Increasing enjoyable activities to treat depression in nursing home residents with dementia: A pilot study

Abstract

This pilot study aimed to assess the feasibility and acceptability of a behavioral activities intervention (BE-ACTIV) in Australian nursing homes. BE-ACTIV was developed by researchers at the University of Louisville, USA, to improve mood and quality of life (QOL) in nursing home residents with mild to moderate dementia. An eight-week trial was conducted and 10 residents with mild to moderate dementia received the BE-ACTIV intervention while eight residents received a Walking and Talking intervention. Measures of depression (GDS-12R) and QOL (QOL-AD-NH) were administered prior to and following the interventions. Qualitative feedback indicated residents benefited from BE-ACTIV, evident by improved mood, although no statistically significant treatment effect was found. Moreover, the intervention was found to be feasible and acceptable to Australian nursing home staff and our findings highlight the importance of individualizing activities for people with dementia, of which 1:1 staff attention was a key component.

Keywords

dementia depression nursing home intervention study psychosocial intervention

Introduction

Depression is very common in patients with Alzheimer’s disease (AD) and other dementias, and while estimates vary somewhat, prevalence rates of between 30% and 50% are most frequently reported (Lee & Lyketsos, 2003; Olin, Katz, Meyers, Schneider, & Lebowitz, 2002). Depression is associated with serious adverse consequences for both the individual concerned and their caregivers, and in addition to causing substantial distress, depression reduces quality of life (QOL), impairs social and interpersonal functioning and results in more rapid cognitive decline and greater caregiver burden and depression (Berardi et al., 2002; Lee & Lyketsos, 2003). Rates of depression have been reported to be particularly high in older nursing home residents and in 2009, an estimated 31% of Australian nursing home residents with dementia also had a diagnosis of depression or mood disorder recorded, while the number of residents with symptoms of depression has been reported to be as high as 41.6% (Australian Institute of Health and Welfare (AIHW), 2011a, 2011b). Of concern, depression in residents is strongly associated with symptoms of agitation, verbal and physical behavioral difficulties, and higher care needs which increases with the severity of the depressive symptoms (AIHW, 2013; Volicer, Frijters, & Van der Steen, 2012).

Despite its very high prevalence and associated adverse outcomes, however, depression is frequently under-recognized and under-treated in this population. For example, approximately one-third (32%) of Australian nursing homes residents with depression did not receive either a diagnosis or treatment in 2012 (AIHW, 2013). Furthermore, antidepressant medications which are generally effective for younger and middle-aged adults (Arroll et al., 2009) do not appear to be effective for older adults with depression and/or dementia and may have adverse consequences (Coupland et al., 2011; Bains, Birks, & Dening, 2002). Despite the clear need to develop safe and effective treatments for depression in this population, relatively few studies have assessed the effectiveness of psychosocial interventions for depression in older people with dementia.

Recently, however, researchers in the US have reported the results of two studies of a promising behavioral activities intervention (BE-ACTIV) to treat depression in nursing home residents with dementia (Meeks, Looney, Van Haitsma, & Teri, 2008; Meeks, Van Haitsma, Schoenbachler, & Looney, 2014). The 10-week intervention aims to increase residents’ involvement in simple, enjoyable activities, thereby increasing enjoyment and positive affect and involves two components. The first is weekly sessions between a research staff member and individual residents to identify pleasant activities, which must be feasible within the confines of the nursing home environment and the resident’s abilities, and plan for their increased involvement in those activities. The second component is the education of facility staff regarding depression in nursing home residents and their involvement in the intervention as co-therapists to facilitate the implementation of the pleasant activities. The intervention was compared against a control group who received treatment as usual and while statistically significant treatment effects were not observed, possibly due to low power, clinically significant reductions in symptoms of depression and improved functioning were observed in the treatment group compared with the control group. Results also indicated the intervention was well received by both residents and nursing home staff.

