ORIGINAL ARTICLE
The Journal of Nursing Research h VOL. 22, NO. 2, JUNE 2014
Depression in Older Residents With Stroke Living in Long-Term Care Facilities Hui-Tzu Huang1 & Yeu-Hui Chuang2 & Yi-Hua Hsueh3 & Pao-Chen Lin4 Bih-O Lee5 & Ching-Huey Chen6* 1
PhD, RN, Lecturer, Department of Nursing, Chung Hwa University of Medical Technology & 2PhD, RN, Assistant Professor, College of Nursing, Taipei Medical University & 3BSN, RN, Psychiatric Center Bali, Ministry of Health and Welfare & 4PhD, RN, Associate Professor, National Tainan Junior College of Nursing & 5PhD, RN, Associate Professor, Department of Nursing, Chiayi Campus, Chang Gung University of Science and Technology & 6PhD, RN, Professor, Institute of Allied Health Sciences and Department of Nursing, College of Medicine, National Cheng Kung University.
Introduction
ABSTRACT Background: Stroke is the third leading cause of death in Taiwan. Poststroke older adults are often admitted to long-term care facilities. The impacts of the two concurrent life events of stroke and relocation may increase the risk of depression in stroke survivors. Depression in elderly stroke survivor residents of long-term care facilities has not been studied. Purpose: This study explores the factors associated with depression in older residents with stroke living in long-term care facilities. Methods: A cross-sectional design was used. Twenty-three institutions in southern Taiwan participated in this study, including seven nursing homes, 11 intermediate-care facilities, and five domiciliary-care facilities. Purposive sampling enrolled 111 participants who met the following inclusion criteria: 65 years or older, experienced a stroke that did not cause cognitive defects, and capable of verbal communication. Data were collected using a sociodemographic data questionnaire, Barthel’s Index, and the Taiwan Geriatric Depression Scale. Results: Depression was experienced by 41 of the 111 participants (36.9%). Prevalence of depression was 45.7% in nursing homes, 36.2% in intermediate-care facilities, and 22.2% in domiciliary-care facilities. Participants living in nursing homes and intermediate-care facilities and illiterate participants with low Barthel’s Index scores showed more depressive symptoms. Conclusions/Implications for Practice: Healthcare providers should conduct depression screening for elderly residents with stroke on admission to long-term care facilities. Regular assessment and monitoring of depressive symptoms, especially in residents with less formal education and limited physical functions, are important in nursing homes and intermediate-care facilities.
KEY WORDS: activity of daily living, depression, long-term care facility, older resident, stroke.
Adults older than 65 years face an increased risk of cerebrovascular problems (Chen, Balami, Esiri, Chen, & Buchan, 2010). This group constitutes roughly 11.15% of the population of Taiwan (Ministry of the Interior, 2012a). Cerebrovascular accident, also known as stroke, is the third leading cause of death in Taiwan (Ministry of Health and Welfare, 2013). Stroke may impair motor, sensory, and perception functions and lead to dependence in activities of daily living (ADLs; Robinson, 2003). The loss of independence in ADLs necessitates that older adults with stroke receive a great deal of care, which leads to many elderly patients with stroke moving into long-term care facilities (LTCFs; Farner et al., 2010; Lee & Choi, 2002). Nursing homes (NHs), intermediatecare facilities (ICFs), domiciliary-care facilities (DCFs), and dementia care institutions are the different types of LTCFs in Taiwan. In Taiwan, NHs provide nursing care to patients with long-term chronic diseases, ICFs serve individuals who lack the capacity to take care of themselves, and DCFs offer housing to people who can take care of themselves in daily life (Ministry of the Interior, 2012b). Long-term residence in LTCFs has been associated with prevalence of depression in older residents at a rate that is three to four times higher than in community-dwelling peers (Jongenelis et al., 2004). In Taiwan, the prevalence of depression among older residents in LTCFs has been reported to range from 39% to 82% (Lin, Wang, Chen, Wu, & Portwood, Accepted for Publication: July 28, 2013 *Address correspondence to: Ching-Huey Chen, No.1, University Rd., East District, Tainan City 70101, Taiwan, ROC. Tel: +886 (6) 235-3535 ext. 5834; Fax: +886 (6) 237-7550; E-mail: [email protected] Cite this article as: Huang, H. T., Chuang, Y. H., Hsueh, Y. H., Lin, P. C., Lee, B. O., & Chen, C. H. (2014). Depression in older residents with stroke living in long-term care facilities. The Journal of Nursing Research, 22(2), 111Y118. doi:10.1097/jnr.0000000000000028
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The Journal of Nursing Research
2005; Lin, Wang, & Huang, 2007; Lin, Yu, & Chang, 2004). This is higher than the 8.1%Y24% range reported in Western countries (Jongenelis et al., 2004). In addition, the prevalence of depression among patients with stroke in Taiwan (27.4%Y33.3%; Cheng et al., 2005; Li, Wang, & Lin, 2003) is higher than that in Western countries (5.5%Y37%; Hackett, Yapa, Parag, & Anderson, 2005; Whyte & Mulsant, 2002; Williams, Rittman, Boylstein, Faircloth, & Haijing, 2005). Several studies have identified various factors associated with depressive symptoms in older LTCF residents. These factors include age (Drageset, Eide, & Ranhoff, 2011; Lin, 2007), gender (Tsai, Chung, Wong, & Huang, 2005), educational level (Lin et al., 2007), length of residence and number of chronic conditions (Lin et al., 2007), functional status as measured using the Barthel Index (Lin et al., 2005; Tsai et al., 2005), and type of institution (Lin et al., 2005). Depression is significantly associated with lower quality of life (Chang, Ling, Chen, & Lu, 2006; Schmid et al., 2012), which can increase morbidity and mortality (Ellis, Zhao, & Egede, 2010). Stroke survivors may experience losses in terms of health, occupation, social role, and independence. Any of these factors may cause major changes in a person’s life (Whyte & Mulsant, 2002). Poststroke depression has been associated with brain damage and increased disability, cognitive impairment, and mortality (Robinson, 2003; Whyte & Mulsant, 2002). Previous studies have shown that gender (Liao et al., 2004), age (Farner et al., 2010; Hornsten, Molander, & Gustafson, 2012), and risk of recurrent stroke (Yuan et al., 2012) are factors associated with depressive symptoms in poststroke patients. In summary, previous studies indicate that depressive symptoms among older patients with stroke are affected by interrelated factors that include gender, age, education, functional status, length of residence, number of chronic conditions, risk of recurrent stroke, and type of LTCF. Limited research has examined depression among poststroke elderly residents of LTCFs. Because filial piety is a central theme in Asian culture (Laidlaw, Wang, Coelho, & Power, 2010), older people expect to be with and be taken care of by their families when they are old or ill. Therefore, older adults who experience a stroke and subsequent relocation to a care facility may face a higher risk of depression. This study explored the factors associated with depression in older LTCF residents with stroke. The main hypothesis of this study was that risk of depression differs in older residents living in different LTCFs (Lin et al., 2005).
