PEARL - Program Enhancing Adjustment to Residential Living

PEARL program is an intervention designed to enhance new residents to permanent aged care adjust to residential living. It is designed to be suitable for the majority of depressed residents in residential aged care facilities (RACFs), including those with mild-moderate dementia. RACFs will be matched by organisation and facility size (number of permanent beds). Matched RACFs will be randomly allocated to the intervention 'care as usual' plus PEARL intervention or ' care as usual' (control group) using a random number generator by a biostatistician who is not otherwise involved in the project and blind to the allocated condition. Residents who are admitted to RACFs over a 24 month recruitment period will be referred to the study by the facility manager (or admission officer) and approached by a researcher for consent(directly or via next of kin as appropriate) and will be screened for eligibility within four weeks of their admission. Participants in RACFs allocated to the intervention group will receive the PEARL program. This intervention group is described as 'care as usual' plus PEARL intervention. Depression is a serious issue in RACFs, affecting one third of older people, but current management approaches are inadequate. Late life depression is associated with higher mortality and increased care needs. The transition to a RACF is often highly traumatic and newly admitted residents are at an extreme risk of depression. The transition period therefore represents an ideal opportunity for early intervention. Currently, there are no interventions specifically targeting depressed aged care residents early in their admission to RACFs. The PEARL program addresses the key factors that facilitate adjustment to life in RACFs. They key factors include the resident's view or perception of the move, social support, self-efficacy, autonomy, perceived control and meaningful activity. These factors are aligned with the framework and key constructs of Self-Determination Theory (SDT) of autonomy, relatedness and competence, and Ryff's theoretical model of late life adjustment where environmental mastery, autonomy and purpose in life have been confirmed as essential components of psychological wellbeing and healthy ageing and predict successful adjustment to RACFs. PEARL intervention uses SDT and behavior therapy framework to orient newly admitted residents to their environment and is designed to encourage collaboration with residents and staff to develop care approaches that enhance their purpose in life, autonomy and environmental mastery. PEARL program is delivered over seven weeks and consists of three weekly 60 minute individual sessions with residents in a one-on-one format in the privacy of residents' own rooms plus two additional booster sessions provided two and four weeks after the final session to review and modify strategies. Session 1 will focus on orientation to the aged care facility and social support. Session 2 will focus on enhancing purpose in life through identification of residents' personal goals and values. Session 3 will assist residents enhance their autonomy and environmental mastery through identification of daily choices important to them and the development of strategies to maintain or adapt their level of autonomy within the RACF environment. The booster sessions will review the program and reinforce progress and assist residents address any concerns or problems. PEARL is simple, brief, and adapted to the characteristics of each RACF and is tailored to each resident's needs, interests, aptitudes and background. Strategies selected to meet resident's needs are behavioral in nature specifically tailored to each individual's level of cognitive function. PEARL program will be delivered by three trained clinicians using a highly structured treatment manual. Clinicians will have experience in RACFs settings, with a background in psychology, nursing, occupational therapy or social work. Treatment fidelity will be monitored using a random review of audio-taped sessions (5% of total sessions, spread across the 5 sessions) with sessions coded for adherence to the intervention manual. The clinicians will receive fortnightly individual clinical supervision with principle investigator during the first six month of the intervention period, thereafter reducing in frequency to meet their clinical needs. RACF staff are actively involved in the implementation of PEARL intervention. A recent meta-analysis found that psychological treatments for depression that involved RACF staff collaboration achieved better outcomes. Thus, each session with a resident will be followed by a 30 minute consultation with a key staff member involved in their daily care and care plan development. To ensure successful collaboration with RACF staff, a one hour training session will be provided to RACF staff as group sessions to introduce the program to as many staff as possible and establish rapport with the research team. This training will incorporate key learning from the program. In addition, clinicians will provide ongoing support and supervision to RACF staff to assist them implement the selected strategies or modify individual care plans where necessary.