Depression is not normal in old age. It is a myth that getting old means being depressed and sad or grumpy. Despite the “Grumpy old men” stereotype we all know many older people for whom happiness and peace is the way they age. Rates of depression in the community among older people are about the same as for younger people, ie. about 20% at some time will experience depression.
However, we know depression is at higher rates in aged residential care and higher still for people with dementia than it is for. Australian figures suggest 1 in 3 residents have a depression that requires treatment.
So what can we do about it?
People with dementia and living in residential care have reduced social engagement, lack proximity to attachment figures and have little power over their lives.
The first point is lack of social engagement. Often I find the physical arrangement of furniture prevents social interaction. Seat lined up along the wall or around the walls of a lounge, meters away from each other or from the person opposite. This is not conducive to communication, or easy hearing of soft voices. People just give up and go to sleep. Often the activities provided are led by well motivated activity staff who talk talk talk and don’t really engage people who just go to sleep and then the worker wonders why they can’t get engagement. They are boring and not really engaging the people they are there for.
Lack of proximity to attachment figures is a common problem because the losses of attachment are many and varied when a person comes into an aged care home. Families visit less often and fewer of them. Friends don’t visit you in a dementia unit. You can’t have your pets I most aged care homes. You have a limited selection of furniture if you are lucky and often have memorabilia taken from your room by other residents with dementia. So you feel angry, sad, lonely and in grief and can’t find the words to express it, so you get aggressive, anxious, and clingy and the staff don’t handle this well because they are busy and not really wanting to get to know anything much about you.
There is much evidence to suggest that having control over your life in at least one area is a vital element of mental health. Torturers take over control to create a sense of helplessness and force their victims to give up and give in. In aged care we take over and do more for people than they often require, not out of a sense of wanting to do harm. On ht contrary it is mostly designed to help the person have a easier time of it. However, it can also be designed to make life easier for the carer who is then able to work more quickly, more efficiently and feel in control of a very demanding schedule.
But what does this do to the person in care. It makes them feel like they have no control over what used to be their very personal domain of personal care activities. Other areas can also be affected by this “take over” that occurs when people are admitted to aged care, including lifestyle choices, where to sit, how much to eat, when to eat, what to eat, how much to eat, when to go out, whether or not to go out. All this is often decided by others who do it mostly out of good motive but in a misguided attempt to give care. What they give is instead a sense of helplessness and if you live long enough in this mental space you end up depressed.
Not a happy picture.
What do we need to do more of? So the solution for me is to do two things:
- Increase social interactions that are affectionate, stimulating and meaningful
- Provide choice and control – avoid taking away control
Be affectionate in your work interactions. Look for opportunities to be comforting with a touch, a smile a word. Find something about the person you are working with that can make this a “personal” time. Use their name instead of “darling”, “honey” or “love”. Think outside the box for ways to make life “normal”. What makes your life enjoyable? What gives you stimulation and enjoyment? These things can be what makes life enjoyable and in fact bearable for people in your care. Social interactions will be meaningful if you are really present and concentrating on the person you are with. Give them all of your attention when you are with them.
Choice and control can begin with you asking more questions than you might normally. What time would you like to have your shower? Then stick to it or negotiate about it. Treat the person as a social equal who is to be taken seriously. Modify your routine to fit them and their preferences. This is where the rubber hits the road for most care staff because it means changing your preferences and giving more weight to the preferences of a person with dementia for instance.
If you do these two things you will remedy the problem of depression in aged care. It will look different in each of your care homes and it will be a unique reflection of the people you care for and people you provide the care.