However, the feasibility and effectiveness of the intervention have not yet been trialed in Australian nursing homes and because of important cultural and ethnic differences between the US and Australia as well as differences in the health and aged care systems of the two countries, it cannot be assumed that the intervention will be equally effective in Australia. Thus, the main aim of this project was to assess the feasibility and acceptability of BE-ACTIV as originally conceived by Meeks et al. (2008), within the Australian context.

The second aim was to compare the effectiveness of BE-ACTIV against a control condition, comparable in terms of providing individual attention to nursing home residents, to provide some edification regarding the key mechanism underlying BE-ACTIV’s efficacy. While results suggest BE-ACTIV may be an effective intervention for depression in nursing home residents with dementia (Meeks et al., 2008, 2014), it may have been the increased attention residents received by research and facility staff throughout the intervention that accounted for the treatment effects rather than the residents’ increased involvement in activities that accounted for the improvement in symptoms. This possibility was acknowledged by the study authors (Meeks et al., 2008, 2014), and comparing the intervention against an appropriate control condition is required to test this hypothesis.

A Walking and Talking intervention would provide an equivalent amount of individual attention to residents and was selected as an appropriate control condition for this study. Some evidence indicates that 30 min of supervised walking or talking per week are effective in improving mood in nursing home residents with moderate to severe dementia (Williams & Tappen, 2008). While that study compared walking and talking as two separate interventions, they were combined into one Walking and Talking intervention for the present study so as to provide a comparison that reflects both increased activity and increased attention. It has also been suggested that social engagement during walking may be required to motivate residents with dementia to comply with a walking intervention (Bayles & Kaszniak, 1987).

Method

The study was an eight-week pilot randomized controlled trial (RCT) of BE-ACTIV versus a Walking & Talking intervention to improve mood and QOL in nursing home residents with mild to moderate dementia and symptoms of depression.

Ethics approval

Ethical approval was obtained from the Queensland Institute of Technology’s Human Research Ethics Committees, and written consent was obtained from each participant prior to study commencement. While it was considered that participants with mild to moderate dementia would be cognitively able to participate in the identification and planning of enjoyable activities that is central to BE-ACTIV, this was verified by asking potential participants to briefly re-state what their participation might involve, prior to signing the consent form.

The BE-ACTIV intervention

The BE-ACTIV intervention was implemented as described by Meeks and colleagues in their initial publication reporting the intervention and in the BE-ACTIV Treatment Manual which they provided for use in the current study (Meeks & Teri, 2004; Meeks et al., 2008), with one important modification. For practical reasons it was important to avoid the busy Christmas holiday period which is associated with an increased number of activities in nursing homes including concerts and an increased volume of visitors. To avoid this potentially confounding influence, the intervention was shortened from 10 weeks to 8 weeks to allow for its completion prior to Christmas. This meant that two weeks focused on goal maintenance and problem solving rather than four as the program was originally conceived. The intervention is described briefly below:

Individual sessions with participants

A Mental Health Therapist (MHT), employed for the study, worked individually with each resident participant (around 45 min per week) to identify pleasant events that were feasible and practical within the nursing home environment and the resident’s abilities, and develop an individually tailored plan to increase the availability and frequency of those events. Pleasant events were defined simply as activities the resident reported he or she would enjoy doing or enjoy doing more of, and may be as simple as wearing a favorite piece of clothing, watching a preferred TV show or going on an outing. Time in subsequent sessions was allocated to reviewing the prior week’s events, identifying barriers to engaging in planned pleasant events, problem solving if required, and planning the following week’s pleasant events. Resident participants were not asked to do anything they did not want to do or that could be considered harmful.

For this study, a qualified social worker experienced in working with older people including those with cognitive impairment undertook the role of the MHT. Prior to the study’s commencement, the MHT received in-depth training in the intervention by the Project Coordinator (the author who is a registered Clinical Psychologist experienced in working with older people with dementia). This involved training in the nature and expression of depression in older people, particularly in nursing home residents with dementia, and the intervention itself (detailed weekly session plans are included in the Treatment Manual), including its underlying rationale. Weekly contact between the MHT and the Project Coordinator was maintained throughout the intervention to ensure a high level of treatment fidelity and to address any difficulties that arose.