Methods Design and Sample A cross-sectional design was conducted at NHs, ICFs, and DCFs in southern Taiwan. We contacted 64 LTCFs accredited by the Ministry of Health and Welfare, Executive Yuan, and Bureau of Social Affairs in Tainan City. We excluded dementia care institutions from consideration. Nine of the thirty-two institutions that agreed to participate in the study did not
Hui-Tzu Huang et al.
have residents who met our inclusion criteria. Therefore, 23 LTCFs composed the target sample for this study. The directors of the LTCFs referred residents to the researchers. Inclusion criteria for this study required that LTCF residents be 65 years or older, to have experienced a physician-diagnosed stroke, and be cognitively intact. The Short Portable Mental Status Questionnaire assessed cognition, with a score of 98 required for eligibility (Pfeiffer, 1975). This study applied a purposive sampling methodology. Residents unable to communicate in Mandarin or Taiwanese and those exhibiting aphasia were excluded. A minimum sample size of 109 subjects was determined using G*Power 3.0 software (Faul, Erdfelder, Lang, & Buchner, 2007), with the power set at .80, the ! at .05, and the effect size at .262 in accordance with Cheng et al. (2005).
Data Collection Several instruments were used to assess the presence of depression and its associated variables. Demographic information was obtained from medical records and confirmed by nurses at the institutions. Barthel’s Index (BI) assessed basic ADLs (BADLs). The Taiwan Geriatric Depression Score (TGDS) assessed participants’ self-reported depressive symptoms. The researcher read scale items to participants who were unable to read or were illiterate.
Measurements Barthel’s Index The BI, developed by Mahoney and Barthel (1965), assesses BADL in terms of respondent abilities related to feeding, bathing, grooming, dressing, bowel and bladder control, toilet use, transfer, mobility, and stair use. Researchers use observation or participant inquiry to assess each BI item. The BI scores range from 0 to 100, with higher scores representing higher independence in performing BADLs. A total BI score of 0Y20 correlates with total dependence, 21Y60 correlates with severe dependence, 61Y90 correlates with moderate dependence, 91Y99 correlates with slight dependence, and 100 correlates with total independence. The Chinese version was tested in older populations, with Cronbach’s alpha ranging from .79 to .85 (Shyu, Tang, Tsai, Liang, & Chen, 2006). The Cronbach’s alpha for the current study was .93. Taiwan Geriatric Depression Scale The TGDS, developed by Liao et al. in 2004, is a 30-item dichotomous scale. Older adults are asked to answer ‘‘yes’’ or ‘‘no.’’ Each ‘‘yes’’ is scored as 1, and each ‘‘no’’ is scored as 0. Scores range from 0 to 30 points, with higher scores indicating greater depression. The optimal cutoff point for older adults is a score of 15; scores exceeding the cutoff point indicate that depression is likely. Liao et al. (2004) reported a reliability of .94 (KuderYRichardson 20). The KuderYRichardson 20 score for the current study was .87.
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Depression in Older Residents
Ethical Considerations Ethical approval was obtained from the institutional review board of the university. An information sheet was given to all participants. Participants signed written consent forms before data collection. Participant anonymity was assured. Furthermore, participants were informed that they could withdraw from the study at any time without affecting their rights to receive healthcare.
Data Analysis SPSS v.17.0 was used to analyze the data (SPSS, Inc., Chicago, IL, USA). Descriptive analyses described participants’ demographic and disease characteristics. Because assumptions of distribution normality were not met, data were analyzed using the MannYWhitney U tests and KruskalYWallis tests to compare intergroup differences. The Bonferroni method was used to adjust the p value based on the number of tested comparisons. Spearman correlation explored the relationships between variables. The hierarchical multiple regression model investigated the key factors associated with depression. Three hierarchical multiple regression models were tested. The first model controlled for demographic data (e.g., gender, age, and educational level), the second model added BI as an independent variable, and the third model examined institution type to identify predictors of depression. Categorical variables were converted into dummy variables. Illiterate residents were used as the reference group for the education variable, and DCF was used as the reference group for the type of institution. A reported p value below .05 was considered statistically significant.
Results Relationships Among Sociodemographic Characteristics, Physical Function, and Depression The 23 target LTCFs invited to participate included seven NHs, 11 ICFs, and five DCFs. Four hundred fifteen older residents with stroke were approached. Cognitive disorders excluded 135 residents; frailty, discomfort, or refusal excluded 132 residents; and 37 were excluded because of inability to communicate. One hundred eleven (26.7%) residents provided complete data. Data were collected from October 2008 through April 2009. More than half (n = 58, 52.3%) were living in ICFs. Ages ranged from 65 to 100 years (mean = 76.38, SD = 6.89). Three quarters were illiterate or had only an elementary school education (n = 84, 75.7%). Most (n = 92, 82.9%) had experienced one cerebrovascular accident only. Nearly all (n = 107, 96.4%) had developed hemi-paralysis, with the remaining four experiencing quadriparalysis. The mean (SD) score for BI was 44.14 (33.47), indicating severe dependence in BADL. The mean (SD) score for TGDS was 12.55 (6.60), with a range of 1Y27. More
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than one third of the participants (n = 41, 36.9%) scored higher than 15, indicating depression. Prevalence of depression in NHs, ICFs, and DCFs was thus 45.7% (n = 35), 36.2% (n = 21), and 22.2% (n = 4), respectively. Table 1 presents demographic data. Educational level significantly affected participant depression scores (2 2 = 7.499, p G .05). Bonferroni adjustments showed that older residents with stroke who were illiterate experienced higher levels of depression than those with a junior high school education and above. Type of institution also significantly affected participant depression scores (2 2 = 10.735, p G .01). Bonferroni adjustments showed that older residents with stroke in NHs and ICFs had higher depression scores than those in DCFs (Table 1).
Correlation of Demographic Characteristics, Physical Function, and Depression A Spearman correlation was performed to determine the relationship between variables. Age was not significantly correlated with depression level (r = Y .094, p = .327), whereas a negative and significant correlation was found between BI and depression (r = Y .203, p = .033; Table 1).
