Introduction
More than two million of the 34 million Americans age 65+ (“seniors”) suffer from some form of depression. Compared to the average American, seniors are more likely to be on an antidepressant.[1] Seniors with depressive symptoms have roughly 50% higher healthcare costs than non-depressed seniors (1). Depression increases your risk of heart disease by 50% (2). Depression significantly increases your chance of having a stroke, dying from stroke, and developing heart failure (3, 4).
Risk factors for depression include death of a spouse and chronic disease. One-third of widows/widowers meet criteria for depression in the first month after the death of their spouse, and half of these individuals remain clinically depressed after one year (5). Symptoms of clinical depression can be triggered by other chronic illnesses common in later life, such as Alzheimer’s disease (AD, also called Alzheimer’s dementia), Parkinson’s disease, heart disease, cancer and arthritis (5).
Melancholic depression (“depression”) is characterized by negative thoughts about the self, the present, and the future. In more acute cases, depressive symptoms include despair and helplessness. In milder cases, depressive symptoms include sadness, pessimism, diurnal variation in mood, early and late insomnia, and reduced ability to feel pleasure. By comparing these depressive symptoms with apathy, the signature symptom of AD, one can differentiate major depression from AD. However, the distinction is not always clear, especially in milder cases of depression, because depression can present with some features of dementia, a condition called pseudodementia. Depression and AD sometimes coexist or can sometimes succeed each other. Depression is a risk factor for developing AD (6). Differentiating between depression and AD is important since depression can be medically treated, and in many cases remission occurs. AD, at the present time, is a terminal diagnosis. Healthcare can only offer supportive care.
Depression is usually caused by psychological stress (“stress”). Stress activates the hypothalamus, pituitary, and adrenal glands—collectively, the hypothalamic pituitary adrenal (HPA) axis—causing the release of the hormone cortisol. Elevated levels of cortisol in the blood are associated with a person developing depression. One of the most consistent findings in the biology of depression is an altered activity of the HPA axis (7). [2] Seniors are at risk for anxiety and depression because the HPA is adversely affected by aging (9–11).
Question: Can I “take a pill” to reverse aging-related changes to the HPA axis?
Answer: No, but there is some promising research on this subject (12).
Question: What can I do, now, to prevent depression or better manage my stress/anxiety or depression?
Answer: Improve your emotional health and wellness.
Emotional wellness involves the capacity to positively manage and express feelings, recognize feelings in self and others, cope with stress, problem solve, and manage life’s setbacks. Research suggests that positively managing feelings and stress has significant impact on one’s health and well-being. Among older adults, high levels of stress are predictive of greater cognitive decline (13) and lower levels of physical health (14), whereas being more resilient to difficult events is associated with better quality of life, better mental and physical health, and increased longevity (15). The ability to positively regulate one’s emotions—emotional wellness—is an important part of achieving holistic wellness.
Question: How is emotional health and wellness connected to depression?
Answer: See Table 1.
Table 1. Relationship between mental health, behavioral health, and emotional health and wellness.
Question: If one is disease-free, then is one well?
Answer: No. Wellness is more than being disease-free. In pursuing wellness, one attempts to achieve a positive state of well-being.
Question: What is holistic wellness?
Answer: Purposeful living with positive focus on growing one’s abilities (vs. negative focus on one’s disabilities).
[1] 19% of American seniors are on an antidepressant, while 11% of all Americans are on an antidepressant.
[2] The molecular and genetic details of this are being actively researched (8).
What communities can do
Communities can promote the emotional wellness of their residents by lowering stress and equipping residents to better manage their response to stress.
Lowering Stress
To address financial stress, all 501(c)3 Life Plan Communities have resources set aside to provide financial assistance to residents experiencing economic hardship. The level of financial support offered by a community is correlated with the religious affiliation (denomination) of the community. Hutterite communities are exceptional in this respect—they provide complete financial security for their members.
Architects have a strong interest in how space, sound, and lighting can reduce stress.
Lowering sensitivity to stress
In addressing depression, as with most health conditions, a higher return on investment is realized when dollars are spent on prevention as opposed to medical management. A first step towards improving the emotional wellness of your residents is implementing an evidence-based holistic wellness program. An evidence-based wellness program consists of wellness activities that have been shown to be effective at improving the health and wellness of participants. A holistic wellness program effectively improves the health and wellness of residents in all 8 dimensions of wellness.
Evidence of effectiveness can range from answers to subjective questions (e.g, “do you feel better,” “are you more satisfied”) to controlled studies with non-invasive monitoring (wearable devices) or even laboratory testing and/or imaging. The latter studies carry more weight in the medical literature, so we will reference these.
The goal of emotional wellness is to positively modulate one’s sensitivity to stress. Meditation, mindfulness, and yoga have been shown to improve depression and reduce the effects of stress. Meditation is the act of increasing awareness relating to compassion, love, patience, and other topics related to human virtue (Figure 0). A growing body of literature has shown that meditation has profound effects on numerous physiological systems that are involved in major depression (16). The molecular details are being dissected (17).