Involving facility staff

In the first instance, facility staff (activities staff in particular) and volunteers were invited to attend two 90-min depression training sessions that were conducted at the commencement of the study in each facility. The training sessions focused on providing staff with an understanding of depression and dementia in nursing home residents, as well as practical ways to assist residents. An overview of the project including its rationale and methods was also provided. A condensed version of a validated depression training program “Depression Training Program for Caregivers of Elderly Care Recipients” (Mellor, Russo, McCabe, Davison, & George, 2008) was used as the foundation for the training, which was delivered by the Project Coordinator. The program was initially developed as an 8-h program by staff at Deakin University, Victoria, Australia (permission was given by the program developers for its use in this study) and has been shown to significantly improve staff knowledge and self-efficacy in identifying and responding to nursing home residents with depression (Mellor et al., 2008).

In addition to attending the initial training session, one staff member (an activities staff member) was nominated to be actively involved as co-therapist for each resident participant throughout the intervention. Their role was to encourage the resident to achieve their planned pleasant events each week and to facilitate their completion. To promote their involvement and understanding of depression in the nursing home context and the intervention, they were invited to attend sessions 1, 4, and 8 with the individual participant and MHT. For the other weeks of the intervention, the MHT briefed (face-to-face) the nominated co-therapist regarding the specific pleasant events identified by resident participants for the following week and possible barriers to their implementation. A copy of the planned pleasant events for the following week was also placed in each resident participant’s care plan. If the resident agreed, families or relatives of residents were also invited to be involved in the intervention to assist with the implementation of pleasant activities (e.g. going for an outing outside the nursing home).

Participants

The aim was to recruit 20 nursing home residents with mild to moderate dementia (defined as having a standardized Mini-Mental State Examination score (sMMSE) ≥10), and evidence of symptoms of depression as assessed by the 12-item Geriatric Depression Scale (GDS-12R) (scores ≥4 indicate the presence of such symptoms), to participate in the study. The sample size was determined on logistic grounds, and given it was a pilot study aimed at assessing feasibility and acceptability, a sample size of 20 was considered realistic within the study timeframe. Recruitment began by liaising with each facility’s Manager and Clinical Nurse Consultant Nurse (CNC) to identify potentially eligible residents. Eligibility requirements included having a diagnosis of dementia, a sMMSE score ≥10, a GDS-12R score ≥4, the ability to communicate in English, and having resided in the facility for a minimum of three months. Participants were excluded if they were receiving psychotherapy or were dying.

Walking and Talking intervention

The Walking and Talking intervention involved a facility volunteer (identified by facility staff) spending 30 min of one-to-one time, walking and talking with each resident each week. The 30 min could be subdivided into 2 x 15 min sessions or 3 x 10 min sessions, depending on the volunteer and the resident’s preferences. Volunteers were instructed to walk at the resident’s pace with the amount of walking undertaken being dependent on the resident’s ability (wheelchair bound residents were pushed). Rests were permitted if the resident became fatigued. Volunteers were asked to encourage the resident to go for a walk, but if they refused to do so, it was permissible to sit and talk. Volunteers were instructed to use open-ended questions and stimuli from the environment to engage the resident in conversation. They were also asked to keep a record of the amount of walking and talking undertaken throughout the study.

Measures

Baseline assessments

The sMMSE (Molloy, Alemayehu, & Roberts, 1991) was administered as a brief measure of cognitive functioning. It requires approximately 5 min to complete, is easy to administer, has sound psychometric properties including high test–retest reliability (between 0.80 and 0.95), and good sensitivity for cognitive impairment (Tombaugh & McIntyre, 1992).