Factors Contributing to Depression This study tested three hierarchical multiple regression models. The first model controlled for demographic data, with results showing that illiterate participants had a higher incidence of depression than those with a junior high school education. In the second model, BI was added as an independent variable, with results showing that illiteracy and low BI score were significant predictors of depression (F = 3.443, p = .006). In the third model, institution type was added to identify important predictors of depression. A collinearity diagnosis of independent variables showed a tolerance result greater than .1 and variance inflation factors below 10, indicating the absence of multicollinearity among the independent variables (Hair, Black, Babin, Anderson, & Tatham, 2006). Results from the third model indicate type of institution (e.g., NH and ICF) and lower BI scores as significant predictors of depression (F = 3.351, p = .003). All variables explained 19% of the variance in depression (Table 2).
Discussion The current study investigated the incidence of depression in elderly stroke survivor residents of LTCFs in Taiwan. The mean (SD) score for TGDS in this study was 12.55 (6.60). More than one third (36.9%, n = 41) of the participants exceeded the depression scale cutoff score, suggesting that they were likely depressed. Our findings supported the 2011 study of Drageset et al. (2011), which reported that depression is a major health problem among NH residents. Moreover, the depression prevalence identified in this study was somewhat higher than in previous studies, which found a prevalence 113
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Hui-Tzu Huang et al.
TABLE 1.
Demographic and Disease Characteristics of Participants and Differences in Depression, by Variable (N = 111) Variable
n
%
M
SD
Gender Male Female
63 48
56.8 43.2
11.97 13.31
6.18 7.11
76.38
6.89
Age, years Educational level ffiIlliterate fflElementary school Junior high school and above
40 44 27
36.1 39.6 24.3
13.85 13.16 9.63
6.15 7.08 5.72
Marital status Married Not married
45 66
40.5 59.5
11.64 13.17
7.05 6.26
Religion Yes No
90 21
81.1 18.9
12.71 11.86
6.95 4.94
No. of stroke occurrences First time Recurrent
92 19
82.9 17.1
12.45 13.05
6.39 7.69
Number of concomitant diseases One Two Three Four or more
13 48 38 12
11.7 43.2 34.2 10.8
11.46 11.92 14.37 10.50
5.30 6.10 7.73 5.07
107 4
96.4 3.6
12.55 12.50
6.68 4.65
Reason for institutionalization Lack of caregiver Poor physical condition
73 38
65.8 34.2
12.42 12.79
6.62 6.66
Duration of institutionalization, months e6 7Y12 Q13
24 10 77
21.6 9.0 69.4
13.71 11.80 12.29
6.20 6.44 6.78
44.14
33.47
Paralysis Hemi-paralysis Quadri-paralysis
Barthel’s Index Type of institution NH ICF DCF
35 58 18
31.5 52.3 16.2
TGDS (1Y30) Score Q 15 Score G 14
41 70
36.9 63.1
TGDS score Q 15 NH (n = 35) ICF (n = 58) DCF (n = 18)
16 21 4
45.7 36.2 22.2
13.69 13.24 8.11
6.71 6.25 6.01
12.55
6.60
Z/# 2
p
Y.998
.318
Y.094
.327a
7.499
.024b .007
Y1.437
.151
Y.237
.812
Y.161
.872
1.775
.412
Y.135
.893
Y.258
.796
1.160
.560
Y.023
.033a
10.735
.005b .004 .002
Post Hoc
ffi9
ffi9 ffl9
Note. Age range: 65Y100; p = MannYWhitney U test and KruskalYWallis test; NH = nursing home; ICF = intermediate care facility; DCF = domiciliary care facility; TGDS = Taiwan Geriatric Depression Scale. a Spearman correlation test. bPost hoc by Bonferroni method.
ranging between 27% and 33.3% in community settings (Cheng et al., 2005; Hackett et al., 2005; Li et al., 2003). The three previous studies in Taiwan that measured depres-
sion in older LTCF residents found depression prevalence in the 39%Y82% range (Lin et al., 2004, 2005, 2007). Because the current study excludes residents with cognitive impairment,
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TABLE 2.
Hierarchical Multiple Regression Analysis Testing Depression Prediction Factors (N = 111) Model 1
Model 2
Model 3
"
"
"
Gender
j.008
j.010
.037
Age
j.149
j.182
j.177
Educational level Illiterate Elementary school Junior high school and above
Ref j.094 j.315*
Ref j.072 j.271*
Ref j.039 j.198
j.240*
j.197*
Variable
Barthel’s Index Type of institution DCF NH ICF
Ref .299* .291*
Model summary R2
.086
.141
.186
F
2.503
3.443
3.351
p
.047*
.006**
.003**
Note. DCF = domiciliary care facility; NH = nursing home; ICF = intermediate care facility. *p G .05. **p G .01.
overall depression prevalence in Taiwan LTCFs may be underestimated. This study confirmed that a lower level of education, especially illiteracy, correlates closely with increased depression risk in older adults with stroke. This finding is similar to the study results of Lin et al. (2007, 2005), which indicate that individuals with lower educational levels may be less aware of resources available to cope with depression. Illiterate residents may be less likely to communicate their symptoms after stroke. Therefore, LTCFs should develop specific strategies to deliver effective healthcare to older residents with stroke who are illiterate and/or of lower socioeconomic status (Fernandes et al., 2012). This study identified no association between depressive symptoms and any of the following variables: gender, age, marital status, religion, other disease characteristics including stroke recurrence, concomitant diseases, paralysis, reason for institutionalization, or duration of institutionalization. These results were consistent with previous studies of depression in older patients with stroke (Cheng et al., 2005; Li et al., 2003). However, previous studies of communitydwelling patients with stroke suggested that being a woman (Liao et al., 2004), being older (Farner et al., 2010), and having a higher risk of stroke recurrence (Yuan et al., 2012) were significantly associated with depression symptoms. More studies are needed to confirm our research findings regarding the relationships between demographic data and depression in older residents of LTCFs with stroke.
