Mental Health in Long-Term Care Settings

I first must call out the implicit message in the phrasing “who have just been placed…”, which presupposes someone else placed them in long term care. We want to be sure to recognize the agency of older adults and their care choices. Most people are involved in decision-making about where they live and how they are cared for, making these decisions for themselves. For some people, moving to a long-term care setting may be a very positive choice. For others, it could be their last choice or forced upon them by circumstances. A lot depends on a person’s frame of mind when transitioning to long-term care. Also, there are many types of long-term care settings. Fewer people now use nursing homes, and more people use assisted living, for example, than a decade ago. Assisted living settings offer more independence while still providing supervision for personal and medical care.

We can help people maintain their well-being after such a move by helping them to find meaningful activity and engagement. Preferably this would involve supporting continuity with lifelong pursuits and interests and promoting contact with established social supports. If there are changes in physical or cognitive ability that limit access to established pursuits, then people may need assistance adapting their interests to their new abilities. Moving to long-term care settings often involves stressful or negative experiences, including loss of abilities, pain, chronic illness, and interpersonal and material losses. We cannot remove these negatives or the negative affect that is associated with them. Rather, we need to acknowledge their reality and then help people to balance the inevitable negative affect with experiences and routines that generate positive affect. This must be a tailored, individual process.

Compared to the general population of older adults in community settings, rates of depression in nursing homes are higher. How much higher depends on how you define and measure “depression.” However, they are similar to the rates of depression in other populations with significant medical illness or challenge.

Yes. Depression creates inertia, but it is never too late to make changes. We have treated people across the spectrum of “old age,” from those in their late 50s to those in their 80s and 90s. All treatments for depression involve generating hope, either by changing cognitions (cognitive interventions), changing attentional focus (mindfulness) or by changing behaviors (behavioral activation). There is good research supporting these interventions for treating depression in later life.

BE-ACTIV is a part of a “family” of interventions that derive from Peter Lewinsohn’s behavioral therapy for depression, and so originally derived from the behavioral model promoted by Lewinsohn and colleagues in this chapter:

Lewinsohn, Hoberman, Teri, & Hautzinger (1985). Lewinsohn, P.M., Hoberman, H., Teri, L., & Hautzinger, M. (1985). An integrative theory of depression. In S. Reiss & R.R. Bootzin (Eds.). Theoretical issues in behavior therapy. New York: Academic Press.

See our research Meeks, S., & Depp, C. A. (2002). There is also recent work by George Alexopoulos and Patricia Arean and their colleagues on versions of their very similar treatment model, ENGAGE, that gives additional theoretical and neuroscientific support for this form of behavioral activation treatment.

I would be happy to share our Pleasant Events Schedule-NH version if you contact me at smeeks@louisville.edu. The citation for this instrument is Meeks, S., *Shah, S., & Ramsey, S. (2009). The Pleasant Events Scale – Nursing Home version: A useful tool for behavioral interventions in long-term care. Aging and Mental Health, 13, 445-455. DOI: 10.1080/13607860802534617

Aside from the general evidence that exists for behavioral activation for older adults more generally (see, e.g., Alexopoulos citations in #4 above), we have conducted a clinical trial of a particular intervention that was designed for nursing homes. The results of our work suggest that BE-ACTIV is more effective than treatment as usual in bringing depressive syndromes to remission.

All the time! Stereotypes of aging (positive and negative) are pervasive and so well accepted that we are often not even aware that they are operating on our perceptions of our clients or each other.

https://www.aarp.org/research/topics/economics/info-2021/older-workers-new-skills-covid-19-pandemic.html

Here is a link to a systematic review of interventions for fear of falling. There is well-established literature on this issue. https://agsjournals.onlinelibrary.wiley.com/share/JVVD7FGJCMTTWEA7TWKV?target=10.1111/j.1532-5415.2007.01148.x An important take-home is that treating fear of falling by itself may not be the best route, particularly if people have a history of falls. There are well-established treatment for fall prevention that should also reduce the fear of falling. One of these is Tai Chi!
See also: https://www.cdc.gov/homeandrecreationalsafety/falls/community_preventfalls.html