Depression was assessed using the GDS-12R (Sutcliffe et al., 2000), which is a 12-item measure of the symptoms of depression suitable for older people living in nursing and residential care settings, including those with cognitive impairment (Sutcliffe et al., 2000). The scale demonstrates good internal reliability (0.80–0.81), requires approximately 5 min to complete and scores range from 0 to 12, with a score of ≥4 indicative of probable depression.

The Quality of Life—Alzheimer’s Disease (QOL-AD) adapted for use in Nursing Homes (QOL-AD-NH) was used to measure participant’s QOL (Edelman, Fulton, Kuhn, & Chang, 2005; Logsdon, Gibbons, McCurry, & Teri, 1999, 2002). It is a brief, easy to administer 15-item scale designed to assess QOL in nursing home residents. Each item is rated using a four-point scale ranging from 1 being poor to 4 being excellent. The QOL-AD is psychometrically sound, has been found to have good reliability and validity, and can be completed by people with mild to moderate dementia (Logsdon et al., 2002; Thorgrimsen et al., 2003).

Both the Project Coordinator and MHT were involved in data collection and administered the baseline assessments.

Follow-up assessments

The measures of QOL (QOL-AD-NH), and depression (GDS-12R) were re-administered following completion of the interventions by the Project Coordinator only, who was not blinded regarding participant’s group allocation.

The Pleasant Events Schedule—Nursing Home Version (PES-NH, Meeks, Shah, & Ramsey, 2009) was used by the therapist during each session to assist residents to identify pleasant activities. The PES-NH is a 30-item adaptation of the original Pleasant Events Schedule (MacPhillamy & Lewinsohn, 1982) that was developed for the nursing home setting and includes pleasant events and activities that are feasible within that setting and the resident’s abilities. It has been validated in that setting, has been found to be internally consistent and reliable over time, and can be reliably completed by residents with mild cognitive impairment/dementia. Participants are asked to rate how pleasant each activity is (or would be), whether each activity was available during the past month and how often they did each activity in the past week.

Qualitative data

Facility staff were also asked, in a qualitative interview administered by the Project Coordinator, for their opinions regarding the feasibility of the BE-ACTIV intervention and whether they observed any impact of the intervention (positive and negative) on resident participants’ mood or behavior. They were also asked which aspects of the intervention they found most useful for assisting residents with depression, whether there were any barriers to implementing the intervention and suggestions for improving the intervention were also solicited.

Randomization

The Project Coordinator assigned participants a unique study identification number and randomly allocated them to either the BE-ACTIV or the Walking and Talking intervention using the SPSS randomization function (IBM®, 2012).

Statistical analyses

Due to the outcome measures (depression and QOL), having non-normal distributions, non-parametric techniques were used to compare baseline and follow-up depression and QOL scores for each group independently (Wilcoxon signed-ranks test), and to determine whether the groups differed in average change scores (depression, QOL) from baseline to follow-up (Mann Whitney U test). All data were analyzed using SPSS for windows, version 21.0 (IBM®, 2012).

Results

Participants were recruited from four nursing homes near Brisbane, Queensland, Australia. All facilities were located in the southern suburbs of Brisbane and ranged in size from 48 to 126 beds. All catered for residents with high and low care needs and all were accredited with the National Accreditation Agency (Aged Care Standards and Accreditation Agency Ltd). The facilities were managed by religious (two), independent not-for-profit (one) and private (one) organizations and all facilities employed activities staff and provided a variety of organized activities for residents.

Forty-seven residents were initially identified by the CNC in each facility as being potentially eligible for the study. Of those, eight declined participation and 20 were ineligible (primarily because they scored <4 on the GDS-12R—see Figure 1), leaving 19 participants who consented to participate in the study. Ten participants were allocated to the BE-ACTIV intervention and nine to the Walking and Talking intervention. One resident who had been allocated to the Walking and Talking intervention, however, died prior to commencement of the intervention and his data were excluded from all analyses. All remaining participants completed the eight-week interventions.

