“Aging in place” is more than just a slogan at Tiger Place, a Columbia, Mo., retirement home located about two miles from the MU campus. The facility is a collaboration between a company called Americare and the Sinclair School of Nursing at MU.
That Lorraine J. Phillips formally spent at least a few hours each week caring for Tiger Place residents one on one—an unusual side job for an MU assistant professor with a substantial teaching load and on the tenure track—makes sense only in the context of her real-world research.
For decades, in fact, Phillips has been hands-on in dealing with patients. First as a registered nurse, then as a nurse practitioner, she has found employment in hospitals, corporate offices, private residences and geriatric homes.
Her most recent work, detailed in a study published earlier this year, involves figuring out more effective ways of identifying depression in nursing home residents. It is a task that turns out to be surprisingly complicated.
Many of the elderly in nursing homes refuse to call themselves depressed, even if they themselves suspect it. Other residents have never thought about depression as an identifiable, treatable medical problem. Still others cannot express themselves adequately to answer caregivers’ inquiries.
Phillips’ quest to overcome these diagnostic hurdles involved mining the massive amount of information collected each year for the Missouri Minimum Data Set, a federally mandated process by which the health and well-being of Medicare- or Medicaid-certified nursing home patients are measured.
Her study, conducted with MU nursing professor Marilyn Rantz and Gregory F. Petroski, research assistant professor of biostatistics with the MU Office of Medical Research, eventually included more than 14,300 nursing home residents age 65 or older. Of this cohort, she found close to 10 percent were living with depression that had not previously been identified.
Some 1.8 million women and men reside in nursing homes across the United States, and millions more in other nations. Phillips and other gerontologists agree that early identification of depression’s onset could make a world of difference for a significant number of these elders, allowing for interventions that stand a good chance of reducing and reversing painful conditions, both mental and physical, that too often erode the quality of residents’ twilight years.
The reasons for the under-recognition of depression include health-care providers’ minimal training in geriatric mental health, the shortage of in-house mental health clinicians, nursing home residents who deny psychological symptoms, and older adults who do not seem to be exhibiting classic “mood” symptoms such as withdrawal and sadness.
Verbal aggression, urinary incontinence, increased pain, weight loss, falls, reduced cognitive ability, and a decline in performance of daily living activities, have all been associated with depression. Phillips cautions, however, that separating cause and effect is less than straightforward.
“We can’t really say these are consequences [of depression] because our study was not designed to determine causality,” Phillips says. “Although it does seem reasonable to assume that verbal aggression results from depression, the direction of the relationship between other symptoms, say pain, is not so clear. Depression can make pain worse but painful conditions can lead to depression.”
It seems unarguable, however, that an early diagnosis might “provide a window of opportunity to try psychosocial interventions before advancing to pharmacotherapy, a treatment that is often fraught with side effects and poor response in older adults,” Phillips says.
At Columbia HealthCare Center, a skilled-nursing facility in Columbia, Mo., residents responded to photographer Nicholas Benner’s simple query, “How do you feel about living here?” with admirable candor. Researchers such as MU’s Lorraine Phillips have discovered, however, that residents’ statements don’t always serve as effective diagnostic tools, particularly when it comes to depression.
Above: Beverly Roseth, 87, previously made her home in Lily, S.D. “I’m ready to leave: I get very lonesome for family and friends,” she says. “I don’t really have a home to go to, or anybody to be with.”
Tackling a difficult-to-measure topic presented a welcome challenge for Phillips, who embodies an unusual combination of “people-person” and “numbers-person” traits. The daughter of blue-collar parents in Lancaster, Penn., Phillips credits the influence of her two brothers — one 16 years older, the other 14 years older — with her mastery of both the empirical and empathetic. The eldest brother became an engineer, she says. He encouraged her interest and skill in mathematics and the sciences. The other became a physician. He nurtured her natural inclination to nurse the sick.
Decades later, putting her duality to good use, Phillips determined that, in nursing homes, depression diagnoses using guidelines found in the Diagnostic and Statistical Manual of Mental Disorders (generally referred to as DSM IV and published by the American Psychiatric Association) were less than perfect. The guidelines, she found, required a skill level often lacking in nursing home staffs, which frequently do not include psychiatrists, psychologists or other mental health practitioners.
She also discovered that other screening methods sometimes came up wanting. Two respected screening tools, the Geriatric Depression Scale and the Cornell Scale for Depression in Dementia, for example, relied either on patients’ self-reporting their symptoms, or semi-structured interviews. Phillips felt both methods, in some cases, could lead to misleading results.
