Proefschrift: depression in dementia. Development and testing of a nursing guideline

Renate Verkaik promoveerde 20 april jl. op haar proefschrift ‘Depression in dementia. Development and testing of a nursing guideline’, waarin zij een behoorlijke berg onderzoek naar depressie bij demente personen presenteert, waaronder enkele systematische reviews. Doe er uw voordeel mee PG’end Nederland, want volgens mij heeft Verkaik enkele zeer essentiele dingen onderzocht – van snoezelen tot symptomen van depressie – waarbij het verpleegkundig onderdeel niet vergeten is! Om het gehele proefschrift te lezen: hier eventje klikken. Abstracts onder de streep!

The relationship between severity of Alzheimer’s Disease and prevalence of comorbid depressive symptoms and depression

To gain more insight into the association between severity of Alzheimer’s Disease (AD) and prevalence of comborbid depression.
A systematic literature review based on the Cochrane methodology was performed. PubMed, PsychINFO and EMBASE databases were searched for existing studies that fulfilled predefined inclusion criteria. The studies were
divided into: (1) those that analysed the association between severity of AD and prevalence of depressive symptoms (“continuous” approach) and (2) those that investigated the association between severity of AD and diagnosed depression (“categorical” approach). The quality of existing studies was rated and the results were synthesized with a best evidence
Twenty‐four studies fulfilled the inclusion criteria. Nineteen reported results for a continuous approach and seven for a categorical approach. Three of the four high quality studies within the continuous approach did not find a significant association between severity of AD and prevalence of depressive symptoms. None of the three high quality studies using the
categorical approach found a significant association between the severity of AD and the prevalence of diagnosed depression.
Conclusions There is evidence for a lack of association between the severity of AD and the prevalence of comorbid depressive symptoms or diagnosed depression. Until new studies contradict this conclusion, prevention and intervention
strategies for comorbid depression in AD should be aimed at all patients irrespective their disease severity.

Comorbid depression in dementia on psychogeriatric nursing home wards. Which symptoms are prominent?

To provide insight into the prevalence and clinically relevant symptoms of comorbid depression among dementia patients in psychogeriatric nursing home wards, in order to enhance depression recognition.
Cross‐sectional analyses of multi‐centre diagnostic data.
Psychogeriatric wards of Dutch nursing homes.
518 residents with dementia.
1. diagnosis of depression in dementia (PDC‐dAD),
2. dementia (DSM‐IV‐PC),
3. stage of dementia (GDS).
The point prevalence of comorbid depression in dementia (stages 2 to 6) on psychogeriatric nursing home wards was 19%. ‘Depressed mood’, ‘irritability’ and ‘fatigue’ were the most prevalent depressive symptoms. Residents taking antidepressants at the time of the PDC‐dAD depression diagnosis showed more depressive symptoms than residents who were not. The mean number of depressive symptoms was 5.6 (SD 1.84), which did not differ between the dementia stages. Also, no differences were found in the point prevalence of the shown symptoms between dementia stages.
Conclusion‘Irritability’ was put forward by the developers of the Provisional Diagnostic Criteria for Depression of Alzheimer Disease (Olin et al., 2002a), as one of the specific symptoms of depression in Alzheimer Disease. This study shows that ‘irritability’ is one of the most prevalent depressive symptoms in psychogeriatric nursing home residents diagnosed with comorbid depression. ‘Irritability’ should therefore alert caregivers to the presence of depression and could help early recognition. The high prevalence rate of
comorbid depression in dementia in this setting justifies attention to early recognition and intervention.

The effects of psychosocial methods on depressed, aggressive and apathetic behaviors of people with dementia

This systematic review seeks to establish the extent of scientific evidence for the effectiveness of 13 psychosocial methods for reducing depressed, aggressive or apathetic behaviors in people with dementia.
The guidelines of the Cochrane Collaboration were followed. Using a predefined protocol, 11 electronic databases were searched, studies selected, relevant data extracted and the methodological quality of the studies assessed. With a Best Evidence Synthesis the results of the included studies were synthesized and conclusions about the level of evidence for the
effectiveness of each psychosocial method were drawn.
There is some evidence that Multi Sensory Stimulation / Snoezelen in a Multi Sensory Room reduces apathy in people in the latter phases of dementia. Furthermore there is scientific evidence, although limited, that BehaviorTherapy‐PleasantEvents and BehaviorTherapy‐ProblemSolving reduce depression in people with probable Alzheimer Disease who are living at home with their primary caregiver. There is also limited evidence that Psychomotor Therapy Groups reduce aggression in a specific group of nursing home residents diagnosed with probable Alzheimer Disease. For the other 10 psychosocial methods there are no or insufficient indications that they reduce depressive, aggressive or apathetic behaviors in people with dementia.
Although the evidence for the effectiveness of some psychosocial methods is stronger than for others, overall the evidence remains quite modest and further research needs to be done.