Figure 0. The authors, meditating. Left, David Pearson, MD, MBA. Right, John Robinson MD, PhD.
Mindfulness is the act of focusing on being in the present. An example of practicing mindfulness could be focusing completely on drinking a hot cup of tea, taking in its scent, warmth, and taste and removing overpowering emotions from the mind. Mindfulness is a specific form of meditation. Mindfulness can be just as effective as visiting a typical therapist who practices cognitive behavioral therapy (CBT), which necessitates focusing on negative thoughts and having a discussion, as well as running experiments, on them (18).
Yoga combines physical postures, breathing techniques, relaxation, and meditation. Practitioners seek mental and physical balance. Yoga has been shown to improve depression and reduce the effects of stress. In adults with mild-to-moderate major depression, an eight-week hatha yoga intervention resulted in statistically and clinically significant reductions in depression severity (19). An analysis of 42 studies related to the effects of yoga on stress concluded that yoga asanas were associated with improved levels of stress indicators: reduced evening cortisol, waking cortisol, ambulatory systolic blood pressure, resting heart rate, high frequency heart rate variability, fasting blood glucose, cholesterol and low density lipoprotein, compared to active control (20).
Additionally, peer support groups help reduce symptoms of depression. An analysis of 14 studies showed that peer support groups were superior to usual care in reducing depressive symptoms and were as effective as professionally directed CBT (21).
Other dimensions of wellness affect depression as well:
- Social Wellness. The peer support group, being a socially interactive activity, boosts one’s social wellness and reduces the symptoms of depression.
- Physical Wellness. Chronic physical illness can trigger depression (5). Better management of chronic conditions (improved physical illness) should reduce the symptoms of depression.
- Financial Wellness. Financial stress limits individuals’ ability to think with clarity, meet financial demands, and even afford the necessities of life. It can evoke feelings of dread, fear, anxiety, frustration, and anger. Communities can provide financial support to those residents who are experiencing economic hardship. Additionally, providing financial education to residents can help them improve their money management.
- Vocational Wellness. Many communities use art therapy and volunteer opportunities to give residents a sense of purpose.
- Spiritual Wellness. Spiritual study and prayer and the support of a spiritual community can provide hope and comfort to those experiencing depression, stress, and anxiety.
Assessment
How can communities asses the quantity, quality, and impact of their wellness programing? They can begin by examining their coverage of the eight dimensions of wellness. In Wellzesta Life, all wellness events are tagged according to the International Classification of Wellness (ICW-1) taxonomy.[1] This classification permits advanced analysis of the community’s data. To allow for dimensional overlap events can be associated with up to three dimensions of wellness—primary, secondary, and tertiary. For instance, Yoga is associated with emotional, physical, and spiritual wellness.
Figure 1 shows the distribution of primary wellness dimensions among events offered at four Life Plan Communities in the past four months.[2] The communities offered an average of 370 events per community per month. Events focused on improving emotional wellness, vocational wellness, financial wellness, and environmental wellness comprised less than 3% of the total events offered. The event portfolio of a community reflects the background and training of its staff. When presented with data insights like those shown in Figure 1, executives typically make adjustments in staff or staff training to rebalance their events portfolio.
Figure 1. Donut plot showing the distribution of events by primary wellness dimension for actual events offered at four Life Plan Communities over the past four months.
Adequate coverage of the eight dimensions of wellness is a good start towards improving wellness programming. We ask, “Are the events being attended and are they positively impacting the health and wellness of the attendees?” In Wellzesta Life, residents set personal goals for improvement in the eight dimensions of wellness and accrue points for participating in community-sponsored and user-initiated events and reading wellness articles. After an event concludes, residents are asked to confirm their attendance and are invited to rate (1 to 5 stars) how much they “liked” the event (overall satisfaction) and its perceived impact on their health and wellness. We take “like” as a measure of event quality.
In the four communities over the course of the past four months, of those who registered for events, 80% confirmed their attendance. Of those who confirmed their attendance, 95% provided at least one star rating. This is a very high response rate. Figure 2 reports the average reported satisfaction and “impact on health and wellness” of events by primary wellness dimension. Wellness dimensions are ordered by impact on health and wellness.
Figure 2. Bar plot showing the average reported satisfaction and “impact on health and wellness” of events shown in Figure 1. Wellness dimensions are ordered by reported “impact on health and wellness.”
Residents rank events in emotional wellness, social wellness, environmental wellness, and financial wellness has having less impact on their health and wellness than events focusing on the other dimensions (spiritual, physical, intellectual, and vocational). Emotional wellness events suffer the largest gap between event quality and perceived impact on health and wellness, which suggests that residents really do find emotional wellness less impactful on their health and wellness than, say, physical wellness.
We observe an association between the abundance of events offered in a wellness dimension with the resident’s perceived impact of the wellness dimension on health and wellness. It is unclear whether the residents’ reporting of relatively low impact on health and wellness reflect upon those events in particular or a dimension of wellness in general.