Stroke often occurs suddenly and disables patients physically as well as emotionally. This study found depression scores to be significantly and negatively correlated with ADL scores, with higher ADL scores correlating with fewer depression symptoms, which is consistent with previous studies (Cheng et al., 2005). In addition, a poor ADL score was found to be a significant predictor for depression, which is also consistent with previous studies (Drageset et al., 2011; Lin et al., 2007). Depression may promote further deterioration of physical function and lead to a vicious cycle (Richardson, Bedard, & Weaver, 2001). Robinson’s (2003) study indicated that effectively treating poststroke depression may enhance the recovery of ADL independence. Another study found that therapeutic exercise may reduce depression symptoms in patients after a stroke (Lai et al., 2006). The results of the current study show that the prevalence of depression in older residents with stroke varies at different facilities. Participants at NHs (45.7%) and ICFs (36.2%) showed higher depression scores than those at DCFs (22.2%). In Taiwan, NHs are qualified to admit residents with tracheal tubes, nasogastric tubes, and urinary catheters. Therefore, residents in NHs are usually more physically dependent and require more nursing care than those in ICFs and DCFs (Ministry of the Interior, 2012b). The residents in ICFs have considerable self-care deficits, whereas most DCF residents are able to care for themselves (Ministry of the Interior, 2012b). Although residents of these three institutions have various care-need levels, we found no difference in terms of BI scores. However, the surrounding environment will affect stroke survivors who are cognitively intact but face disability limitations. Farner et al. (2010) conducted a 13-month follow-up study on the depression symptoms of older patients with stroke and found that symptoms in the institutiondwelling older adults were worse than their home-dwelling peers and that continuous depression may lead to worse overall functioning. Therefore, we suggest that the emotions of residents living in NHs may be influenced by the poor physical conditions around them. Future study is needed to consider the environmental impact factors that influence depression in older residents with stroke. BI, NH, and ICF together accounted for only 19% of the total variance in depression. This suggests that other confounding factors exist behind depression. Antidepressant medicine (Cheng et al., 2005; Lin et al., 2005), which was not examined in this study, is one identified factor. Social support has also been associated with lower levels of depression in patients with stroke and older adults living in LTCFs (Li et al., 2003; Lin et al., 2007). This study was limited by several constraints. First, older residents with stroke in care facilities who had cognitive deficits, were not able to communicate, or had aphasia were excluded. Second, because a cross-sectional descriptive study design investigated the correlations between selected variables and participants’ depression and physical function, cause-andeffect relationships and the situations in other populations cannot be inferred. Future research should include longitudinal 115
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follow-up studies to investigate changes in depression patterns in this population. Third, this study employed purposive sampling to recruit participants from LTCFs located in southern Taiwan. Therefore, results may not apply to all older residents in care facilities. Finally, the TGDS used in this study was developed specifically for older Taiwanese, with a cutoff point set based on clinically relevant symptoms and culture. Previous studies have supported the reliability of the TGDS measurement and application (Bai, Chiou, Chang, & Lam, 2008; Chung, Chiou, & Chou, 2009).
Conclusions This study found a higher depression incidence in older residents of NHs and ICFs with stroke who were illiterate and/or had poor ADL functions. Moreover, 36.9% of older residents with stroke earned scores indicating that they were highly depressed. Therefore, we recommend that managers and healthcare providers working in care facilities conduct regular screenings and assessments for depression with older residents to facilitate early detection and treatment. In addition, care facilities should provide regular education and training for their caregivers to enhance staff capabilities in terms of identifying the signs and symptoms of depression in older residents. Level of depression relates closely to ADL function recovery in older residents with stroke. Therefore, older stroke residents should be encouraged to participate in physical rehabilitation to prevent further depression, facilitate recovery, and improve quality of life.
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Lin, L. P. (2007). Depression among the elderly: The review of epidemiological analysis and prevention strategies. Taiwan Journal of Gerontological Health Research, 3(1), 53Y64. (Original work published in Chinese) Lin, P. C., Wang, H. H., & Huang, H. T. (2007). Depressive symptoms among older residents at nursing homes in Taiwan. Journal of Clinical Nursing, 16(9), 1719Y1725. doi:10.1111/ j.1365-2702.2006.01743.x Mahoney, F. I., & Barthel, D. W. (1965). Functional evaluation: The Barthel Index. Maryland State Medical Journal, 14(2), 56Y61. Ministry of Health and Welfare. (2013). Annual statistical report of causes of death in 2012, Taiwan. Retrieved from http://www .mohw.gov.tw/cht/DOS/DisplayStatisticFile.aspx?d=13718&s=1 (Original work published in Chinese) Ministry of the Interior. (2012a). Population by age. Retrieved from http://sowf.moi.gov.tw/stat/year/y02-01.xls (Original work published in Chinese) Ministry of the Interior. (2012b). Establishment standards of senior citizens’ welfare institutions. Retrieved from http://sowf.moi .gov.tw/04/02/02_3.htm (Original work published in Chinese) Pfeiffer, E. (1975). A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. Journal of the American Geriatrics Society, 23(10), 433Y441. Richardson, J., Bedard, M., & Weaver, B. (2001). Changes in physical functioning in institutionalized older adults. Disability and Rehabilitation, 23(15), 683Y689. doi:10.1080/09638280110055084 Robinson, R. G. (2003). Poststroke depression: Prevalence, diagnosis,