Figure 1.

CONSORT diagram for pilot RCT of BE-ACTIV versus Walking and Talking interventions.

Table 1 shows the characteristics of the two groups, which were in general similar. The average age of participants was 86.5 years (SD = 8.8), the majority were female (n = 16; 89%), and they had lived in the facility an average of 2.95 years (SD = 2.13). All had a diagnosis of dementia and all participants had a sMMSE score indicative of mild to moderate cognitive impairment with the average sMMSE score being 18.0 (SD = 4.1). The baseline and follow-up depression and QOL scores are shown in Table 2. Results showed that depression scores did not change significantly from baseline to follow-up for either group (BE-ACTIV: p = 0.51; Walking and Talking: p = 0.10), nor was the change in QOL scores significant for the BE-ACTIV group (p = 0.92). The Walking and Talking group, however, demonstrated significantly improved QOL scores at follow-up compared to baseline (p = 0.04). Table 3 shows there was no difference in average change scores for either depression (p = 0.61) or QOL (p = 0.31).

Table 1.

Demographic characteristics of participants in the BE-ACTIV and Walking and Talking interventions at baseline.

		BE-ACTIV intervention N = 10 (%)	Walking and Talking intervention N = 8 (%)
Age (years)	Mean (SD)	87.2 (7.7)	85.5 (10.9)
Years residing in facility	Mean (SD)	2.65 (1.98)	3.29 (2.38)
sMMSE score	Mean (SD)	19.5 (3.87)	16.13 (3.7)
sMMSE score	Range	13–26	12–22
Number of health conditions	Mean (SD)	2.1 (1.10)	1.67 (0.82)
Dementia type	Alzheimer’s disease	1 (10.0)	3 (37.5)
	Vascular dementia	1 (10.0)	1 (12.5)
	Not specified	8 (80.0)	4 (50.0)
Gender	Female	8 (80.0)	8 (100.0)
Gender	Male	2 (20.0)	0 (0.0)
Marital status	Widowed	9 (90.0)	4 (50.0)
	Separated/Divorced	1 (10.0)	3 (37.5)
	Married	0 (0.0)	1 (12.5)
Mobility status	Independently ambulatory	1 (10.0)	3 (37.5)
	Ambulatory with assistance	5 (50.0)	4 (50.0)
	Non-ambulatory	4 (40.0)	1 (12.5)
Number regularly taking behavior modifying drugs:	Anti-depressants	3 (30.0)	0 (0.0)
	Minor tranquilizers^a	1 (10.0)	0 (0.0)
	Major tranquilizers/mood stabilizers	1 (10.0)	1 (12.5)
Number regularly taking pain medications		7 (70.0)	2 (37.5)
Geriatric Depression Scale (GDS-12R)	Median	4.0	5.0
Geriatric Depression Scale (GDS-12R)	Interquartile range	4.0–7.0	4.0–7.25
Quality of life—Nursing home	Median	34.0	36.0
Quality of life—Nursing home	Interquartile range	31.5–40.25	21.5–42.5

For example: benzodiazepines.

Table 2.

Baseline and follow-up scores of participants in the BE-ACTIV and Walking and Talking (W&T) interventions.

	Baseline median (IQR)	Follow-up median (IQR)	p value
Depression—GDS-12^a BE-ACTIV (n = 10)	4.0 (4.0–7.0)	5.0 (3.75–7.0)	0.51
Depression—GDS-12^a W&T (n = 8)	5.0 (4.0–7.25)	4.0 (1.5–7.25)	0.1
Quality of life (QOL-AD-NH)^a BE-ACTIV (n = 10)	34.0 (31.5–40.25)	35.0 (31.0–37.5)	0.92
Quality of life (QOL-AD-NH)^a W&T (n = 8)	36.0 (21.5–42.5)	36.5 (25.0–43.5)	0.04*

IQR: interquartile range.