To examine programming related to emotional wellness, we ranked, by frequency, events offered at the four communities in the past four months with emotional wellness as a primary, secondary, or tertiary dimension (Table 2). The events can be grouped: the physical group with Yoga and Tai Chi; the spiritual group with Vespers, Centering Prayer, Catholic Rosary, and Dream Work; the vocational group with Art Class, and Hospitality Meeting. The social group with xxx Afternoons, Resident Meetings, Resident Directory Photo Update; the support group with Grief Support Group, Caregiver Support Group, and Low Vision Support Group, and the outlier group with Computer Lab and Buddy Swim. Perhaps the Computer Lab and Buddy Swim reduce anxiety.
Table 2. Relationship between mental health, behavioral health, and emotional health and wellness.
It is important to allow events to be associated with more than one dimension of wellness (multi-dimensionality). We observe that Yoga and Tai Chi were assigned physical wellness as their primary dimension. These events would have been missed if our search did not include secondary wellness dimension assignments.
A first step towards improving the emotional wellness of your residents is the implementation of an evidence-based wellness program at your community. A second step is to offer person-centered programing that empowers residents to better understand and manage their unique abilities and circumstances. Technology can facilitate this second step by delivering automated, personalized notifications, on-demand wellness content recommendations, and peer-to-peer communication.
To fill gaps in community-sponsored wellness programing, Wellzesta offers on-demand wellness content. Wellzesta Life offers curated articles in the eight dimensions of wellness[3] and a personal wellness coach called DOT. DOT is short for “Do One Thing.” DOT possesses a growing set of skills based on artificial intelligence. Personalization in the form of “personalized messaging, recommendations, and coaching” is achieved through machine learning algorithms and predictive analytics. Figure 3 shows a video providing basic instruction in yoga from a certified yoga instructor. The video was delivered by DOT to residents who needed a boost in their emotional wellness.
[1] The ICW taxonomy is available online: https://bioportal.bioontology.org/ontologies/ICW.
[2] Data are from the Wellzesta Health Research Institute analytics database accessed January 29, 2019. Analysis was performed using Looker (Santa Cruz, CA) version 6.4.
[3] Articles related to emotional wellness are freely available at https://life.wellzesta.com/demo/articles?dimensionId=26
Effectiveness
Positively impacting the health and wellness of residents is desirable, but is there some tangible evidence that a community is moving the dial on emotional wellness? Yes: residents are less irritable and complain less. Irritability (sometimes called grumpiness) is an expression of anxiety that is derived from stress mixed with fear, worry (a milder form of fear), and loss of control. Emotional wellness is a tonic for anxiety. Boosting emotional wellness reduces irritability.
Communities spend an untold amount of time and energy dealing with resident complaints. Resident complaints take an emotional toll on staff. Happier residents make for happier staff. Happier staff means lower staff turnover. Thus, a key performance indicator (KPI) of an effective emotional wellness program is reduced staff turnover.
The Client Success Team at Wellzesta also has a KPI. We know that a client community has reached a new state of wellness when the conversation shifts from discussing problems to discussing possibilities.
To learn more about Wellzesta, see us at wellzesta.com.
Acknowledgements
The authors thank Evangeline Wilds (Wellzesta) and the senior living marketing experts at Love & Company for their expert editorial assistance.
Author bios
John M. Robinson, M.D., Ph. D
Dr. Robinson in the Chief Executive Officer of Wellzesta Inc. and the Managing Director of Wellzesta Health Research Institute (WHRI). At WHRI, Dr. Robinson leads the development of the Wellzesta Life mobile health & wellness (mHealth) platform to support preventative health and holistic wellness in senior adults. Dr. Robinson pioneered the development of the first Electronic Wellness Record (EWR) system. He leads the development of International Classification of Wellness (ICW), the most comprehensive and precise wellness terminology in the world. Dr. Robinson has pursued information processing in both academic and business settings. His informatics work spans from the physical limits of information processing (theoretical physics), signaling in macromolecular assemblies (biophysics), to clinical decision support (applied medical informatics).
Dr. Robinson received a BA in Biophysics from The Johns Hopkins University, and a combined MD + PhD (Biochemistry & Molecular Genetics) degrees from the University of Alabama at Birmingham. Prior to co-founding Wellzesta, Dr. Robinson, as an Assistant Professor at South Dakota State University, had a six member NIH-funded research program in the molecular physiology of heart failure. His research combined single molecule fluorescence experiments with modeling to provide deep insight into the cardiac myofilament, a massive allosterically regulated macromolecular assembly that is one of nature’s information processing devices. Dr. Robinson is a 2x NCAA All-American, NCAA Academic-All-American, and a member of the Johns Hopkins Athletic Hall of Fame.
David A. Pearson M.D., M.S., MBA
Dr. Pearson is a board-certified Emergency Medicine (EM) physician, Professor and Chief of Quality, Patient Safety, and Innovation at the Department of Emergency Medicine Emergency Department of Atrium Health, and Chief Medical Officer of WHRI. Dr. Pearson lectures nationally on cardiac arrest, innovation, and critical care and has authored numerous medical publications. Dr. Pearson received his M.D. from Vanderbilt University, an M.B.A. from Wake Forest University, and M.S. and B.S. degrees from the University of Florida.
References (click for reference list)
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