In brief Depression is a common mental health disorder among older adults

In brief Depression is a common mental health disorder among older adults. This is related to a combination of biological, social and economic factors such as stressful life events, bereavement, war exposure, medical comorbidities and decrease functionality. Other contributing factors include disturbed body image, low self-esteem and unwillingness to seek help. In fact, little help is made available for these older adults due to inappropriate implementation of management strategies and poor allocation of resources. If a service is designed to effectively deal with these factors, then older adults would be able to achieve their own potential and would know how to cope better with the normal stresses of life. Raising awareness and enhancing social as well as familial support will help in early detection of depression and will improve health-seeking behaviors. Moreover targeting depression in older adults through individual and group counseling is expected to enhance their body image and their self-esteem and provide them comfort and hope. Goals and objectives Achieve high level of self-coping abilities and resources for older adults in “Dar El Ajaza” for management of depression.In the program serving older adults with depression:Objective: Older adults with depression will be better identified • Outcome: Older adults and their families will verbalize enhanced abilities to recognize depression signs and symptoms at the end of the educational sessions.Objective: Older adults will verbalize better ability to cope with the stresses of life • Outcome: 80% will have lower scores on Geriatric depression scale by the end of the programObjective: Older adults will express higher self-interest• Outcome: 80% of self – report measures and evaluations will show increased self-esteem by the end of the program Objective: Older adults will receive more support from family and friends.• Outcome: 85% of families and friends will develop enhanced abilities to handle and support depressed older adults. Objective: Older adults will become more empowered • Outcome: The objective will be evaluated by checking the proper implementation of coping strategies during the program and within the six months interval after its end Objective: Severe depressed cases will be better managed • Outcome: Proper Referrals will be made when needed in 85% of the times. Interventions The program suggested follows the assumption that individuals, based on their perceptions of the severity of depression and based on their likelihood of becoming depressed, and based on the risks they face, their socioeconomic status and the knowledge about signs and symptoms of depression, will or will not modify their behaviors. Therefore, the health belief model about behavior change is selected as a conceptual framework. The health belief model focuses on the attitudes and beliefs of the individuals and their understanding of health- related behaviors. The model states that taking a recommended and successful health action operates under six constructs which are “perceived susceptibility”, “perceived severity”, “perceived benefits”, “perceived barriers”, “cues to action” and “self -efficacy” (Rosenstock, 1974). The constructs account for individual’s readiness to act and change their health behaviors. According to the model, if an individual feels that a negative health condition can be avoided or if he/she has positive expectation that by taking the recommended action he/she will avoid a negative health condition or if he/she believes that he/she can successfully take a recommended action, he/she will eventually take this action to change the negative behavior into a positive one. Understanding these concepts will allow individuals to get better insight into their condition and to better manage their disease. This model emphasizes the uncertainty regarding the condition and treatment which explains the perceived severity of depression. It also tackles the main barrier which is fear of the unknown treatment which therefore prevents individuals from seeking help. Interpersonal cues to action by providing guidance support and confirmation that help is needed can reduce the uncertainty and promote awareness about the importance of help-seeking (Canstonguay, 2016). In order to reduce uncertainty regarding the condition and treatment process and in order to promote help-seeking, interventions should target friends and family of depressed individuals and should provide information and knowledge to raise awareness and to provide empowerment. Subsequently, strategies are adopted within this framework to provide coping and emotional regulation skills. This will serve as a guide for the planned activities to manage depression. Screening Conducting a thorough assessment for older Adults includes review by the clinician and the nurse specialist of the current depressive symptoms, past history of depression, past and current pharmacological and psychosocial treatments. Geriatric depression scale will be selected as a tool for screening depression. The screening will be done for older adults at the beginning and end of the program in order to measure improvement. Using geriatric depression scale the program will begin with screening for all older adults In “Dar El Ajaza” in Beirut area and thus classifying them according to mild, moderate or severe depressionTherapy: individual and group sessionsAging is challenging for some individuals. As they approach the middle age, all adults might experience health problems and stress which might lead to depression. In order to help facilitating this transition, the therapist can be a source of support to overcome the problem and address emotional and psychological concerns through individual and group sessions. Older adults who are in need of mental health facilities do not receive treatment. Mental health professionals particularly therapist should be aware of the older adult population’s special needs. For the treatment of emotional distress, Acceptance and Commitment therapy (ACT) is an emerging evidenced based approach (Hayes, Strosahl, & Wilson, 1999). Based on the literature, ACT is demonstrated to be very effective in treating depression in older adults. The ACT model explains “psychological inflexibility as an inability to connect with one’s values in the present moment due to experiential avoidance and cognitive fusion”. To note that “Experiential avoidance, cognitive fusion, dominance of conceptualized past or future, attachment to conceptualized self, loss of contact with personal values, and inaction, impulsivity, or persistent avoidance” are six processes that