Guidelines for a Palliative Approach in Residential Aged Care

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7.1.1 Death statements and depression A comprehensive assessment and appropriate response to a resident’s expression of a desire for death is vitally important [63] (Level IV). Depression is frequently undiagnosed and should therefore be considered as a potential reason for ‘desire to die’ statements [63] (Level IV). Diagnosing depression in people with a terminal illness or in the end stage of the ageing process can be complicated (see Table 9 for symptoms of depression). An alternative to the Diagnostic Statisticians Manual (4th ed) (DSM-IV) [273] criteria for depression is available (see table 10) and may be a useful guide for members of the aged care team who are suitably trained [274] (Level IV). Physical manifestations of depression may also be useful in screening for depression in RACF residents. A number of symptoms have been described that may be indicators of depression (see Table 9). If several of these symptoms are apparent to the aged care team, the resident should be referred to an appropriate professional (e.g. geriatrician or psychologist). Table 15: Symptoms of depression — Adaptation from DSM-IV [274] Loss of interest or pleasure Depressed mood Sleep disturbance Poor pain and symptom control Suicidal thoughts Inability to think or concentrate Feelings of worthlessness, hopelessness or helplessness, inappropriate guilt, and/or persistent negativism Agitation or retardation Fatigue Altered appetite Flattened mood (lack of expression in situations that previously had been pleasurable) Frequently expressed death desire Recurring thoughts of suicide or death Social withdrawal (attempts to remain away from people when previously would engage, no connection with care givers) 7.1.2 Assessment It is important to note that no tool currently exists that can assist in distinguishing between delirium, depression and dementia; therefore, different screening tools are required for each. Depression can be screened by the use of very brief scales that are suitable for use with residents. A one-question screening tool has been accepted as an appropriate way of identifying those people requiring a more detailed clinical assessment for depression [274] (Level IV). The tool found to be most effective was the Mental Health Inventory (1-Item Version; MHI-1) [275] which asks: “How much of the time over the past month have you felt downhearted and sad?” [274] (Level IV). Possible responses range from 1 to 6, as shown below, with a score of 3 or higher indicating potential depression. The aged care team could incorporate this question into their plan of care as a simple way of screening residents for depression. Guidelines for a Palliative Approach in Residential Aged Care 119
Table 16: Mental Health Inventory (1-item version) [275] Question: How much of the time over the past month have you felt downhearted and sad? Response choices: All of the time 6 Some of the time 3 Most of the time 5 A little of the time 2 A good bit of the time 4 None of the time 1 It should be noted that the MHI-1 is only recommended for identifying those who require further assessment for depression; it should not be used in the place of a formal assessment for depression, such as the Geriatric Depression Scale or the Cornell Scale. The Geriatric Depression Scale (GDS) is available in two formats: a 30-item scale (GDS-30) [276] and a 15-item scale (GDS-15). [277] The GDS is an assessment tool to assist in determining depression for older persons, including those in long-term care. A study of the GDS found the use of this scale for screening for depression could increase the frequency of treatment or referral of people in long-term care by primary care physicians [278] (Level II). A recent study of the GDS-15 found that the tool was suitable for diagnosing depression in the over 85-yearold population [279] (Level QE). Additionally, the authors recommended setting a low cut-off point of 2 out of 3 points to provide GPs with a reliable sensitivity for ensuring that people with clinical depression would not be overlooked. The GDS’s suitability for older persons with cognitive impairment has yet to be determined [279] (Level QE). The Cornell Scale for Depression in Dementia (CSDD) is a 19-item instrument using information gathered from an interview with the person with dementia and a caregiver (e.g. family member or staff member). [280] The scale’s items were developed based on a literature review to determine the experience of depression for people with or without dementia and information based on a questionnaire administered to geriatric psychiatrists and other experts in the field. The scale categorises depression into five content areas: [280] 1. mood-related signs (anxiety, sadness, lack of reactivity to pleasant events, irritability); 2. behavioural disturbances (agitation, retardation, multiple physical complaints, loss of interest); 3. physical signs (appetite loss, weight loss, lack of energy); 4. cyclic functioning (mood swings, difficulty falling asleep, multiple awakenings during sleep, early morning awakenings); and 5. ideational disturbances (suicide, poor self-esteem, pessimism, mood-congruent delusions). The CSDD was found to be a reliable scale of depressive symptoms among older persons with dementia [281] (Level IV). Additionally, CSDD scores have demonstrated moderate to high correlations with clinical diagnoses of major depression for older persons with or without dementia. [281] However, further analysis of the CSDD found evidence of four factors rather than the five proposed by the authors of the CSDD [282] (Level IV). These results indicate that the CSDD sub-scales should be interpreted with some caution until further studies determine 120 Guidelines for a Palliative Approach in Residential Aged Care
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Guidelines for a Palliative Approac
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NHMRC APPROVAL These guidelines wer
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4 ADVANCE CARE PLANNING 55 4.1 Impl
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16 MANAGEMENT’S ROLE IN IMPLEMENT
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17 Ann and Mr Wells’ family Helpi
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IMPORTANT NOTICE On 8 December 2005
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achieved for these guidelines from
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facets of a palliative approach are
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Additional levels of evidence The N
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Guidelines Ref No. Evidence level A
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Guidelines Ref No. Evidence Cachexi
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Guidelines Ref No. Evidence Anxiety
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Guidelines Ref No. Evidence 70. Und
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1.1.1 Aims The aims of the systemat
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Table 1: Search terms Terms Aborigi
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1.1.5 Exclusion Criteria Although t
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in the methodology that may invalid
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To ensure the reliability of the re
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1.2.2 Methodology When the first re