Instead, she and her research colleagues, Rantz and Petroski, turned to the aforementioned Missouri Minimum Data Set.
Nursing home personnel prepare an 8-page report on a patient when he or she is admitted. Portions of the report are updated as often as every three months, while the record as a whole is reviewed every year. Any significant change in clinical status is also recorded.
This data had not been mined in important ways, however. The majority of studies citing the data, Phillips noted, “did not examine whether a change in clinical status occurred parallel to the development of depression.”
Phillips assumed that “some observable change in resident status prompts providers to diagnose depression.” That suggested to her that “knowing which changes commonly occur may help nurses and other health care providers detect depression sooner rather than later.”
To help that process, Rantz, Petroski and Phillips developed 13 measurable variables that might help in detecting depression, then set about using the Missouri Minimum Data Set to identify a group of patients against whom the variables might be compared.
The resulting database covered 27 months and included more than 127,000 patient assessments. Phillips first eliminated all patient assessments with an existing diagnosis of depression, then eliminated others based on other factors that would have devalued the integrity of the data. These included patients residing in a hospital-based skilled nursing facility, comatose patients, those with severe cognitive impairment, patients younger than 65 at the time of the first assessment, and those already taking an antidepressant at the time of the first assessment.
The final sample population totaled about 14,300 cases. The average age was slightly more than 85 years old. Most were widowed white women.
Phillips and her colleagues next used the 13 variables to complete a reevaluation of the patients’ depression risk. They discovered 1,342 of the nursing home residents were likely suffering from the condition.
Phillips says three findings from the study might be of particular relevance to nursing home staff. First is the recognition that symptoms not normally associated with depression — such as increased verbal aggression, pain and urinary incontinence — might indeed signal the condition. The second involves the need for routine surveillance of patients’ behavior, particularly in the weeks just after admission. The third demands a rethinking of standard practice in evaluating depression risk: in elders, Rantz, Phillips and Petroski found, women and men are equally likely to develop depression.
The study appeared in the January issue of the Journal of Gerontological Nursing. The journal’s editor, Kathleen C. Buckwalter, director of the University of Iowa’s John A. Hartford Center of Geriatric Nursing Excellence, says the article “makes important contributions in a number of ways.”
“First, it reminds us that depression is undetected in long-term care settings, and [also] emphasizes the need for ongoing assessment—but not just at admission and according to [Minimum Data Set] schedules.”
Perhaps the most significant finding, Buckwalter says, is the article’s identification of “signs and symptoms that may herald the onset of depression and yet are seldom, with the exception of weight loss, considered in this way. It suggests that nursing home nurses must think broadly and outside the usual assessment parameters.” Such revised thinking is especially vital, Buckwalter says, regarding declines in the activities of daily life. Too often such declines “have been chalked up to relocation, normal aging or some other phenomenon,” according to Buckwalter, rather than to depression.
“Lorraine is savvy about conceptual models and statistical techniques,” Buckwalter says. “Perhaps most important, she tackles issues that can improve quality of care and quality of life for vulnerable populations in a scholarly manner. And she understands the need to disseminate her findings to complete the research process.”
As a long-time nurse dealing directly with elderly patients, Phillips knows how grateful some of her fellow professionals will be to receive new tools.
“The difficulty that nurses and other health professionals have in recognizing true depression is understandable given that depressive symptoms commonly overlap with symptoms of medical illness,” Phillips says. “Depression may actually magnify pain and discomfort related to medical conditions. As a result, residents may require treatment for physical complaints as well as depression to achieve optimal mental health.”
Much of Phillips’ research has focused on how to make the daily lives of the unhealthy more tolerable. While a doctoral student at the University of Texas, she worked with nursing professor Alexa Stuifbergen, whom Phillips describes as a mentor, on a study involving multiple sclerosis patients and depression.
A separate doctoral study, this one published under her own name in the journal Geriatric Nursing, carried the eye-catching title, “Dropping the Bomb: The Experience of Being Diagnosed with Parkinson’s Disease.”
Left: Annie Kelly, 90, originally from Jackson, Tenn. “I’d rather be living with my daughter,” she says, “but if you ain’t got no place else to go, you come here.” Right: Martha Rees, 82, is from Columbia. She is no longer able to answer a reporter’s questions.