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treatment, and disease progression. Biological Psychiatry, 54(3), 376Y387. doi:10.1016/s0006-3223(03)00423-2 Schmid, A. A., Damush, T., Tu, W., Bakas, T., Kroenke, K., Hendrie, H. C., & Williams, L. S. (2012). Depression improvement is related to social role functioning after stroke. Archives of Physical Medicine and Rehabilitation, 93(6), 978Y982. doi:10.1016/ j.apmr.2011.12.012 Shyu, Y. I. L., Tang, W. R., Tsai, W. C., Liang, L., & Chen, M. C. (2006). Emotional support levels can predict physical functioning and health related quality of life among elderly Taiwanese with hip fractures. Osteoporosis International, 17(4), 501Y506. doi:10.1007/s00198-005-0020-y Tsai, Y. F., Chung, J. W. Y., Wong, T. K. S., & Huang, C. M. (2005). Comparison of the prevalence and risk factors for depressive symptoms among elderly nursing home residents in Taiwan and Hong Kong. International Journal of Geriatric Psychiatry, 20(4), 315Y321. doi:10.1002/gps.1281 Whyte, E. M., & Mulsant, B. H. (2002). Post stroke depression: Epidemiology, pathophysiology, and biological treatment. Biological Psychiatry, 52(3), 253Y264. doi:10.1016/s0006-3223(02)01424-5 Williams, C. L., Rittman, M. R., Boylstein, C., Faircloth, C., & Haijing, Q. (2005). Qualitative and quantitative measurement of depression in veterans recovering from stroke. Journal of Rehabilitation Research & Development, 42(3), 277Y290. doi:10 .1682/JRRD.2004.02.0017 Yuan, H. W., Wang, C. X., Zhang, N., Bai, Y., Shi, Y. Z., Zhou, Y., I Wang, Y. J. (2012). Poststroke depression and risk of recurrent stroke at 1 year in a Chinese cohort study. PLoS One, 7(10), e46906. doi:10.1371/journal.pone.0046906
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憂鬱與中風老年住民
VOL. 22, NO. 2, JUNE 2014
長期照護機構中風老人憂鬱之探討 黃惠子1 莊宇慧2 薛逸華3 藺寶珍4 李碧娥5 陳清惠6* 1
中華醫事科技大學護理系講師 2臺北醫學大學護理學院助理教授 3行政院衛生福利部 八里療養院精神科病房護士 4國立台南護專護理科副教授 5長庚科技大學嘉義分部 護理系副教授 6國立成功大學健康照護科學研究所暨護理學系教授
背 景
在台灣腦中風為死亡原因之第三位 ，中風後老人由於失能或照顧之需要而入住長期機 構。中風與機構安置此兩種生活事件之衝擊 ，可能使中風存活者傾向憂鬱。然而目前 缺乏長期照護機構中風老人憂鬱之研究。
目 的
探討長期照護機構中風老年住民憂鬱的相關因素。
方 法
採橫斷式研究 ，於南台灣共 23 家長期照護機構參與本研究 ，包含 7 間護理之家 、11 間 養護中心及 5 間安養機構。以立意取樣 ，選取 65 歲以上有中風病史之住民 ，排除認知 及溝通障礙者。資料收集包含社會人口學資料 、巴氏量表及台灣老人憂鬱量表。
結 果
共 111 位中風老年住民參與本研究 ，結果 36.9%（n = 41）之中風老年住民有憂鬱情形。 憂鬱比率分別是護理之家 45.7%、養護中心 36.2%、安養中心 22.2%。護理之家及養護 機構 、不識字及低巴氏分數的老年中風住民顯示較多的憂鬱症狀。
結 論 健康照護者需針對中風老人入住機構時進行憂鬱篩選 ，並定期評估及監測老人的憂鬱 實務應用 狀況 ，特別是低教育 、身體功能差 、及居住於護理之家及養護中心的老年住民 ，需特 別關注憂鬱的適當照護。
關鍵詞：日常生活功能、憂鬱、長期照護機構、老年住民、中風。
接受刊載：102年7月28日 *通訊作者地址：陳清惠 70101台南市東區大學路一號 電話：（06）2353535－5834 E-mail: [email protected]
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Depression in Older Residents With Stroke Living in Long-Term Care Facilities Hui-Tzu Huang1 & Yeu-Hui Chuang2 & Yi-Hua Hsueh3 & Pao-Chen Lin4 Bih-O Lee5 & Ching-Huey Chen6* 1
PhD, RN, Lecturer, Department of Nursing, Chung Hwa University of Medical Technology & 2PhD, RN, Assistant Professor, College of Nursing, Taipei Medical University & 3BSN, RN, Psychiatric Center Bali, Ministry of Health and Welfare & 4PhD, RN, Associate Professor, National Tainan Junior College of Nursing & 5PhD, RN, Associate Professor, Department of Nursing, Chiayi Campus, Chang Gung University of Science and Technology & 6PhD, RN, Professor, Institute of Allied Health Sciences and Department of Nursing, College of Medicine, National Cheng Kung University.
Introduction
ABSTRACT Background: Stroke is the third leading cause of death in Taiwan. Poststroke older adults are often admitted to long-term care facilities. The impacts of the two concurrent life events of stroke and relocation may increase the risk of depression in stroke survivors. Depression in elderly stroke survivor residents of long-term care facilities has not been studied. Purpose: This study explores the factors associated with depression in older residents with stroke living in long-term care facilities. Methods: A cross-sectional design was used. Twenty-three institutions in southern Taiwan participated in this study, including seven nursing homes, 11 intermediate-care facilities, and five domiciliary-care facilities. Purposive sampling enrolled 111 participants who met the following inclusion criteria: 65 years or older, experienced a stroke that did not cause cognitive defects, and capable of verbal communication. Data were collected using a sociodemographic data questionnaire, Barthel’s Index, and the Taiwan Geriatric Depression Scale. Results: Depression was experienced by 41 of the 111 participants (36.9%). Prevalence of depression was 45.7% in nursing homes, 36.2% in intermediate-care facilities, and 22.2% in domiciliary-care facilities. Participants living in nursing homes and intermediate-care facilities and illiterate participants with low Barthel’s Index scores showed more depressive symptoms. Conclusions/Implications for Practice: Healthcare providers should conduct depression screening for elderly residents with stroke on admission to long-term care facilities. Regular assessment and monitoring of depressive symptoms, especially in residents with less formal education and limited physical functions, are important in nursing homes and intermediate-care facilities.
KEY WORDS: activity of daily living, depression, long-term care facility, older resident, stroke.
Adults older than 65 years face an increased risk of cerebrovascular problems (Chen, Balami, Esiri, Chen, & Buchan, 2010). This group constitutes roughly 11.15% of the population of Taiwan (Ministry of the Interior, 2012a). Cerebrovascular accident, also known as stroke, is the third leading cause of death in Taiwan (Ministry of Health and Welfare, 2013). Stroke may impair motor, sensory, and perception functions and lead to dependence in activities of daily living (ADLs; Robinson, 2003). The loss of independence in ADLs necessitates that older adults with stroke receive a great deal of care, which leads to many elderly patients with stroke moving into long-term care facilities (LTCFs; Farner et al., 2010; Lee & Choi, 2002). Nursing homes (NHs), intermediatecare facilities (ICFs), domiciliary-care facilities (DCFs), and dementia care institutions are the different types of LTCFs in Taiwan. In Taiwan, NHs provide nursing care to patients with long-term chronic diseases, ICFs serve individuals who lack the capacity to take care of themselves, and DCFs offer housing to people who can take care of themselves in daily life (Ministry of the Interior, 2012b). Long-term residence in LTCFs has been associated with prevalence of depression in older residents at a rate that is three to four times higher than in community-dwelling peers (Jongenelis et al., 2004). In Taiwan, the prevalence of depression among older residents in LTCFs has been reported to range from 39% to 82% (Lin, Wang, Chen, Wu, & Portwood, Accepted for Publication: July 28, 2013 *Address correspondence to: Ching-Huey Chen, No.1, University Rd., East District, Tainan City 70101, Taiwan, ROC. Tel: +886 (6) 235-3535 ext. 5834; Fax: +886 (6) 237-7550; E-mail: [email protected] Cite this article as: Huang, H. T., Chuang, Y. H., Hsueh, Y. H., Lin, P. C., Lee, B. O., & Chen, C. H. (2014). Depression in older residents with stroke living in long-term care facilities. The Journal of Nursing Research, 22(2), 111Y118. doi:10.1097/jnr.0000000000000028