Introducing a nursing guideline on depression in dementia. A multiple case study on influencing factors

Successfully introducing care innovations depends on the type of care setting, the intervention and specific circumstances. In this study the factors influencing the introduction of an evidence based nursing guideline on depression in psychogeriatric nursing home residents were studied.
A qualitative multiple case study design was used. The cases consisted of nine psychogeriatric wards participating in the intervention group of a controlled clinical trial. Eight types of data source (qualitative and quantitative) were used in the analyses. Triangulation of researchers, data and methods took place. Factors were categorized according to their
organizational level: nursing home management (level 1), nursing team (level 2), CNAs (level 3), and residents (level 4).
Factors influencing guideline introduction were mainly found at the levels of the nursing home management and the nursing team. Most factors concern stability of the organization and team (e.g. the inhibiting effects of reorganizations and other innovations), motivation (e.g. the facilitating presence of an opinion leader) and compatibility with current practice and
vision (e.g. a facilitating emotion‐oriented care vision). Factors influencing a successful application of the guideline are mainly found at CNA and resident level. At CNA level most factors relate to an emotion‐oriented care vision (e.g. having a warm and creative personality). At resident level inhibiting factors mainly concern the residents’ health status (e.g. feeling
sick and/or having much pain). Important facilitating factors are positive attitudes of relatives and observing a reduction of depression severity.
Special facilitating factors for the guideline introduction and application seem to be the presence of a local opinion leader and the positive attitudes of relatives. Together they can motivate a nursing team in using the guideline. After a successful introduction of the guideline it’s important to focus on its consolidation in daily practice.

The effects of a nursing guideline on depression in psychogeriatric nursing home residents

To study the effects of introducing a nursing guideline on depression in demented residents of psychogeriatric nursing home wards.
A multi‐centre controlled clinical trial with randomization at ward level was used to study the effects of the guideline introduction. Nursing teams were trained in applying the guideline to their own residents diagnosed with depression in dementia. Key elements of the nursing guideline are increasing individualized pleasant activities and decreasing unpleasant
events. Participating residents were 97 residents diagnosed with dementia and comorbid depression, from 18 psychogeriatric nursing home wards, in 9 Dutch nursing homes. Measurements took place at pre‐test, post‐test and follow‐up. Primary outcome is severity of depression measured with the MDS/RAI‐Depression Rating Scale and the Cornell Scale for Depression in Dementia. Secondary outcome is mood as measured by the FACEobservation scale.
Compliance with the nursing guideline was moderate. Despite this, residents on the experimental wards showed a significant reduction in depression on the Depression Rating Scale. With the Cornell scale a reduction of depression was found as well, although not significantly different from that in the control group. No effects on observed mood were found.
This study shows significant reductions in depression severity by introducing a nursing guideline on psychogeriatric nursing home wards. Better compliance with the guideline could probably enlarge the effects. Some ways to achieve enhanced compliance are: (1) additionally train noncertified nurse assistants, and (2) emphasize necessary conditions for successful introduction of the guideline to nursing team managers.

The introduction of a nursing guideline on depression at psychogeriatric nursing home wards. Effects on Certified Nurse Assistants

To improve care for residents with depression in dementia, an evidence based nursing guideline was developed. Using the guideline has already shown positive effects on depression in psychogeriatric nursing home residents.
To study the effects of the introduction of the nursing guideline ‘Depression in Dementia’ on perceived professional autonomy, workload and feelings of powerlessness and confidence in Certified Nurse Assistants.
A multi‐center controlled intervention study with randomization at ward level, using pre‐test, post‐test and follow‐up measurements.
18 psychogeriatric wards in 9 Dutch nursing homes.
193 Certified Nurse Assistants working on psychogeriatric nursing home wards for at least 20 hours per week.
An evidence based guideline for nursing teams of psychogeriatric nursing home wards was introduced on nine experimental wards to reduce depression in residents diagnosed with depression in dementia. The guideline introduction consisted of team training and the installation of a promotion group. The nine control wards continued providing usual care. Primary outcomes are: (1) perceived professional autonomy and (2) perceived workload in Certified Nurse Assistants measured with the VBBA
subscales ‘autonomy’ and ‘pace and amount of work’. Secondary outcomes are perceived powerlessness and confidence in caring for depressed and demented residents, using two self developed scales.
The guideline introduction had a small, significant, positive effect on generally perceived professional autonomy in the Certified Nurse Assistants of the experimental wards. No short term effects were found on generally experienced workload, or on confidence and powerlessness in caring for depressed residents with dementia.
The introduction of the nursing guideline ‘depression in dementia’ has small, positive effects on perceived professional autonomy among the Certified Nurse Assistants. Long term effects on experienced workload should be studied.

