RSI pioneered the idea of care management for the "whole person" for elderly residents of assisted living facilities. In the course of years of research, they developed a comprehensive training and care management program that helps the elderly person stay active physically and mentally.

Together, ElderCare Online and RSI have tailored key components of the Caring Community program to meet the needs of family caregivers. Over the next several months, we will be presenting a new series of Skill Builders that focus on how caregivers – at home and in residential facilities – can learn more about chronic conditions and improve quality of care to their loved ones.

Introduction

Depression can be overcome, even though it disabling to daily functioning, happiness and personal growth. People with depression can be helped to manage and stabilize the disabling aspects of the condition and result in lives, which continue to have meaning, personal growth and a sense of hope for the future. When frail elderly people are depressed, they need to be helped to exercise as many personal choices and decisions as they are able. Depression affects the whole person, body, mind and spirit. Because of this, any plans of care for addressing depression, must include all these dimensions. The final responsibility for overcoming depression rests with the frail elderly person. It is unlikely that they can do this without the help of their caregivers. Depression so extensively saps the energy and spirit of people that other resources are needed to initiate recovery.

It is essential for caregivers to have the knowledge, skill and attitudes to address the complexities which managing depression demands. This Skill Builder provides these competencies for family caregivers. When caregivers possess the competencies to manage depression, they will, in turn, be able to assist their loved ones to participate in their own care. The mutual involvement of caregivers and their loved ones result in keeping chronic conditions stable and enhancing the capacity for elderly people to successfully address and manage their complex chronic physical, psychosocial and spiritual issues.

Maslow and Depression -- Meeting Your Loved One’s Needs

ElderCare Online and RSI emphasize promoting independence for frail elderly people. But, when frail elderly have depression it requires that family caregivers know that they can initiate actions to alleviate depression rather than expect the depressed person to initiate their own self-help activities. Depression saps energy and decision-making capacity. This leaves the depressed elderly person with only a small amount of energy to help him/herself. The progress of recovery from depression is very often slow and results are difficult to see. It is important for us to understand that depressed people can be very self-centered. Knowing that the responsibility for improvement lies with the resident can balance the, oftentimes, overwhelming responsibility which caregiving staff feels.

Physical/Biological Needs

Frail elderly, in particular, express depression through physical symptoms such as headaches, backaches, backaches, stomach distress and constipation. Often medical evaluation has determined there is no organic cause for these symptoms. Physiological needs for balanced, nutritious meals, regular exercise and adequate, usual, uninterrupted sleep are of utmost importance for health and improvement of depression. Depressed people are often sedentary and have no motivation to move. Yet, exercise is known as a positive force for relieving depression. Exercise activates serotonin and norepinephrine and increases socialization, both known to enhance mental health.

Safety and Security Needs

Depression causes preoccupation with self, which may result in ignoring potential environmental hazards. For whatever reason, depressed persons feel a very strong need for a predictable, lawful, orderly world in which unexpected, unmanageable or other dangerous things do not happen.

Love and Belonging Needs

A depressed person is at risk for not having his/her needs for love and belonging met because of feelings of being a burden to others, of being no fun and spreading doom and gloom to others.

Self-esteem Needs

Depression is often the cause or result of feeling inadequate as a person. Some people with depression have been unsuccessful in handling their emotions alone. Feeling powerless and giving up can result when repeated attempts to help their own depression have failed. Depressed people have very negative opinions about themselves and feel very negative about their future. They often can’t describe one good thing about themselves and one thing they enjoy. They minimize past achievements, concentrate on present failures even minor ones. They feel they have nothing to look forward to. This leads to abandoning previous roles because they can’t be perfect and are afraid of failing. This leads to withdrawal of activities.

Self-actualization Needs

Depression needs to be freed first because it is unlikely there is any energy left for these creative self-expressions and personal achievements.

• Listen. This is the most important. Give your time, full attention and listen. Depressed elderly need an opportunity to put their feelings into words, to hear themselves explain the problem and to know that you are hearing them and attempting to understand. Be consistent and make fifteen minutes every day to spend alone with the resident.
• Don’t tell your own stories or the stories of people you know. Every elderly person’s depression is different. Your stories won’t help. Your listening will.
• Don’t change the subject when your loved one pauses. Instead, try echoing his/her words. For example, "You feel like you’re disappointing your daughter when you don’t feel like going to her home for dinner." This encourages the elderly person to say more about it.

