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Best Practices in Nursing Care to Older Adults

Issue Number 4, Revised 2007 Series gdltor: Marie Boltz, PhD, A1'RN, BC, GNP Managing Editor: Sherry A, Greenberg, MSN, APRN, BC, GNP New York University College o( Nursing

The Geriatric Depression Scale (GDS) By: Lenore f(ul'lowicl;, PhD. RN, CS, FMN, Universitll ofPennsylvania School ofNursing aM

Sherry A. Greenberg, MSN, APflN, BC, GNP, Hartford Inslitule for Gerialric Nursing, NYU College ofNursing

WHY: Depression is common In late life, affecting nearly 5 million of II,. 31 million ArnericaJl1l aged 65 and older, Both major nnd minor depression are reported in 13% o( community dwelling oider adults, 24% of older medical outpalients, 30% of older acute care patients, and 43% of nursing bome dwelling older adults (Blazer, 2002a). Contrary to popular bell,f, depression Is not a natural part o( aging. Depr.."lon is often reversible with prompt and appropriate treatment However, I( left untre..1ted, depression .nay r..,ult in the onset of physital, cognitive and social l'l'pairment. as w,,11 as delayed recovery (rom medical illness and surgery. increased health ""re utilization, and suicide.

BEST TOOL: While there nre many instruments available to measure depr;'slon, the Gerialric Depression Scale (GIlS), first created by Yesavage, ,I aI., hilS been tested and used extensively with the older population. The GDS Long Form Is a brief, 30·llem quesllonnalre in which participants arc asked to respond by answering yes or no in reference to how they (elt over tlle past week. AShort Form GDS consisting of 15 questions was developed in 1986, Questions from the Long Form GDS which had the highest cortelation with depressive ''l'mptoms in validation studies lvere selected for the short version. Of the 15 Items. 10 indicated the presence o( depression when answered positivcly. while the rest (question numbers I, 5, 7, II, 13) indicated depression when answered negatively. Scores of 0-4 are considered normal, depending on age, education, and complaint,; 6-lllndiC/lte mild depression: 9·11 indicate moderate depression; und 12·15 Indicate ,"vere depre"lon.

The Short Form i' more easily used by phy,ically III :md mildly to moderately demented patients who have 'hort attention ,pans and/or (eel easily fatigued, It lakes about 5 to 7 n;lnules to complete.

TARGET POPULATION: The GDS may be used with healthy, medically ill and mild to moderately cognitlveiy Impaired older adults. It has been extensively used In community, acute and long·term care settings.

VALIDITY AND RELIABUITY: The GDS was found to have a 92% sensitivity and a 89% specificity when evaluated against diagnostic criteria. The validity and reliability of the tool have been supported through both clinical practice nnd research, In a validation study comparing the Long and ShOlt FOIms o( the GDS (or self-rating o( symptoms of depression, both were successful in differentiating depressed (rom non-depressed adults with a high correlation (r = ,84, p < .001) (Sheikh & Yesavage, 1986).

STRENGTHS AND LIMITATIONS: The CDS is not a substitute for a diagnostic interview by mental health professionals. It is • use(ul screening tool In the clinical setting to facilitate assessment of depression In older adults esp«:I.lly when baseline measurements are compared to subsequent scores. It does not assess (or sulcld.lity.

FOLLOW·UP: The presence of depression warrants prompt intervention and treatment The GDS may be osed to monitor depression over time In all clinical ..tllngs. Any posillve score above 5 on the GDS Short Form should prompt an In·depth psychological assessment and evaluation (or suicidaJlty,

MORE ON THE TOPIC: Best practice Information on care of older adults: www;CooSIIUCariRN pr4. The StanfordIVNNIA A~lnlof Clinical Hesource Center (ACNe) w~b$itc. Rctrle....~d Jan 9. 2007, (rom blto'/Avww ~ljln(ord t;dJl/-Yi;SjlVMlc/ACRC.Jtlm.l.