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2005; Lin, Wang, & Huang, 2007; Lin, Yu, & Chang, 2004). This is higher than the 8.1%Y24% range reported in Western countries (Jongenelis et al., 2004). In addition, the prevalence of depression among patients with stroke in Taiwan (27.4%Y33.3%; Cheng et al., 2005; Li, Wang, & Lin, 2003) is higher than that in Western countries (5.5%Y37%; Hackett, Yapa, Parag, & Anderson, 2005; Whyte & Mulsant, 2002; Williams, Rittman, Boylstein, Faircloth, & Haijing, 2005). Several studies have identified various factors associated with depressive symptoms in older LTCF residents. These factors include age (Drageset, Eide, & Ranhoff, 2011; Lin, 2007), gender (Tsai, Chung, Wong, & Huang, 2005), educational level (Lin et al., 2007), length of residence and number of chronic conditions (Lin et al., 2007), functional status as measured using the Barthel Index (Lin et al., 2005; Tsai et al., 2005), and type of institution (Lin et al., 2005). Depression is significantly associated with lower quality of life (Chang, Ling, Chen, & Lu, 2006; Schmid et al., 2012), which can increase morbidity and mortality (Ellis, Zhao, & Egede, 2010). Stroke survivors may experience losses in terms of health, occupation, social role, and independence. Any of these factors may cause major changes in a person’s life (Whyte & Mulsant, 2002). Poststroke depression has been associated with brain damage and increased disability, cognitive impairment, and mortality (Robinson, 2003; Whyte & Mulsant, 2002). Previous studies have shown that gender (Liao et al., 2004), age (Farner et al., 2010; Hornsten, Molander, & Gustafson, 2012), and risk of recurrent stroke (Yuan et al., 2012) are factors associated with depressive symptoms in poststroke patients. In summary, previous studies indicate that depressive symptoms among older patients with stroke are affected by interrelated factors that include gender, age, education, functional status, length of residence, number of chronic conditions, risk of recurrent stroke, and type of LTCF. Limited research has examined depression among poststroke elderly residents of LTCFs. Because filial piety is a central theme in Asian culture (Laidlaw, Wang, Coelho, & Power, 2010), older people expect to be with and be taken care of by their families when they are old or ill. Therefore, older adults who experience a stroke and subsequent relocation to a care facility may face a higher risk of depression. This study explored the factors associated with depression in older LTCF residents with stroke. The main hypothesis of this study was that risk of depression differs in older residents living in different LTCFs (Lin et al., 2005).
Methods Design and Sample A cross-sectional design was conducted at NHs, ICFs, and DCFs in southern Taiwan. We contacted 64 LTCFs accredited by the Ministry of Health and Welfare, Executive Yuan, and Bureau of Social Affairs in Tainan City. We excluded dementia care institutions from consideration. Nine of the thirty-two institutions that agreed to participate in the study did not
Hui-Tzu Huang et al.
have residents who met our inclusion criteria. Therefore, 23 LTCFs composed the target sample for this study. The directors of the LTCFs referred residents to the researchers. Inclusion criteria for this study required that LTCF residents be 65 years or older, to have experienced a physician-diagnosed stroke, and be cognitively intact. The Short Portable Mental Status Questionnaire assessed cognition, with a score of 98 required for eligibility (Pfeiffer, 1975). This study applied a purposive sampling methodology. Residents unable to communicate in Mandarin or Taiwanese and those exhibiting aphasia were excluded. A minimum sample size of 109 subjects was determined using G*Power 3.0 software (Faul, Erdfelder, Lang, & Buchner, 2007), with the power set at .80, the ! at .05, and the effect size at .262 in accordance with Cheng et al. (2005).
Data Collection Several instruments were used to assess the presence of depression and its associated variables. Demographic information was obtained from medical records and confirmed by nurses at the institutions. Barthel’s Index (BI) assessed basic ADLs (BADLs). The Taiwan Geriatric Depression Score (TGDS) assessed participants’ self-reported depressive symptoms. The researcher read scale items to participants who were unable to read or were illiterate.
Measurements Barthel’s Index The BI, developed by Mahoney and Barthel (1965), assesses BADL in terms of respondent abilities related to feeding, bathing, grooming, dressing, bowel and bladder control, toilet use, transfer, mobility, and stair use. Researchers use observation or participant inquiry to assess each BI item. The BI scores range from 0 to 100, with higher scores representing higher independence in performing BADLs. A total BI score of 0Y20 correlates with total dependence, 21Y60 correlates with severe dependence, 61Y90 correlates with moderate dependence, 91Y99 correlates with slight dependence, and 100 correlates with total independence. The Chinese version was tested in older populations, with Cronbach’s alpha ranging from .79 to .85 (Shyu, Tang, Tsai, Liang, & Chen, 2006). The Cronbach’s alpha for the current study was .93. Taiwan Geriatric Depression Scale The TGDS, developed by Liao et al. in 2004, is a 30-item dichotomous scale. Older adults are asked to answer ‘‘yes’’ or ‘‘no.’’ Each ‘‘yes’’ is scored as 1, and each ‘‘no’’ is scored as 0. Scores range from 0 to 30 points, with higher scores indicating greater depression. The optimal cutoff point for older adults is a score of 15; scores exceeding the cutoff point indicate that depression is likely. Liao et al. (2004) reported a reliability of .94 (KuderYRichardson 20). The KuderYRichardson 20 score for the current study was .87.
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Depression in Older Residents
Ethical Considerations Ethical approval was obtained from the institutional review board of the university. An information sheet was given to all participants. Participants signed written consent forms before data collection. Participant anonymity was assured. Furthermore, participants were informed that they could withdraw from the study at any time without affecting their rights to receive healthcare.
Data Analysis SPSS v.17.0 was used to analyze the data (SPSS, Inc., Chicago, IL, USA). Descriptive analyses described participants’ demographic and disease characteristics. Because assumptions of distribution normality were not met, data were analyzed using the MannYWhitney U tests and KruskalYWallis tests to compare intergroup differences. The Bonferroni method was used to adjust the p value based on the number of tested comparisons. Spearman correlation explored the relationships between variables. The hierarchical multiple regression model investigated the key factors associated with depression. Three hierarchical multiple regression models were tested. The first model controlled for demographic data (e.g., gender, age, and educational level), the second model added BI as an independent variable, and the third model examined institution type to identify predictors of depression. Categorical variables were converted into dummy variables. Illiterate residents were used as the reference group for the education variable, and DCF was used as the reference group for the type of institution. A reported p value below .05 was considered statistically significant.