are associated with psychological inflexibility(Hayes et al., 1999). Educational sessionsFour educational sessions shall be given with each having clear objectives. The first session shall target definition of depression and warning signs to be looked out for. Therefore a clean overview of the problem identification and understanding will be provided by this session. Incorporating therapeutic communication strategies and appropriate response selection are provided on the second educational session. Education about crisis intervention in handling emergent situations (suicidal ideations and suicidal plan) shall be provided on the third session. A summary of all previous sessions and addressing questions and concerns shall be incorporated in the last session. Supportive counseling Placing value on the person’s subjective experience and challenging him/her to accept responsibility for his/her own life refers to a therapeutic approach called “counseling”. Personal growth can be fostered when developing a relationship between the counselor and the client. Providing an opportunity for the client to work towards living in a way he/she experiences as more satisfying and resourceful is the overall aim of counseling. Addressing and resolving specific problems, making decisions, coping with stress and crises, working through conflicts and improving relationships with others may be resolved in counseling (Rainsford, 2002)Social activities Engaging older adults in physical activities such as walks, trips or outings to watch movie, have lunch or dinner would make them feel empowered and motivated. Furthermore, encouraging older adults to cook if they used to enjoy cooking or any physical activity that they used to like is beneficial since they can feel independent, hopeful and happy. Scheduling physical activities such as physical therapy sessions that are suitable for their age that make them feel healthy. In addition, Dietician can schedule nutritional sessions about the importance of eating healthy diet. Service pathway After screening all older adults, the nurses will divide them according to the severity scores. Mild depression category shall receive group therapy and counseling; moderate depression category shall receive both individual and group therapy/counseling sessions; while severe depression category shall be referred for management to a psychiatric physician. Two graduate psychiatric nurses will conduct the counseling sessions while two therapists will conduct the therapy sessions. To obtain the best effect these sessions will be done in parallel. Furthermore, Teaching sessions for families will be given by the advanced practice nurses to promote awareness of depression disorders and proper therapeutic communication strategies. Weekly meetings should occur after the sessions are done to discuss each individual’s progress through the program and what the next steps are. Evaluation plan The goal of the evaluation plan is to determine the effectiveness of the previously mentioned interventions strategies. Continuous evaluation of the program and daily feedback must be present to improve any arising issue along the duration of the program. With the aim of ensuring that the program components are maintained and implemented correctly, the evaluation will be done at the end of the program, within the first week and after three months. Hence the evaluation plan will reflect the objectives of this program. The objectives to be evaluated are:1) Older adults with depression will be better identifiedThis objective will be evaluated by the number of reported cases within 3 months of program termination.2) Older adults will verbalize better ability to cope with the stresses of life This objective will be evaluated by pretest posttest technique where older adults are screened before and after the program using the geriatric depression scale. 3) Older adults will express higher self-interestThis objective will be evaluated by pretest posttest on self-coping skills as well as verbalization of high self-interest4) Older adults will receive more support from family and friends.This objective will be evaluated by self-reports from older adults and their families as well as evaluations done during group sessions.5) Older adults will become more empoweredThis objective will be evaluated by observing the older adults engagement in activities and increase in their self-confidence 6) Severe depressed cases will be better managedThis objective will be evaluated by checking the appropriate diagnosis of severe cases as well as their remission period, referrals and follow ups. Organizational plan Establishing clear channels of communication are a must to ensure proper coordination among stakeholders of the program. Accurate and thorough documentation between members of the group shall be formalized. Discussion and preparation should be done on weekly basis between team members. Besides, circulation of meeting minutes via email between team members should be done. When it comes to making important decisions email exchanges between the team members shall be made. The American University of Beirut Medical Center specifically the faculty of psychiatry will be the organization targeted for funding. In addition, the advanced practice nurses will be asked to be major members of the program. Moreover, proposing the program through a presentation made by the team members shall be held. Concerning the updates, communication with team members and funders should be made by two secretaries with business major. To ensure organization and to inform team members of the pertinent issues of the program coordination and regulation of the program should be made by these two secretaries. Introducing the program by the service providers and allocation of older adults after conducting screening should be made by the service providers. Nurses should also offer pamphlets on mental health support and coping skills during therapy and counseling sessions. Finally, family should be informed about the need for referral for the cases that are found to be severe and in need for psychiatric care. Afterwards, the nurses communicate with the physician for referrals and document in a formalized manner. Conclusion In conclusion developing a program for older adults who have depression will have an impact on personal and environmental level. Older adults will be provided with services that promote their mental health by enhancing their coping skills and resources. Families of older adults will be better able to deal with them accommodate them and understand their hardships. Depleting stigma and creating an adequate support system

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