was used in cooking and milk drinks, this approach could allow residents to achieve a dietary calcium intake close to recommended levels. A vitamin D supplement would be recommended to ensure adequate vitamin D status for all residents.

Moving beyond resistance to restraint minimization : a case study of change management in aged care

Aim: This case study describes a quality initiative to minimize restraint in an Australian residential aged care facility.

Approach: The process of improving practice is examined with reference to the literature on implementation of research into practice and change management. The differences between planned and emergent approaches to change management are discussed. The concepts of resistance and attractors are explored in relation to our experiences of managing the change process in this initiative. The importance of the interpersonal interactions that were involved in facilitating the change process is highlighted.

Implications: Recommendations are offered for dealing with change management processes in clinical environments, particularly the need to move beyond an individual mind-set to a systems-based approach for quality initiatives in residential aged care.