Results Relationships Among Sociodemographic Characteristics, Physical Function, and Depression The 23 target LTCFs invited to participate included seven NHs, 11 ICFs, and five DCFs. Four hundred fifteen older residents with stroke were approached. Cognitive disorders excluded 135 residents; frailty, discomfort, or refusal excluded 132 residents; and 37 were excluded because of inability to communicate. One hundred eleven (26.7%) residents provided complete data. Data were collected from October 2008 through April 2009. More than half (n = 58, 52.3%) were living in ICFs. Ages ranged from 65 to 100 years (mean = 76.38, SD = 6.89). Three quarters were illiterate or had only an elementary school education (n = 84, 75.7%). Most (n = 92, 82.9%) had experienced one cerebrovascular accident only. Nearly all (n = 107, 96.4%) had developed hemi-paralysis, with the remaining four experiencing quadriparalysis. The mean (SD) score for BI was 44.14 (33.47), indicating severe dependence in BADL. The mean (SD) score for TGDS was 12.55 (6.60), with a range of 1Y27. More
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than one third of the participants (n = 41, 36.9%) scored higher than 15, indicating depression. Prevalence of depression in NHs, ICFs, and DCFs was thus 45.7% (n = 35), 36.2% (n = 21), and 22.2% (n = 4), respectively. Table 1 presents demographic data. Educational level significantly affected participant depression scores (2 2 = 7.499, p G .05). Bonferroni adjustments showed that older residents with stroke who were illiterate experienced higher levels of depression than those with a junior high school education and above. Type of institution also significantly affected participant depression scores (2 2 = 10.735, p G .01). Bonferroni adjustments showed that older residents with stroke in NHs and ICFs had higher depression scores than those in DCFs (Table 1).
Correlation of Demographic Characteristics, Physical Function, and Depression A Spearman correlation was performed to determine the relationship between variables. Age was not significantly correlated with depression level (r = Y .094, p = .327), whereas a negative and significant correlation was found between BI and depression (r = Y .203, p = .033; Table 1).
Factors Contributing to Depression This study tested three hierarchical multiple regression models. The first model controlled for demographic data, with results showing that illiterate participants had a higher incidence of depression than those with a junior high school education. In the second model, BI was added as an independent variable, with results showing that illiteracy and low BI score were significant predictors of depression (F = 3.443, p = .006). In the third model, institution type was added to identify important predictors of depression. A collinearity diagnosis of independent variables showed a tolerance result greater than .1 and variance inflation factors below 10, indicating the absence of multicollinearity among the independent variables (Hair, Black, Babin, Anderson, & Tatham, 2006). Results from the third model indicate type of institution (e.g., NH and ICF) and lower BI scores as significant predictors of depression (F = 3.351, p = .003). All variables explained 19% of the variance in depression (Table 2).
Discussion The current study investigated the incidence of depression in elderly stroke survivor residents of LTCFs in Taiwan. The mean (SD) score for TGDS in this study was 12.55 (6.60). More than one third (36.9%, n = 41) of the participants exceeded the depression scale cutoff score, suggesting that they were likely depressed. Our findings supported the 2011 study of Drageset et al. (2011), which reported that depression is a major health problem among NH residents. Moreover, the depression prevalence identified in this study was somewhat higher than in previous studies, which found a prevalence 113
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Hui-Tzu Huang et al.
TABLE 1.
Demographic and Disease Characteristics of Participants and Differences in Depression, by Variable (N = 111) Variable
n
%
M
SD
Gender Male Female
63 48
56.8 43.2
11.97 13.31
6.18 7.11
76.38
6.89
Age, years Educational level ffiIlliterate fflElementary school Junior high school and above
40 44 27
36.1 39.6 24.3
13.85 13.16 9.63
6.15 7.08 5.72
Marital status Married Not married
45 66
40.5 59.5
11.64 13.17
7.05 6.26
Religion Yes No
90 21
81.1 18.9
12.71 11.86
6.95 4.94
No. of stroke occurrences First time Recurrent
92 19
82.9 17.1
12.45 13.05
6.39 7.69
Number of concomitant diseases One Two Three Four or more
13 48 38 12
11.7 43.2 34.2 10.8
11.46 11.92 14.37 10.50
5.30 6.10 7.73 5.07
107 4
96.4 3.6
12.55 12.50
6.68 4.65
Reason for institutionalization Lack of caregiver Poor physical condition
73 38
65.8 34.2
12.42 12.79
6.62 6.66
Duration of institutionalization, months e6 7Y12 Q13
24 10 77
21.6 9.0 69.4
13.71 11.80 12.29
6.20 6.44 6.78
44.14
33.47
Paralysis Hemi-paralysis Quadri-paralysis
Barthel’s Index Type of institution NH ICF DCF
35 58 18
31.5 52.3 16.2
TGDS (1Y30) Score Q 15 Score G 14
41 70
36.9 63.1
TGDS score Q 15 NH (n = 35) ICF (n = 58) DCF (n = 18)
16 21 4
45.7 36.2 22.2
13.69 13.24 8.11
6.71 6.25 6.01
12.55
6.60
Z/# 2
p
Y.998
.318
Y.094
.327a
7.499
.024b .007
Y1.437
.151
Y.237
.812
Y.161
.872
1.775
.412
Y.135
.893
Y.258
.796
1.160
.560
Y.023
.033a
10.735
.005b .004 .002
Post Hoc
ffi9
ffi9 ffl9
Note. Age range: 65Y100; p = MannYWhitney U test and KruskalYWallis test; NH = nursing home; ICF = intermediate care facility; DCF = domiciliary care facility; TGDS = Taiwan Geriatric Depression Scale. a Spearman correlation test. bPost hoc by Bonferroni method.
ranging between 27% and 33.3% in community settings (Cheng et al., 2005; Hackett et al., 2005; Li et al., 2003). The three previous studies in Taiwan that measured depres-
sion in older LTCF residents found depression prevalence in the 39%Y82% range (Lin et al., 2004, 2005, 2007). Because the current study excludes residents with cognitive impairment,
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Depression in Older Residents
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TABLE 2.
Hierarchical Multiple Regression Analysis Testing Depression Prediction Factors (N = 111) Model 1
Model 2
Model 3
"
"
"
Gender
j.008
j.010
.037
Age
j.149
j.182
j.177
Educational level Illiterate Elementary school Junior high school and above
Ref j.094 j.315*
Ref j.072 j.271*
Ref j.039 j.198
j.240*
j.197*
Variable
Barthel’s Index Type of institution DCF NH ICF
Ref .299* .291*
Model summary R2
.086
.141
.186
F
2.503
3.443
3.351
p
.047*
.006**
.003**
Note. DCF = domiciliary care facility; NH = nursing home; ICF = intermediate care facility. *p G .05. **p G .01.
overall depression prevalence in Taiwan LTCFs may be underestimated. This study confirmed that a lower level of education, especially illiteracy, correlates closely with increased depression risk in older adults with stroke. This finding is similar to the study results of Lin et al. (2007, 2005), which indicate that individuals with lower educational levels may be less aware of resources available to cope with depression. Illiterate residents may be less likely to communicate their symptoms after stroke. Therefore, LTCFs should develop specific strategies to deliver effective healthcare to older residents with stroke who are illiterate and/or of lower socioeconomic status (Fernandes et al., 2012). This study identified no association between depressive symptoms and any of the following variables: gender, age, marital status, religion, other disease characteristics including stroke recurrence, concomitant diseases, paralysis, reason for institutionalization, or duration of institutionalization. These results were consistent with previous studies of depression in older patients with stroke (Cheng et al., 2005; Li et al., 2003). However, previous studies of communitydwelling patients with stroke suggested that being a woman (Liao et al., 2004), being older (Farner et al., 2010), and having a higher risk of stroke recurrence (Yuan et al., 2012) were significantly associated with depression symptoms. More studies are needed to confirm our research findings regarding the relationships between demographic data and depression in older residents of LTCFs with stroke.