• Acknowledge the sadness, irritability or withdrawal. This means that you should respond to the feelings as much as to the words spoken. You might say, " Your sadness makes you cry very often." If you name the feeling, your loved one will know that he/she is being heard and understood. If your loved one doesn’t agree with the way you phrased it, she/he will explain the true feelings more carefully. Don’t observe a feeling and just leave. Distressed feelings need to be addressed when they are identified.

• Do not judge your loved one’s feelings. Avoid saying "You shouldn’t feel that way." Instead, restate the feelings you think you are hearing to see if that is actually what the person meant. Find out what is behind those feelings. For example, "you are wondering whether your life could ever be as meaningful as when you were in your 30’s."

• Resist giving advice. The solutions that "take" are the ones that the elderly person "owns" himself. If he thought of it, or believes that he thought of it, he is more likely to follow through and make the change. We all dislike thinking that someone else is running our lives. After letting your loved one express his concerns and feelings turn the ownership for the solution to him. Ask him what he thinks would help him to feel better or improve the situation that is problematic. Do discuss alternative solutions to problems with him and adopt an approach that encourages him to generate his own solutions. For example, "you need to discover what is best for you" "Tell me what are the solutions and their pro and con".

• Praise even minor accomplishments. Make sure that your praise is an honest acknowledgement of what progress has been made in any activity but particularly those that you know will alleviate depression. Engage your loved one in conversations about previous successes, what he does well and likes about himself.

• Be honest and promote realistic expectations. Unrealistic expectations can lead to further failure and feelings of worthlessness. Help your loved one set goals that he/she can meet. For example, "Two days ago you didn’t think you could walk into the dining room alone but today, you went there for breakfast".

• Be patient and don’t push the your loved one to respond. Depression slows many processes and oftentimes the elderly person needs time to formulate a response. Depression can numb feelings and it may take more time to feel and to even put a name on the feeling.

Making Choices – My Own Decisions, Please

One of the major issues for a depressed person is his/her pervasive feeling of being unable to control the people or events in his/her surroundings. This is sometimes called "learned helplessness." Learned helplessness means that no matter how hard one tries, one is unable to have any influence on others or on the environment. This results in giving up making choices and trying to influence. Planning for, encouraging and assisting residents to make as many choices as they are able and applauding their efforts when they do can become a turning point in reducing depressions grip on the frail elderly person.

Relieving Mild Depression – Special Activities

The prevalence of depression in frail elderly persons living in assisted living is approximately 25% -- and perhaps higher in the home-bound population. The vast majority of those with depression are experiencing a milder form of depression. All people with depressive symptoms need medical care and treatment. When depression is mild and when the people will not seek help from mental health providers, these alternative forms of treatment or special activities may be helpful. These special activities impact on some of the underlying reasons for depression in elderly persons such as loneliness, losses of all kinds especially of health and functioning and lack of pleasurable activities each day. People who are not trained as mental health specialists can do all of the special activities discussed in this Skill Builder.

• Relaxing and can help clear a person’s mind so he/she can work through problems.
• Creative outlet for expression of sad and empty feeling.
• Relive positive experiences and bring forgotten meaning to current life.
• Distractor from worries, disturbing thoughts or physical discomforts.

• You can conduct your own music therapy session by spending time with your loved one listening to music, discussing it or drawing/painting while listening to the music.
• Bring your loved one to a small live musical performance conducted by children or in a park.
• Quiet music at bedtime may aid sleeping.
• Use music to aid exercise sessions or physical therapy.
• Dance or move slowly to the music with your loved one

• Relieve loneliness and isolation.
• Provide new and continued life meaning.
• Rekindle new interests.
• Stimulate resident to be more interested in his/her own personal care and feeding

• Ask a young neighbor to regularly bring over a small pet, such as a cat, dog or rabbit.
• Pet visitation programs in residential facilities.

• Refocuses your loved one to "living things" and "new growth" rather than "sick and old".
• Sense if personal pride in creating something beautiful or edible.
• For many, a continuation of an enjoyable lifetime interest.
• Stimulus for related activities such as dried flowers, bird watching or cooking.

• Raised plant beds and growing seedlings under fluorescent lights.
• Creating a Garden Club with neighbors or friends.

• More acceptable and less anxiety producing substitute for psychotherapy.
• Facilitates expression of all ranges of feelings.
• Provides socialization opportunities.

• Group pantomime, acting out sections of plays or doing charades.
• Using pictures or paintings to stimulate acting out moods and personalities of characters seen in the pictures.
• Role play a person that is admired.
• Attending plays or viewing drama/humor on video and discussing portions.

• Using selected readings (short stories and poetry) to stimulate discussion of feelings and ideas that might be repressed.
• Can meet the needs of small groups and individuals.

Reminiscence