Infonn"t1on 01\ the COS. Retrieved Jan 9, 2007, from bttD;//WWW stanford el!II/-yesiwmtglGOS btml BI.m, D.C. (2002.). Dopr4lSSion In lola lifo (3 01 ed,), St. Lools: Mo'bl' Yllar Book. !{oenlg, H.G., Meador, K.G., Cohen, J.J" &: B1a?cr, D.G. (1988J. Se\{~ratcd deprcssion scales and scrtening for major ueprl:Sslon In the older

ho,pllaliwd pallent with medicalll1n'ss. JAGS, 36, 699·706, Kurlowitz. LJI.. 6< NICHE Facully.IIY971. Norslng sland or practice protocol: Depression In elderly p.llenl'. GerIatric NursIng. 18151. lYt·19Y. NIH Conseo,u, Development Panel. 11992), Dla~no'is .nd treatment of depression In laW IHe.JAMA, 268, 1018·102~

Sheikh, J.I., &: YcsavJ'scJ JA (1986). Geriatric Depression Scale (CDS), Recent evidence and devclo~mcnt of a 5hort.er version. In 1'.L. Brink (Ed.)) CliniC<11 Gerontology: A Guide 10 Asscssmenl and Inleroent/on (pp. 165·1T.l), NY: The H.worll, Press. Inc.

Yesavi\ge. JA1 Brink, T.L" Rose, T.L.. Lum, 0., Huanp:, V" Adey, M.B., & Lelrer, V.C. {19831. Development and validiltion of a geriatric depression screening scale: Apreliminary report. Journal ofPsychiatric Research, 17, 37·49.

rtrmls:iion b hereby l:r~nted La rcproduCl.:, (lOst, download, and'or di$lrlbutc, tlUs material in its cntiretv only for not·fur-profit L-dutatlonal PUlllUSC:S unly, IlTwldcd that The Hartford Institute lor Geriatric Nur::inll. CoUcRe of Nursing, N~\\1 York Univcn;il)' is died as the source. This material may be downloaded an&'or distributed in ~Iectronic

format, including rOA formaL Av.ulablt: un the intemet at \\;wwJartJordlgn.org and/or www.ConsuIIGerlRN.ofll:. E-mail notincaUOfI of usage to: hartfom.lgn@nyu.edu.

Geriatric Depression Scale: Short Form

Choose the best answer for how you have felt over the past week:

1. Are you basically satisfied with your life? YES / NO

2. Have you dropped many of your activities and interests? YES / NO

3. Do you feel that your life is empty? YES / NO

4. Do you often get bored? YES / NO

5. Are you in good spirits most of the time? YES / NO

6. Are you afraid that something bad is going to happen to you? YES / NO

7. Do you feel happy most of the time? YES / NO

8. Do you often feel helpless? YES / NO

9. Do you prefer to stay at home, rather than going out and doing new things? YES / NO

10. Do you feel you have more problems with memory than most? YES / NO

11, Do you think it is wonderful to be alive now? YES / NO

12. Do you feel pretty worthless the way you are now? YES / NO

13. Do you feel full of energy? YES / NO

14. Do you feel that your situation is hopeless? YES / NO

15. Do you think that most people are better off than you are? YES / NO

Answers in bold indicate depression. Score 1 point for each bolded answer.

Ascore;> 5 points is suggestive of depression. Ascore? 10 points is almost always indicative of depression.

Ascore;> 5 points should warrant a follow-up comprehensive assessment.

Source: htto://www.staoford.edu/-yesayage/GDS.html

A SEAlES PROVIDED BY

The Hartford Institute for Geriatric Nursing·(J·fJ7Y"ZO.. (\:0>' O,"',o"I<o,'n N""lng alAll: hartford,lgn@nyu,cduWII ' V~.))() Co1rotoOldorAdulu

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Care & Wellness

7PARKINSON Report • SUMMER 2008

iving with a chronic progressive illness like Parkinson’s disease can pose many challenges. Socialworkers play a key role at a Parkinson’s Center, helping persons with Parkinson’s and their families to

deal with those challenges, and to navigate both the health care system and the many feelings and situations that resultfrom living with a chronic illness such as Parkinson’s. Because these challenges change over the years, many families findthat what worked at one point, may not be the best option at another time. Whether you are seeking help in managingchanges brought on by the impact of Parkinson’s, or need help finding resources—such as a support group or new housingpossibilities—talking to a licensed social worker can be an important step in helping to explore new options and creativeways of living well with Parkinson’s.

