an inTeRlink feature article

Easy Rider wheelchair biking: A nursing-recreation therapy clinical trial for the treatment of depression

Suzanne Fitzsimmons ¹ and Linda L. Buettner ²

¹ Suzanne Fitzsimmons is a graduate student at Decker School of Nursing, Binghamton University, Binghamton, NY studying to become a Geriatric Nurse Practitioner and a Clinical Nurse Specialist.

² Linda L. Buettner is an assistant professor at Decker School of Nursing, Binghamton University.

The Duet bike was funded by a grant from the Helen Holland Foundation, Binghamton New York.

Zeta Iota Chapter of Sigma Theta Tau provided partial funding for this masters research project.

Introduction

It is estimated that the incidence of depression in older adults living in long term care facilities can be is as high as 50% (Tueth, 1994) and is the most common mood disorder of late life (Butler & Lewis, 1995). Depression often goes undiagnosed and therefore untreated (Devanand, et al., 1994). Diagnosing depression in this group is often difficult as older persons may exhibit non-specific somatic complaints rather than DSM-V classified symptoms of depressed mood (Waintraub, 1998). Minor depression often becomes a chronic illness in this group but is not a part of normal aging (Lammer & Ham, 1997). Depression may be associated with side effects of medications or compounded by medical conditions such as a cerebral vascular accident, Parkinson’s or heart diseases. It may be caused by a multitude of psychological conditions such as coping with chronic illness and frequent pain, gloomy institutionalized environments, and an assortment of losses including function, independence, social roles, friends and relatives, and past leisure activities. Depression is associated with functional decline and excess mortality and therefore should be treated vigorously. It has also been demonstrated that depression is a contagious condition (Lammer & Ham, 1997).

Social interactions and pleasurable experiences are ways of providing the elderly with opportunities to attain happiness, purpose and quality of life. The ability to reach this mood state level is often out of reach to those elderly residing in long term facilities with depressive diseases. This group frequently has compounding constraints to leisure in the form of multiple chronic conditions such as cognitive and mobility impairments and numerous medical diagnoses (Buettner & Martin, 1995). Research examining the link between the body and mind has repeatedly demonstrated that a person’s mood and attitude affects not only their immune system but other body systems as well (Carlin, 1997). The physical effects of depression increases the parasympathetic nervous system leading to a vast assortment of medical illnesses (Lammer & Ham, 1997).

Research shows that for mild depression, non-drug therapies are as effective as antidepressant medications (National Institutes of Health, 1998). Psychotherapy interventions for persons in long term care are not frequently offered and its usage is questionable given its high cost and poor efficacy rate in persons with dementia, who comprise 60 - 80% of long term care residents (German, Rover, Burton, Brandt, & Clark, 1992). Psychosocial interventions may provide a feasible, safe alternative or complementary intervention to the current treatment modality for this population. Care to residents of long term care facilities is best delivered, and even mandated by state and federal regulations, in an interdisciplinary manner (National Institutes of Health, 1991). The expertise of nursing and recreation therapy professionals combined, make development of psychosocial interventions for depression feasible.

Explanation

The purpose of this study is to determine if participation in a therapy biking program has an effect on the degree of depression in older adults living in a long term facility in Upstate New York. This study was designed to answer the following research question: What is the relationship between therapy biking program participation and the level of depression in older adults living in long term care facilities?

The following hypothesis was developed to guide the study: Older adults who participate in a therapy biking program will have lower levels of depression than those who do not participate in a therapy biking program.

The design for this study was a classical experimental design with randomization, a control and treatment group and pre- and post-testing. All consenting residents were pre-tested for depression using the short form Geriatric Depression Scale (GDS) (Sheikh, & Yesavage, 1986). Recreational Therapy students trained by the principle investigator and by her committee chairperson did the testing. Only those subjects who scored a four or greater on the GDS were considered eligible for inclusion in the study.

The sample was taken from a 242-bed long-term care facility in New York State. The target population was residents with a diagnosis of, or symptoms of depression. After the initial screening and consents were obtained, fifty-five subjects were eligible for the study. Forty subjects were then randomly selected from the fifty-five eligible subjects and those forty were randomized into an equal number of participants in the experiment and control groups. At baseline, there were no significant differences between control and treatment groups in any other demographic characteristics as summarized in Table 1.

Within the subjects in the treatment group there were three subjects who required lifting equipment to be transferred into the wheelchair bike. One subject required portable oxygen to be attached to the bike, one had an indwelling catheter and one had a continuous tube-feeding device that required continuous feeding during riding. Five of the eleven treatment subjects with a diagnosis of dementia resided on a special care unit. Four subjects were over the age of 92 and one would be turning 100 shortly after the study ended.

All subjects received medical clearance to participate in the program and those in the experimental group received physician orders for recreational therapy 1x per day, 5 days per week for two weeks for depressive symptoms. A Certified Therapeutic Recreation Specialist (CTRS) developed the protocols for the program (see Appendix A). The CTRS set up trainings for staff members who wanted to assist in riding during in the program. Facility staff members who voluntarily helped included staff from nursing, management, recreational therapy, physical therapy, occupational therapy, housekeeping and security. Many of these staff members enjoyed it so much they devoted their lunch or break times to assist with the program.