Phillips’ research included in-depth interviews with 11 individuals diagnosed with Parkinson’s. “Dropping the bomb,” she says, signified “sorting through the rubble and picking up the pieces of lives shattered by the diagnosis.” Other themes were keyed to the progression of the ailment: “guarded anticipation, becoming informed, disease dynamics, and negotiating with ‘Mr. Parkinson.’”
Phillips concluded that nurses “might ease the impact of the diagnosis and the context of the disease if they contextualize their interventions within the preferences of the persons living with it.” The issue hit home for Phillips. Her parents, both now deceased, each suffered from Parkinson’s Disease.
When Phillips chose nursing as her educational path, she stayed close to home, earning a bachelor’s degree from Pennsylvania State University. While employed as a nurse, Phillips completed graduate courses in health administration and public health at West Chester University near Philadelphia.
It didn’t take long, however, before she decided the administrative emphasis wasn’t for her. Not enough patient contact, she says. Instead, Phillips switched to the University of Delaware’s family nurse practitioner program, where she earned a master’s degree in 1996.
Seven years later, she decided to feed the mostly suppressed quantitative part of her mind by enrolling in a doctoral nursing program at the University of Texas. She deciphered another motive, too. She wanted to help train a new generation of nurses.
The choice of Texas was an obvious one. Phillips was already on campus working as a nurse practitioner at the campus’s student health center.
While at Texas, Phillips won a national research service award in women’s health. The award paid tuition and a two-year stipend, allowing her to leave the student health job and become a full-time student. It also gave her more time to join in scholarly investigations.
“Although I entered the doctoral program with the intention of assuming primarily a teaching role when I finished, I quickly realized how well suited I am to quantitative research. My detail-oriented, over-analytical mind was finally put to good use,” she says.
As a post-doc, Phillips decided to focus on exploring a form of dementia therapy that geriatric researchers call “storytelling interventions.” Her work determined that one particular storytelling intervention, TimeSlips, improved the communications of nursing home dementia patients and promoted a more positive affect, measured as observed pleasure, at least for a while.
Grants from the John A. Hartford Foundation, the Iowa Gerontological Nursing Interventions Research Center, and the MU Interdisciplinary Center on Aging allowed Phillips to compare the TimeSlips storytellers to a control group. Buckwalter, the Gerontological Nursing editor, and MU’s Rantz, who chairs the Minimum Data Set and Quality Research Team, served as Phillips’ postdoctoral mentors.
The search for a position at a nursing school where research was emphasized began during 2007, the same year Phillips graduated with her doctorate. Phillips eventually chose MU’s Sinclair School of Nursing because of its strong infrastructure supporting nursing research, and its shared interest in gerontological studies.
A well-timed employment offer from MU for her husband helped, too: Win Phillips is a clinical assistant professor of health management and informatics. Two of Phillips’ daughters attend Columbia Public Schools. The other two are working professionals: one a social worker, the other a nurse.
Today Phillips is training nurses not only through her publications and on-campus teaching, but also through the University’s distance learning program. Last semester her online advanced practice class drew an enrollment of 29 students, many of them employed already within hospitals. “The online students have accumulated expertise in a hospital setting,” Phillips says, but not so frequently in long-term care facilities outside hospitals. “I learn from them while they learn from me.”
During her own years of in-hospital nursing, Phillips had focused on adult care. When her emphasis became home health care, she again chose to work with adults — many of them elderly, many relying on Medicare. A major concern was that her patients were participating fully in their treatment plans.
“In cases where patients’ agendas differed from that of their physician, I did what any nurse would do,” she recalls. “I relayed my assessment and the patient’s perspective to the physician and requested an alternate treatment plan.” Such patient advocacy, she says, is an essential part of nursing. In her case, she adds, it helped keep her attuned not only to the desires of her patients, but also to their seen and unseen conditions, including depression.
Even before beginning her doctoral program, Phillips knew that serving older adults had become her passion, not just her professional interest. “Ageism,” she feared, had infected society. Phillips wanted to advocate for its victims, just as other professionals advocated for children or ethnic minorities.
Part of societal ageism had resulted in adoption of a conventional wisdom that the elderly will slowly and inexorably decline until death, with lowered quality of life a given by-product. Knowing from her research that a phenomenon termed “compression of morbidity” could be achieved — that elderly patients could live well longer before death — Phillips had found her niche within academia. “I see this as an ethical obligation,” she says.