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DEPRESSION AND ENGAGEMENT IN A RESIDENTIAL HOME FOR THE ELDERLY

SARA SIMPSON’, ROBERT WOODS’ and PETER BRITTON~

‘Psychology Department. Prestwich Hospital. Bury New Road, Manchester; ‘Department of Psychology. lnstitute of Psychiatry, De Crespigny Park. Denmark Hill. London,

and ‘Department of Psychology, University of Newcastle upon Tyne. Newcastle upon Tyne. U.K.

(Receiced 17 February 1981)

Summary-Traditional residential care environments for the elderly have been criticized because of the observed low levels of residents’ engagement. Behavioural models of depression suggest an inverse relationship between engagement in pleasant activities and depression. The present study examined the relationship between depression and engagement in the residents of a home for the elderly. Correlational analyses indicated no relationship between level of depression and level of engagement but an association was found between level of depression and engagement in activi- ties subjectively most enjoyed. There was considerable variation in the residents’ perception of their behaviour; some residents viewed active engagement negatively whilst clearly enjoying behaviour that is technically disengaged. It is suggested that the results of the study emphasize the importance both of individual differences in behaviour and of covert behaviour. Implications for the engagement concept are discussed. In particular it is suggested that programmes in care environments aimed at increasing engagement in order to enhance the quality of life should focus more on the individual and on his perception of his behaviour.

INTRODUCTION

Recently a number of behavioural models of depression have been developed (Costello, 1972; Ferster, 1973; Seligman, 1975; Lewinsohn, 1975). Generally these models suggest that depression is a function of inadequate reinforcement for adaptive behaviour, although there are different hypotheses as to the exact changes in both behaviour and reinforcement and in their interrelationship. The model set out by Lewinsohn (1975) is particularly well developed and emphasizes the inverse relationship between partici- pation in pleasant activities and depression.

Lewinsohn and MacPhillamy (1974) point out the similarities in the behaviour of many depressed people and many elderly people, specifying low self-esteem, loss of interest, feelings of emptiness and hopelessness, depressed libido and appetite, feelings of rejection, psychosomatic symptoms and complaints and a progressive reduction in rate of behaviour.

Furthermore, many institutions for the elderly have been described as places where there is a great deal of apathy, lack of interest and inactivity on the part of the residents, with them having little control over their daily lives (e.g., DHSS, Social Work Service, 1979) and with the environment apparently often not supporting adaptive behaviour (e.g. Lipman and Slater, 1977; Marston and Gupta, 1977). In a series of studies conducted by the Wessex Health Care Evaluation Research Team the activity level of elderly people resident in old people’s homes has been investigated (e.g., Jenkins et al., 1977; Powell et al., 1979).

They, and other workers (e.g. Quilitch, 1974) place great stress on the importance of providing activities for elderly residents in view of the undesirable physical effects of inactivity, its suggested association with poor adjustment and its contribution to the ‘bleak and depressing’ environments characteristic of many traditional residential care settings for the elderly. These studies have shown that the low initial levels of engagement in activities can be increased to some extent, for example by the provision of recreational materials.

In a comparative study of nondepressed elderly people and depressed and non- depressed younger people Lewinsohn and MacPhillamy (1974) found that both the elderly and the depressed groups showed less engagement in potentially pleasant activi-

435

436 SARA StMps0~ et al.

ties, but that the elderly group in contrast to the depressed sample did not report any less subjective enjoyment of these activities.

However, Lewinsohn and MacPhillamy’s stereotyped view of elderly people described earlier might well be challenged in the light of what is known of the successful adjust- ment that many elderly people do make to the changes of later life (e.g., Savage et al.. 1977). A comparison between depressed and nondepressed elderly people would then be of some interest, particularly in a residential care environment where the assumed impor- tant activity variable is already low: perhaps being both elderly and depressed would be associated with an even lower activity level as well as with less subjective enjoyability of activity. This comparison could be a useful extension of the Wessex studies as these have concentrated on group levels of engagement and so have not been able to explore the characteristics of high and low ‘engagers’ or the relationship between engagement and adjustment, about which, as yet, little is known. The present study aims to look at individual levels of engagement and subjective enjoyability and to relate these to de- pression in elderly people in residential care. The hypotheses to be tested were:

1. That the resident’s level of depression will be inversely related to his level of engage- ment.

2. That the resident’s level of depression will be inversely related to his engagement in those activities subjectively most enjoyed.

METHOD

Setting and subjects

Discussion with senior staff in the residential care section of Newcastle upon Tyne Social Services Department produced a list of six homes each having approximately 40 beds. EM1 Homes were excluded as measures to be used required the cooperation of mentally alert elderly people. A four-year old purpose built home was selected where the staff were reasonably accepting of the research and where the physical structure of the home and the daily routine of the residents suited the observational methodology to be used.

The average age of the 38 residents was 81 years. Nearly all were ambulant although many used walking aids. They came from different parts of Newcastle and from mixed socio-economic levels, Staff were responsible for nearly all the major daily living tasks of the home and the majority of residents spent their day in the large ground floor lounge where their routine consisted largely of free-time punctuated by the landmarks of meal- times, morning coffee and afternoon tea. There were virtually no organized activities and only a very few residents regularly went out of the home.

Selection of subjects

The primary aim of selection was to exclude residents whose cognitive functioning was substantially impaired as their responses on psychiatric questionnaires and in interview would have been difficult to interpret. Thirty-two residents were screened on the Infor- mation-orientation sub-test of the Clifton Assessment Schedule (Pattie and Gilleard, 1975); two residents did not consent to participate in the study and four were excluded because of clear evidence of cognitive impairment. Twenty-two residents had a score of 8 or more, the cut-off suggested by Pattie and Gilleard for the discrimination of organic disorders from functional disturbances.