Stroke often occurs suddenly and disables patients physically as well as emotionally. This study found depression scores to be significantly and negatively correlated with ADL scores, with higher ADL scores correlating with fewer depression symptoms, which is consistent with previous studies (Cheng et al., 2005). In addition, a poor ADL score was found to be a significant predictor for depression, which is also consistent with previous studies (Drageset et al., 2011; Lin et al., 2007). Depression may promote further deterioration of physical function and lead to a vicious cycle (Richardson, Bedard, & Weaver, 2001). Robinson’s (2003) study indicated that effectively treating poststroke depression may enhance the recovery of ADL independence. Another study found that therapeutic exercise may reduce depression symptoms in patients after a stroke (Lai et al., 2006). The results of the current study show that the prevalence of depression in older residents with stroke varies at different facilities. Participants at NHs (45.7%) and ICFs (36.2%) showed higher depression scores than those at DCFs (22.2%). In Taiwan, NHs are qualified to admit residents with tracheal tubes, nasogastric tubes, and urinary catheters. Therefore, residents in NHs are usually more physically dependent and require more nursing care than those in ICFs and DCFs (Ministry of the Interior, 2012b). The residents in ICFs have considerable self-care deficits, whereas most DCF residents are able to care for themselves (Ministry of the Interior, 2012b). Although residents of these three institutions have various care-need levels, we found no difference in terms of BI scores. However, the surrounding environment will affect stroke survivors who are cognitively intact but face disability limitations. Farner et al. (2010) conducted a 13-month follow-up study on the depression symptoms of older patients with stroke and found that symptoms in the institutiondwelling older adults were worse than their home-dwelling peers and that continuous depression may lead to worse overall functioning. Therefore, we suggest that the emotions of residents living in NHs may be influenced by the poor physical conditions around them. Future study is needed to consider the environmental impact factors that influence depression in older residents with stroke. BI, NH, and ICF together accounted for only 19% of the total variance in depression. This suggests that other confounding factors exist behind depression. Antidepressant medicine (Cheng et al., 2005; Lin et al., 2005), which was not examined in this study, is one identified factor. Social support has also been associated with lower levels of depression in patients with stroke and older adults living in LTCFs (Li et al., 2003; Lin et al., 2007). This study was limited by several constraints. First, older residents with stroke in care facilities who had cognitive deficits, were not able to communicate, or had aphasia were excluded. Second, because a cross-sectional descriptive study design investigated the correlations between selected variables and participants’ depression and physical function, cause-andeffect relationships and the situations in other populations cannot be inferred. Future research should include longitudinal 115
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follow-up studies to investigate changes in depression patterns in this population. Third, this study employed purposive sampling to recruit participants from LTCFs located in southern Taiwan. Therefore, results may not apply to all older residents in care facilities. Finally, the TGDS used in this study was developed specifically for older Taiwanese, with a cutoff point set based on clinically relevant symptoms and culture. Previous studies have supported the reliability of the TGDS measurement and application (Bai, Chiou, Chang, & Lam, 2008; Chung, Chiou, & Chou, 2009).
Conclusions This study found a higher depression incidence in older residents of NHs and ICFs with stroke who were illiterate and/or had poor ADL functions. Moreover, 36.9% of older residents with stroke earned scores indicating that they were highly depressed. Therefore, we recommend that managers and healthcare providers working in care facilities conduct regular screenings and assessments for depression with older residents to facilitate early detection and treatment. In addition, care facilities should provide regular education and training for their caregivers to enhance staff capabilities in terms of identifying the signs and symptoms of depression in older residents. Level of depression relates closely to ADL function recovery in older residents with stroke. Therefore, older stroke residents should be encouraged to participate in physical rehabilitation to prevent further depression, facilitate recovery, and improve quality of life.
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Depression in Older Residents
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憂鬱與中風老年住民
VOL. 22, NO. 2, JUNE 2014
長期照護機構中風老人憂鬱之探討 黃惠子1 莊宇慧2 薛逸華3 藺寶珍4 李碧娥5 陳清惠6* 1
中華醫事科技大學護理系講師 2臺北醫學大學護理學院助理教授 3行政院衛生福利部 八里療養院精神科病房護士 4國立台南護專護理科副教授 5長庚科技大學嘉義分部 護理系副教授 6國立成功大學健康照護科學研究所暨護理學系教授
背 景
在台灣腦中風為死亡原因之第三位 ，中風後老人由於失能或照顧之需要而入住長期機 構。中風與機構安置此兩種生活事件之衝擊 ，可能使中風存活者傾向憂鬱。然而目前 缺乏長期照護機構中風老人憂鬱之研究。
目 的
探討長期照護機構中風老年住民憂鬱的相關因素。
方 法
採橫斷式研究 ，於南台灣共 23 家長期照護機構參與本研究 ，包含 7 間護理之家 、11 間 養護中心及 5 間安養機構。以立意取樣 ，選取 65 歲以上有中風病史之住民 ，排除認知 及溝通障礙者。資料收集包含社會人口學資料 、巴氏量表及台灣老人憂鬱量表。
結 果
共 111 位中風老年住民參與本研究 ，結果 36.9%（n = 41）之中風老年住民有憂鬱情形。 憂鬱比率分別是護理之家 45.7%、養護中心 36.2%、安養中心 22.2%。護理之家及養護 機構 、不識字及低巴氏分數的老年中風住民顯示較多的憂鬱症狀。
結 論 健康照護者需針對中風老人入住機構時進行憂鬱篩選 ，並定期評估及監測老人的憂鬱 實務應用 狀況 ，特別是低教育 、身體功能差 、及居住於護理之家及養護中心的老年住民 ，需特 別關注憂鬱的適當照護。
關鍵詞：日常生活功能、憂鬱、長期照護機構、老年住民、中風。
接受刊載：102年7月28日 *通訊作者地址：陳清惠 70101台南市東區大學路一號 電話：（06）2353535－5834 E-mail: [email protected]
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