Persons and families living with Parkinson’s disease might see a social worker for many reasons and at different pointsin the disease.

Some reasons might be:• to better understand PD and to discuss reactions to receiving the diagnosis• to talk about when and how to share the diagnosis with family and friends, or at the workplace• to find ways to cope with feelings such as sadness, depression, anger, worries, frustration, and other feelings• to plan for the future, including understanding advance directives, insurance issues, and home care and housing options• to talk about and find ways to cope with loss• to discuss changes in the family, e.g. the situation of being a carepartner for someone with Parkinson’s disease• to find ways to build or maintain good communication with a carepartner or other family members about the impactof living with Parkinson’s throughout the illness

• to learn about and access resources in your local community

L

BY:GLADYS GONZALEZ-RAMOS, PhD, LCSWAssociate Professor of Social WorkNew York University School of Social Work

DIANE BRESLOW, MSW, LCSWCenter Coordinator Northwestern Parkinson’s Diseaseand Movement Disorders CenterNational Parkinson Foundation Center of Excellence

Social Workersin the ForefrontProviding Care to Those Living with Parkinson’s

PARKINSON Report • SUMMER 20088

Social workers offer an important set of skills and aretrained in the biopsychosocial model of assessmentand care. That is, they are trained to understand thatindividuals and families are a composite of complexphysical (biological), emotional (psychological), andsocial/cultural aspects, all of which combine to play arole in behavior. Some social workers are specificallytrained in the unique challenges posed by Parkinson’sdisease—challenges to the individual, his or her spouseor partner, and their families.

Ideally, social workers can provide the best care in arelationship with a person with PD and their family that isbuilt on trust over a period of time. This allows the socialworker to understand their perspective, strengths, andunique challenges—and to work with them to developa plan. However, it is not uncommon that people talkwith a social worker only once—for a specific issue, forinformation about a service, or at a point of crisis. Somepersons with Parkinson’s and their families also see socialworkers at periodic intervals when specific needs emergeduring the course of the disease.

For example, at one NPF Center, a man with Parkinson’sand his carepartner sought counseling to deal withchanges in their relationship brought about by theprogression of PD. Specifically, the husband and wife bothacknowledged that they were “always angry with eachother.” They reported to the social worker that theyneither understood the reasons for their arguments,nor ways to improve their relationship. Through thecounsel ing relationship, the husband’s underlyingdepression and the carepartner’s underlying anxietywere brought into the open and explored. It became clearthat the husband was feeling “down” about his increasingdependence upon his wife and his shrinking socialactivities. At the same time, the wife was experiencinggrowing anxiety about her own capacity as caregiverand about the uncertainty regarding the course of thedisease. Rather than being able to identify and talk abouttheir respective emotions, the couple found themselves“constantly arguing.” Counseling helped them to deal withtheir emotions. The wife gained a better understandingof her ambivalence about when and how to help herhusband, when to allow him to try on his own, and mostimportantly, how to communicate in such instances. Theman with Parkinson’s came to see how his emotionaldistance (part of his depression) and private anger aboutPD affected his wife. Counseling helped them gain agreater understanding of themselves and each other. Thesocial worker was then able to help them communicatewith each other in a more respectful and productiveway. In addition, the social worker requested from theneurologist a referral for Occupational Therapy, wherebythe person with PD was able to learn and to practicenew techniques for dressing himself, as well as to obtainsome devices that made the task easier. This social workassistance was comprised of supportive and psychological

Did you know that:

• Social work degrees areawarded at the Bachelors,Masters and Doctoral levels.Most licensed social workershave a Masters in SocialWork degree (MSW), whichis required for the majorityof social work licenses.