Five of the 22 residents refused to cooperate with measures of depression, two were excluded as they did not use the main lounge and so could not be observed and two more were excluded because they were severely mentally disturbed, leaving a group of 13 residents.

Measurement of depression

The Beck Depression Inventory (BDI) (Beck, 1961) was used in view of its coverage of the broad manifestations of depression, its wide use in clinical and research settings and

Depression and engagement in a residential home for the elderly 437

its relatively easy administration. It was administered twice to each resident, immediately before and after their period of observation. Two residents’ scores shifted markedly on reassessment and were excluded from this analysis. For other residents the mean score of the two BDI assessments was used.

Direct observation

The Wessex system for the measurement of engagement (Jenkins et al., 1976) provides only a measure of the proportion of residents engaged at particular times, and neither gives individual levels of engagement nor discriminates different types of engagement (social, daily living, recreational etc.) although these are detailed in their handbook. For the present study then, the system had to be modified:

(a) by recording details of each individual’s behaviour, using a time-sampling procedure with observations made in sequential order every 15 seconds;

(b) by sub-dividing the categories of engagement and disengagement along the lines of the Wessex handbook (full details on request). Interobserver agreements, using Harris and Lahey’s (1978) formula, ranged from 77.2% for ‘gazing’ to 100% for ‘daily living activity’, ‘recreational activity’, ‘ smoking’ and ‘walking with aids’. Figures for engage- ment and disengagement were 96.5 and 95.6% respectively.

Residents were observed on five or six days over a two to three week period between 10 a.m. and 5 p.m. The observation period included two mealtimes and residents were observed both in the main lounge and in the dining room. The average number of behaviours observed per resident was 714. For purposes of comparative analysis the frequency data were converted into percentages of total behaviour observed.

Measurement of enjoyment of activities

Originally it was planned for residents to rate various activities on a five point scale from ‘very pleasant’ to ‘not pleasant’. In practice residents had great difficulty in using such a scale and so a forced choice rank ordering of their preferences was obtained in place of this measure. One resident was unable to complete this procedure.

RESULTS

Analyses of data are possible for the 10 residents for whom reliable preference ratings for different activities were obtained.

Correlational analyses (Pearson product-moment coefficient) indicated no relationship between mean Beck Depression Inventory score and proportion of total behaviour cate- gorized as engaged (r = +0.12; NS). The correlation between Beck score and proportion of time engaged in most preferred activity was significant (r = -0.70; P < 0.05). Attempts to repeat this analysis with the second most preferred activity failed because three depressed residents did not have more than one preferred activity.

Qualitative examination of interview data suggests that the more depressed residents had a strongly negative view of the environment and a perception of little control over events. There are also noticeable differences in the types of activity preferred by de- pressed and nondepressed residents. the former concentrating more on ‘internal’ and self-generated activity e.g., reading, smoking or ‘thinking about things’.

DISCUSSION

The study does not support the hypothesis that the resident’s level of depression will be inversely related to his level of engagement; however, there is support for the view that the more depressed residents engage less in the activities that they report as being most enjoyable.

The results of this study emphasize the importance both of individual differences in behaviour and of covert behaviour. If depression is assumed to be related to lack of reinforcement the fact that some highly inactive residents are not depressed would sug- gest that overt activity per se is not necessarily the only source of reinforcement available

438 SARA SIMPSON er al.

in this environment. Indeed, covert behaviour may have considerable functional signifi- cance; the quiet individual who is apparently staring into space, and so technically disengaged, may report recall of happy memories which although difficult for the ob- server to elicit and quantify perhaps have considerable functional importance.

The resident’s perception of his overt behaviour may also be relevant. Activity which may be enjoyed by some individuals may be perceived negatively by others and so is not an equal source of reinforcement for all. A high engager who evaluates his behaviout negatively may thus ensure lack of positive reinforcement and depression as effectively as if he had not engaged at all. Depression treatment studies have suggested that this possibility can interfere with the success of interventions involving activity programmes (e.g. Hammen and Glass, 1975). Clearly then the situation is not as simple as those who advocate the importance of overt activity would suggest.

The negative correlation between preferred activity and depression can be considered in several ways. It is possible that depressed residents do not or cannot participate in activities they would enjoy. Alternatively, depressive attributions may lead them to per- ceive activities in which they do not participate as being most important. Our qualitative data tend to support the former view.

Despite the exploratory and correlational nature of this study some conclusions clearly emerge. Programmes aimed at increasing activity in residential care settings as a means of improving the quality of life offered to residents must place greater emphasis on analysing the reasons for the observed disengagement. In particular efforts should be made to differentiate a lack of opportunity to engage, a lack of the appropriate instru- mental behaviour on the part of the residents, and the possibility that an active choice has been made by the resident not to engage. Individual differences in perception of activities should be taken into account and the potential of covert behaviour as a con- tributor to adjustment and satisfaction should also be explored.

The engagement concept has become a popular one. However, care must be exercised lest it becomes yet another convenient label the use of which might too easily be substi- tuted for a proper examination of the concept itself.

.1~~nr)\~lrtlymlrnts--The Authors thank the StaR of Riverside View Old People‘s Home. Newcastle upon Tyne for their cooperanon in this study and Dr Mark Williams. Lecturer in Clinical Psychology, University of Newcastle upon Tyne for helpful discussion during the project.

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