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2 thoughts on “Proefschrift: depression in dementia. Development and testing of a nursing guideline

  1. jennyj0 schreef:

    Dank je Bram. Allebei mijn ouders zitten in het verpleeghuis en met name van mijn moeder hebben we de indruk dat ze behoorlijk depressief is. Er staat iets over ‘pleasant events’. Wat moet ik me daarbij voorstellen? Zijn daar dingen bij die wij zelf kunnen doen?

  2. Bram Hengeveld schreef:

    Mantelzorgers zoals jij zijn meestal onmisbaar voor een hoge mate van welzijn van iemand in een verpleeghuis! Het beste advies dat ik je op het moment kan geven: overleg met het zorgverlenend personeel wat je kunt doen. Geloof me dat zorgverleners er van houden als ze zo af en toe een ‘paar extra handen’ hebben. De etenstijden zijn het meest in het oog springend: mochten je ouders bij het eten geholpen worden, dan kan je daar een heleboel winst boeken, zo heb ik de indruk. Wellicht dat het in het begin wat moeilijk loopt (‘onwennig’), een rolverdeling ontwikkelen duurt soms even, maar de aanhouder wint. Het dossier van je ouders is (hopelijk) ook een belangrijke bron van informatie.
    Het eldercare ABC blog, mocht je het niet kennen, is misschien ook een bruikbare bron van informatie;

    Een richtlijn als de gepresenteerde is afhankelijk van een goed georkestreerde en algemene invoering, het zou jammer zijn om er blind op te varen (niet dat ik denk dat je dat zou willen doen, maar ter volledigheid).

    Maar blijf communiceren met het zorgverlenend personeel. Waarschijnlijk hebben je ouders ook een voorkeur voor enkele zorgverleners, probeer erachter te komen waar het verschil in omgang in zit. Zorgverleners vinden het leuk om te horen dat hun manier van werken gewaardeerd wordt; vraag er naar. Hoe lang wonen je ouders al in een verpleeghuis?

    Het pleasant events systeem was mij ook volslagen onbekend eigenlijk. Interessante, evidence based materie! Voor zover ik het tot nog toe kan beoordelen is het een manier van zorg die streeft naar beleving van zoveel mogelijk leuke activiteiten en voorkomen van ‘bezorgdheid’. Maar ik wil me er eerst op inlezen, voor ik verdere informatie verstrek. De strekking van het proefschrift vond ik echter interessant genoeg om er melding van te maken. Het is nl. het geval dat de veel gebruikte benaderingswijzen als validation geen effect kunnen aantonen in gerandomiseerd onderzoek, maar wel als zoete koek worden geslikt door instellingen, studenten en zorgverleners. Een bewijs dat het evidence based werken nog in de kinderschoenen staat. Stel je dan nog eens voor dat invoering plaats moet vinden in een omgeving waarin wetenschap niet bekend is. Dé reden dat ik hamer op een beter begrip van wetenschap in het algemeen en uitbanning van maffe methoden als therapeutic touch. Daar wordt nota bene door mijn hogeschool zelf aandacht en geld aan besteedt, maar ik ben bang dat een enquete over de mogelijkheden van Pubmed en het systematisch lezen van vakliteratuur (en gebruik in de praktijk!) een weinig veelbelovende uitslag zal geven. Overigens zijn die cijfers er gewoon niet, ook weinig goeds natuurlijk, geen zaken waar ik op zou willen ‘gokken’ als beroepsgroep, maar we moeten wel.

    But I disgress. Voor de Pleasant Events methode is dat wetenschappelijk bewijs er wel ( Een veel belovende vooruitgang! Het mooie vind ik ook dat de wetenschappelijke informatie goed beschikbaar is; delen van het proefschrift zijn in wetenschappelijke periodieken terecht gekomen, waar je dik voor moet dokken, maar een klikje via de NIVEL doet het zonder pardon op het scherm verschijnen. Ik houd van dergelijke openheid! In mijn utopie kan iedereen alle informatie uit ieder wetenschappelijk tijdschrift raadplegen; voor niets. Zoals bijvoorbeeld de Canadezen toegang hebben tot de Cochrane databases. Schattingen die ik heb gelezen berekenen een geweldige kostenpost: 1,5 dollarcent(!) per inwoner van Canada…. But I digress again:

    Vanaf pag. 219 van de PDF van het proefschrift (voor het gemak: staat het een en ander uitgelegd over de methode. Het stomme is een beetje dat het allemaal wel erg ‘vanzelfsprekend’ aandoet: wie had gedacht dat het doen van leuke activiteiten zin zou hebben voor het welbevinden?
    Ah, the elegant beauty of science.

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