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1.4.2 Method When feedback was requ
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Several Working Party members conve
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or disagreed with each stakeholder
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All the feedback received was colla
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CHAPTER 2 A PALLIATIVE APPROACH A s
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• Profound weakness • Trouble s
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• Has the resident had a recent d
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in the RACF rather than transferrin
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palliative care teams is more appro
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or ageing progression (see Table 4)
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Table 7: A practical model of socia
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Vignette 2: Robert’s story Robert
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CHAPTER 4 ADVANCE CARE PLANNING Car
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efore discussing the advance care p
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• A change in their health status
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CHAPTER 5 ADVANCED DEMENTIA Advance
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A study was conducted to investigat
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5.3.2 Acute illness One study found
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Vignette 5: Anna’s story Anna was
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Page 87 and 88: Table 8: Common myths about pain ma
Page 89 and 90: 6.2.4 Breakthrough pain The term
Page 91 and 92: Pain can lead to behavioural change
Page 93 and 94: Vignette 7: Mrs Harris’ story Mrs
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Page 101 and 102: The reasons for malnutrition in old
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Page 105 and 106: To assist in such a discussion, a d
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Page 109 and 110: Guideline: Hydration 24. Recommenda
Page 111 and 112: 6.7 NAUSEA AND VOMITING Nausea is t
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Page 115 and 116: 6.9.1 Assessment A thorough oral as
Page 117 and 118: 6.10 SKIN INTEGRITY The major skin
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Page 121 and 122: Brocklehurst and colleagues (1999)
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Page 130 and 131: CHAPTER 7 PSYCHOLOGICAL SUPPORT A r
Page 134 and 135: the factor structure of the CSDD. I
Page 136 and 137: 7.2.2 Management Non-pharmacologica
Page 138 and 139: Table 17: Distinguishing delirium f
Page 140: is recognised that in many rural an
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Page 145 and 146: 8.4 FAMILY INVOLVEMENT The role of
Page 148 and 149: CHAPTER 9 SOCIAL SUPPORT, INTIMACY
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Page 152 and 153: 9.2.2 Management Imaginative progra
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Page 160 and 161: CHAPTER 11 CULTURAL ISSUES Australi
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Page 164 and 165: CHAPTER 12 SPIRITUAL SUPPORT Dein a
Page 166 and 167: Vignette 13: Jack’s story Jack wa
Page 168: Guideline: Spiritual Support 68. A
Page 171 and 172: interpersonal and leadership skills
Page 174 and 175: CHAPTER 14 END-OF-LIFE (TERMINAL) C
Page 176 and 177: mood (61%), constipation (59%) and
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14.5 PREPARING FOR IMMINENT DEATH
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education of the aged care team and
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Table 21: Grief, loss and bereaveme
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• excessively avoiding tasks remi
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Vignette 18: Reflections When provi
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may have been able to contribute to
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CHAPTER 16 Management’s role in i
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REFERENCES 1. World Health Organiza
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31. Hanson, L. C., Danis, M. & Garr
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60. World Health Organization Quali
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89. McCarthy, M., Addington-Hall, J
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121. Saunders, C. M. (1998). Forewo
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150. Sindrup, S. H. & Jensen, T. S.
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177. Berry, E. M. & Marcus, E.-L. (
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208. Robinson, S. B. & Rosher, R. B
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237. Brocklehurst, J., Dickinson, E
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265. Barraclough, J. (1997). ABC of
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295. Brown, T. M. & Boyle, M. F. (2
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328. Kristjanson, L. J., Leis, A.,
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360. McGrath, P., Vun, M. & McLeod,
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392. Saunders, C. M. & Baines, M. J
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424. Rawlings, D. & Glynn, T. (2002
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Glossary acetaminophen Acetaminophe
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coordinator of volunteers coping A
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geropsychologist A geropsychologist
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opioids Opioid is a specific term u
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specialised palliative team A speci
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Ms Wendy Shiels Dr Jane Sims Dr Chr
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APPENDIX B The Australian Governmen
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APRAC GUIDELINES: EVIDENCE EVALUATI
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APRAC GUIDELINES: EVIDENCE EVALUATI
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APPENDIX F: Summary of the frequenc
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APPENDIX G: An example of how the g
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APPENDIX I: Resource list PALLIATIV
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Psychological Challenge Depression
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APPENDIX J: Examples of advance dir
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Schedule 1 MEDICAL POWER OF ATTORNE
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APPENDIX K An example of a Genogram
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INDEX Abbey Pain Scale 64, 71, 78 A
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evidence levels 5, 6, 20, 21, 22 ev
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andomized controlled trials 5, 21 R
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Palliative Care Australia PO Box 24
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Guidelines for a Palliative Approach in Residential Aged Care

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