• All 50 states in the U.S. license social workers;however, the title “social worker” is not regulatedin most states. Many persons can call themselvessocial workers and not have a social work degree.The best way to get clarity is to ask the personyou are seeing if they are a licensed social worker.“Licensed social worker” is a regulated title, socialworker is not.

• LMSW, LCSW, LGSW and LSW are typical initialsyou might see after a licensed social worker’sname. There are variations among the states, soask about the licenses awarded in your state.

• The National Association of Social Workers(NASW) is the main professional association.

• In helpstartshere.org, an NASW site, you cansearch for a licensed social worker by state and/orzip code (see “social worker finder”).

• Licensed social work services (after sufficientsupervised experience) in private practice andmany other settings are reimbursable.

TABLE 1

Care & Wellness

9PARKINSON Report • SUMMER 2008

counseling as well as a referral for rehabilitation therapyand concrete resources. It is reflective of the manysituations in which a couple is struggling with changes infamily relationships or roles, questions about a person’sabilities, and the availability of services and resources.

Many social work interventions, whether one-time orover time, likewise incorporate the skills of listening,understanding, problem-solving, and practical concreteguidance. Another example involves a younger person,age 45, who was referred by the Movement DisorderNeurologist for counseling about her anxiety and worriesabout the future. She saw a clinical social worker on andoff for a period of a year to discuss the diagnosis of PDand to look at options as she planned for her future. Thefact that PD is so unpredictable and that no one could tellher exactly what her functioning would be like in 5, 10, or15 years made it very difficult for her. She expressed “likingto always be in control of my life” and felt overwhelmedthat PD seemed to remove this sense of control. Shedescribed herself as a “life-long worrier, even beforereceiving this diagnosis.” Besides the individual counseling,which focused on her anxiety, the socia l workerrecommended that she attend a support group for personswith young-onset PD. The group offered her a way to makeconnections with the new community, and learn aboutrelaxation, meditation, and guided imagery techniques thatothers found helpful. In this case, social work counselingprovided this woman with a safe environment to begin todiscuss her various reactions to the diagnosis and to findways to creatively cope with the range of feelings. Problemsolving, referral to a support group, and informationabout resources she might need in the future were partof the care she was given. Most of all, she made a goodconnection to the social worker and knew that it wassomeone with whom she could seek further counseling infuture years and as her needs changed.

Healthcare settings where you can findsocial workers:

TABLE 2

Couple and family stress

Parkinson’s disease is a “family disease”; while one personmay have the diagnosis, the whole family experiences theeffects. Persons, couples, and families often seek socialwork services when the challenges of living with PDbecome very stressful and they want a trained professionalto help them to more fully understand their situation andfeelings, and to explore possible options.

Social workers aim to understand each person’s uniquesituation and goals. Each situation needs to be understood,listened to, and approached in a creative way. Social workintervention is not a “one size fits all” approach. What onecouple or family finds helpful may be very different foranother couple. For example, one couple wants help toremain in their own home, while another couple wantshelp understanding assisted living options and locating anappropriate community. Furthermore, it is fairly commonfor one person in a couple to see a situation differentlyfrom the other, or for adult children to sees thingsdifferently from one another. A woman with PD maybelieve that she can still travel the world, while thehusband-carepartner feels quite reluctant about this. Orone adult child views Dad as “not changed at all,” while theother adult child overreacts and treats Dad as helpless.These kinds of different perspectives can create newconflicts or cause old conflicts to re-emerge. The goodnews is that social workers are trained, experienced, andoften successful in dealing with these kinds of issues.

• medical centers

• rehabilitation centers

• adult day programs

• home health programs

• skilled nursingfacilities/nursing homes

• assisted living facilities

• Veteran’sAdministration(VA) centers

• private practice

Care & Wellness