Higher scores are indicative of higher QOL.

p < 0.05.

Table 3.

Comparison of the changes in scores over follow-up for participants in the BE-ACTIV and Walking and Talking (W&T) interventions.

	BE-ACTIV	W&T	p value
Depression-GDS-12	0.5 (−1.00 to 2.25)	1.5 (−0.25 to 2.5)	0.61
Quality of life (QOL-AD-NH)	0.50 (−5.0 to 4.75)	−1.0 (−3.5 to −0.75)	0.31

Treatment fidelity

Participation

A total of 53 staff and volunteers from across the four facilities attended the depression training program. Eight BE-ACTIV sessions were provided for each resident and an attendance rate of 100% was achieved, which was in large part due to the willingness of the therapist to be flexible and accommodate each resident’s availability. The participation rate in the Walking and Talking intervention was also very high—a minimum of 30 min was achieved each week in 93.75% of cases, and in only two cases the intervention was not fully completed.

Weekly contact between the MHT and the Project Coordinator was maintained throughout the intervention and the MHT liaised with the nominated activities staff member on a weekly basis to discuss each participant’s planned activities for the following week. Weekly sessions between the MHT and each participant took slightly longer (approximately 45 min) than the 30–40 min reported by Meeks et al. (2008, 2014), although the MHT adhered to the weekly session plans. In addition, the time required to brief activities staff each week took longer than originally anticipated (a minimum of 20 min each week versus an expected 10 min) as it was often time consuming to locate staff which varied according to the size and layout of the facility. This, however, became less time consuming over time as a regular routine was established.

Attendance by the staff member at sessions 1, 4, 8, as specified in the manual, was less than it should have been. A staff member attended an individual session with the MHT and resident on only five out of a possible 30 occasions, representing a 16.7% attendance rate. While this was occasionally due to the absence of the activities staff member from the workplace, it was most frequently due to their pre-existing commitment to group activities.

Outcomes

The average number of pleasant activities completed by BE-ACTIV participants increased significantly (Z = −2.82, p < 0.005) from 2.3 in week 1 to 5.8 in week 7, and the six most frequently endorsed pleasant activities are listed in Box 1. An overall completion rate of 89.5% was achieved for planned activities and the main reasons for planned activities not occurring included volunteers not being aware of the activity (only in week 1 of the project); volunteers being too busy or insufficient staff; the resident being unwell or undertaking an alternative activity to that planned.

Box 1.

Pleasant activities most frequently endorsed by residents.

Activity	Number of residents nominating activity (%)
Reading printed materials (i.e. books, newspaper, magazine),	9 (90)
To be pushed around the grounds in wheelchair/scooter/golf buggy,	6 (60)
Sitting outside in the sun/shade/fresh air,	6 (60)
Have hands massaged,	6 (60)
Having a manicure,	5 (50)
Attending Happy Hour (in one facility),	3 (30)

Qualitative results

While a formal evaluation of the depression training program was not undertaken, qualitative feedback indicated the sessions were informative and well received.

Fourteen staff (10 were activities staff) and volunteers from across the four facilities were interviewed, following the study, for their opinions regarding the feasibility of the BE-ACTIV intervention and its impact on residents. A majority (n = 13; 92.9%) reported that the intervention was beneficial for participants with substantially improved mood in four residents and greatly reduced anxiety and sundowning (sundowning describes the phenomena of increased confusion, agitation and other neuropsychiatric symptoms that occur in many people with dementia in late afternoon—early evening; Khachiyants, Trinkle, Son, & Kim, 2011) in one resident. The most frequently reported comment was “they loved the 1:1 attention from staff”, which they appeared to prefer over organized group activities. Staff indicated they would endeavor to continue to provide 1:1 attention. Other comments included: the residents “seemed to be happier”, she “appeared calmer, more sociable”, and J (who was wheelchair bound) “really enjoyed going outside”. Two staff members reported that the Pleasant Events Planning Form was very helpful in assisting them to learn about the preferred activities of individual residents and which they indicated they would continue to use.

