Depression in dementia : Development and testing of a nursing guideline

Abstract

It is widely acknowledged that depression in dementia is a burden for patients as well as for their caregivers. A pro-active attitude among caregivers is needed to recognize this severe health problem in demented residents and to respond to it. This thesis firstly provides greater insight into depression in dementia on Dutch psychogeriatric nursing home wards. We found that 19% of the residents suffered from depression in dementia. We showed that irritability, one of the two symptoms specific for depression in Alzheimer Disease (PDC-dAD: Olin et al., 2002a), is one of the most prominent symptoms. Irritability could alert caregivers to the possible presence of depression in dementia. We found no differences between the dementia stages in the mean number of depressive symptoms, or in the prevalence of each of the symptoms. We also conclude that there is no relationship between the severity of Alzheimer Disease and the prevalence of comorbid depression. In other words, depression in dementia occurs as frequently in the latter stages of dementia as in the earlier stages, with a similar pattern of depressive symptoms throughout all stages of dementia. Secondly, the thesis describes the development of the nursing guideline ‘Depression in Dementia’. The seven stages of the development process were: 1 assembling existing guidelines; 2 systematic literature review; 3 assessing existing guidelines; 4 developing a draft guideline; 5 evaluation of the draft guideline by a group of experts and the steering committee; 6 testing the guideline in a practice trial; 7 final adaptations to the guideline. After passing all these seven stages we had a guideline that was applicable in nursing practice. The guideline was based on the so-called BehaviorTherapy-PleasantEvents (Teri et al., 1997). Main principles of the ‘Pleasant Events Method’ are increasing pleasant and reducing unpleasant events. Thirdly the thesis presents the results of a multicentre randomized controlled clinical trial into the effects of the guideline introduction on depressed and demented residents and their CNAs. We concluded that introduction of the guideline significantly reduces depression severity on the Depression Rating Scale of the MDS-RAI.. In CNAs the introduction of the guideline had a significant positive effect on the perceived professional autonomy. Finally, the factors that may facilitate or hamper the guideline introduction and application were described. Most factors influencing the introduction have to do with the (in-)stability of the organization (e.g. reorganizations) and the nursing team (e.g. staff turnover rate).The factor most important for a successful introduction seemed to be the presence of a local opinion leader. A factor that appeared crucial for successful application of the guideline was the involvement of relatives in facilitating and executing pleasant activities. We recommend all nursing homes to integrate (the main principles of) the guideline into their usual care for depressed and demented residents.