By comparison, two staff members (14%) thought the activities planning form (Pleasant Events Schedule) was too complex for residents with dementia and should be simplified. No one reported the intervention to be onerous (most reported it was part of their duties), although several staff reported that additional time and/or staff would assist to improve the intervention. Timing was reported to be an issue occasionally, as residents were not always available for an activity when the activities staff member was available while inclement weather interfered with the completion of some activities on some occasions.

Discussion

This study demonstrates the feasibility of implementing an individually tailored program of pleasant activities (BE-ACTIV) for Australian nursing home residents with mild to moderate dementia, confirming previous reports by researchers in the US (Meeks et al., 2008, 2014). In the current study, BE-ACTIV was well-accepted by both residents and staff and importantly, staff did not consider the intervention to be onerous. While participants in the BE-ACTIV group demonstrated a significant increase in the number of pleasant activities they engaged in over the eight-week intervention, statistically significant improvements on measures of depression and QOL were not found, perhaps due to the small sample size. Nevertheless, qualitative data indicated that residents benefited from the BE-ACTIV intervention and observed benefits included improved mood in half the participants, while anxiety and sundowning were reported to be considerably less in one participant. The results of this study also showed that nursing home residents with dementia were readily able to identify activities they would enjoy and appreciated very simple activities such as going for a walk with someone or sitting in the sun. They overwhelmingly appreciated having 1:1 time with a staff member which they appeared to prefer over other organized group activities, underscoring the importance of individual attention in this setting.

Participants in the Walking and Talking group also showed significant improvement on a measure of QOL, but not depression (although depression scores decreased), following the intervention. By comparison, other investigators (Williams & Tappen, 2008) have reported significantly improved mood in nursing home residents with dementia and depression following a 16-week intervention of either supervised individual walking or individualized attention. Participants in both groups improved, although there was a tendency towards greater improvement in the walking group. QOL was not assessed in that study, however, and their sample was more cognitively impaired and had worse depression scores than participants in the current study, whose relatively low depression scores are likely to have limited the potential for statistically significant improvement. Nevertheless, our results together with those of Williams and Tappen (2008) indicate that a Walking and Talking intervention either implemented independently or in combination appears to be beneficial for nursing home residents with dementia and depression.

The findings of improved mood following increased individual attention was also reported by Meeks et al. in their RCT of BE-ACTIV compared to Treatment As Usual (TAU; 2014). Participants in the TAU group received brief (5–30 min) weekly visits (and accordingly increased 1:1 attention) by research staff to collect data. Following the interventions, participants in both groups showed improved mood with those in the BE-ACTIV group demonstrating (non-significantly) greater improvement. Results of these two studies indicate that individual attention is an important intervention to address depression in nursing home residents with dementia.

While individual attention appears to be beneficial for nursing home residents with dementia and depression, the two previous studies also indicate that increased activity either physical activity (Williams & Tappen, 2008) or more pleasant activities (Meeks et al., 2008, 2014) confer a further advantage. As both appear to confer a benefit, it may be that it is the increased activity that is key, rather than the specific activity itself. Any increase in activity could address boredom in nursing home residents as well as distract residents from their own thoughts and feelings. To clarify the relative importance of individual attention versus increased physical activity or pleasant activities in addressing depression in this population, however, further research is required. Although needed, conducting research in this setting is challenging and includes difficulties recruiting eligible research participants. For instance, considerable difficulties were encountered recruiting eligible participants in the present study, as the numbers of potentially eligible participants were low in each facility approached (the majority of residents were deemed by the facility’s CNC to be too cognitively impaired to be considered for the study). In addition, more than one-third of those screened (36%) did not have symptoms of depression, and hence it was necessary to conduct the study in four facilities rather than two, as originally planned. Similar recruitment issues were reported by Meeks and colleagues in their 2014 study, in which 53% of potentially eligible residents were found to be ineligible at screening, although their inclusion criteria differed somewhat.

This does not mean this type of research should not be attempted, but that careful planning is required and the establishment of good working relationships between research and nursing home staff is essential for success. The successful implementation of the current study was due, in large part, to the truly collaborative working relationship between the study therapist and facility staff who ensured the pleasant activities nominated by residents were implemented. That relationship was fostered by the considerable efforts of the study therapist to keep facility staff informed and updated regarding each participant’s plans and progress.

Treatment fidelity

An important departure from the BE-ACTIV protocol as developed by Meeks and Teri (2004) was the shortening of the intervention from 10 to 8 weeks in the current study. This meant that two weeks focused on goal maintenance and problem solving rather than four as the program was originally conceived. While this may have contributed, in part, to the lack of a significant intervention effect, this seems unlikely given the very small magnitude of change in outcome scores from baseline to follow-up. If this departure was to have an impact, it seems more likely that this might be more apparent over the longer term due to the reduced emphasis on maintenance. This, however, is not known as longer term outcomes were not assessed in the current study and the optimal number of intervention weeks and weeks required for maintenance remain a question for further research.

An additional important departure from the protocol was the low level of staff attendance at BE-ACTIV sessions between the MHT and participant in weeks 1, 4, and 8. In spite of this, the MHT maintained weekly contact with facility staff and participants achieved a high completion rate of their planned activities. A low staff attendance rate at those sessions was also reported by Meeks and colleagues in their 2014 study. They also reported that this did not seem to negatively influence staff’s ability to assist residents to complete their planned activities, raising questions regarding the importance of this protocol component. It seems more important that facility staff understand the nature of the intervention and its rationale, and are regularly updated by the MHT regarding each participant’s plans and progress. In comparison to the low staff attendance at the individual BE-ACTIV sessions, the initial depression training sessions were well attended by staff. This was facilitated by managerial staff in all four facilities regarding the sessions as a staff development activity and releasing staff from their duties to attend. Given that nursing home staff are very busy and have limited time, the simplification of BE-ACTIV by removing the requirement that staff attend the individual sessions with the participant and MHT is likely to increase its acceptability to nursing home staff. Whether removal of this component from the protocol is feasible without unduly affecting treatment outcomes, however, is a question for future research.

Limitations of the study

An important study limitation was the small sample size, which although appropriate given it was a pilot study, means the study was most likely under-powered, contributing to the absence of a significant intervention effect. An additional limitation was the lack of blinding of the Project Coordinator who administered the follow-up questionnaires to participants. While blinding the Project Coordinator regarding participants’ group status would be a methodological improvement, this shortcoming appears not to have influenced the results.

Conclusion

We conclude that individualized activity interventions appear to improve the mood and QOL of residents with mild to moderate dementia living in nursing homes. It is a simple, feasible and relatively inexpensive intervention and our findings add to the growing body of evidence confirming the importance of individualizing activities for people with dementia and depression, in particular 1:1 attention. This has important implications for how diversional therapists and activities staff allocate their time in nursing homes. A key issue, of course, is that individualized attention is time intensive and addressing resident's needs for attention against limited staff time requires careful planning.

Footnotes

Acknowledgements

I would also like to acknowledge the original authors of this intervention—Suzanne Meeks, Stephen Looney, Kimberley Van Haitsma, and Linda Teri, who kindly provided us with copies of their BE-ACTIV treatment manual and the Pleasant Events Schedule—Nursing Home version which were used in the current study. Australian New Zealand Clinical Trials Registry (ANZCTR) Number: ACTRN12613000296730.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was funded by the JO & JR Wicking trust.

Dr Catherine Travers is a Research Fellow with the Dementia Collaborative Research Centre (DCRC) at the Queensland University of Technology, Australia. Her research interests include ageing, dementia, and interventions to improve older people’s quality of life including those with dementia. She has published widely and regularly presents her work at national and international conferences.

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