This intervention utilized a Duet bike, which is a modified tandem bicycle manufactured in Germany by Robert Hoening GmbH. The front of this system is a detachable wheelchair that acts as the front wheel of the bike. This system enabled the subjects, at all functioning levels, even with severe disabilities, to ride in the wheelchair while the caregiver pedals and steers from the back. The experimental group received the therapeutic biking program for one hour a day, five days a week, for two weeks. This program involved groups of three to five residents for each session. The one-hour program had two components. In part one residents had a small group discussion program about bike riding. In part two each resident took a 15-minute ride in or around the facility. During this time staff sat with those residents who were waiting for their turn to ride and the group discussed past life bike riding events.

The therapy program, called the Easy Rider program, was scheduled to run four times during the day with a maximum of five subjects scheduled into each session. Subjects were assigned to a particular session based on their availability. Care was taken not to schedule a subject for a session that would interfere with their current schedule of activities, therapies, appointments or meals. Once the group was assembled the first rider was assisted into the wheelchair portion of the bike. The subjects were encouraged to put their safety helmet and H-harness on themselves. While this subject was riding the remainder of the group was involved in the discussion portion of the program. As each subject finished his or her ride, that subject was encouraged to talk about their ride with the group. This continued until all subjects had the opportunity to ride.

Post-testing for the both groups took place on the last day of the two-week period. In the two weeks following this intervention the facility staff offered the program to the control group.

Comparisons made between the two groups determined that equality between groups, in relationship to the extraneous variables, had been achieved through random assignments, as detailed in Table 1. The GDS scores were analyzed using a t-test for independent samples with a two-tailed significance at the a = .05 level, as shown in Table 2. The control groups pre-test means of 7.95 increased slightly at the post-test to 8.65, indicating a slight increase (+0.70) in depression. The treatment groups pre-test means of 7.68 decreased to 4.21 (-3.47) at the post-test denoting a marked decrease in depression. The analysis of these variables determined that the difference in post-test GDS means for the treatment group was significant at the p<.000 level.

The hypotheses, older adults who participate in a therapy biking program will have lower levels of depression than those who do not participate in a therapy biking program was accepted at a highly significant level.

Discussion

The results of this study show a very positive effect on depression levels through the use of an interdisciplinary psychosocial intervention. The mean GDS scores for the treatment group dropped 3.47 points after the two-week intervention. With the exception of one subject, whose score remained the same, all depression scores improved. Thirty-one percent of all participants were without a chart diagnosis of depression, substantiating the claim that depression is frequently undiagnosed. Fifty-one percent of the participants were currently not receiving any treatment at all for depression. This finding supports previous finding that depression is often untreated.

Demographic data repeatedly warn health care providers of the continually growing number of older adults. This population shift will give rise to an increase in long term care beds and facilities to care for the frailest of this population. This rise in numbers will also bring a rise in the number of older adults suffering from depression. Geriatric nurse practitioners, along with long term care nurses, are increasingly being sought after to care for this population. Armed with the knowledge that psychosocial interventions can be effective in treating depression may prevent these nurses from automatically resorting to the medical model of pharmacological treatment. This may be accomplished by working closely with the therapeutic recreation specialist and by writing or requesting orders for recreational therapies.

The majority of new interventions for the treatment of depression have been medications that can present serious side effects. Future research into nonpharmacological approaches is needed to add additional tools to the clinical repertoire of those caring for the depressed elderly. Controlled studies on the efficacy of psychosocial interventions may provide safe alternatives or complementary interventions to the current treatment modalities. There are many gaps in the current research regarding interventions for the nursing home resident with depression. Future research should be designed around this population’s needs and limitations, which often include functional, sensory and cognitive impairments.

Further studies are necessary to examine the full impact of this intervention. Specific populations such as those with dementia, those on rehabilitation units, and male and female participation differences, could provide greater insight as to which population could benefit the most. Impacts on the effects on staff members and on family satisfaction levels are additional areas open to investigation. Examination of variables other than depression is also recommended such as agitation, sleep, appetite, socialization and quality of life.

In summary, depression is a problem that will continue to burden our elderly and confront all health care providers. Failing to recognize and effectively treat depression in the institutionalized elderly is sanctioning these members of society to live their final years in despair and emotional suffering. This recreational therapy-nursing intervention provides a refreshing, safe new tool to use in the battle.

References

Buettner, L. L., & Martin, S, L. (1995). Therapeutic Recreation in the Nursing Home. State College, Pa: Venture Publishing, Inc.

Butler, R. N., & Lewis, M. I. (1995). Late-life depression: when and how to intervene. Geriatrics, 50(8), 49-52.

Carlin, P. A. (1998). Depressed mind, sick body. Hippocrates. 12(12):36-42.

Devanand, D. P., Nobler, M. S., Singer, T., Kiersky, J. E., Turret, N., Roose, S. P., & Sackeim, H. A. (1994). Is dysthymia a different disorder in the elderly? American Journal of Psychiatry, 151(11), 1592-9.

German, P., Rover, B., Burton, L., Brandt, L., & Clark, R. (1992). The role of mental morbidity in the nursing home experience. The Gerontologist, 32, (2), 152-163.

Lammers, J. G., & Ham, R. J. (1997). Primary Care Geriatrics (3^rd ed.), Chapter 18. St. Louis: Mosby.

National Institutes of Health Consensus Statement Online. (1991) Nov. 4-6: [1999, March 4]. Diagnosis and Treatment of Depression in Late Life. Available online at http://text.nlm.nih.gov/nih/cdc/www/86txt.html.

National Institutes of Health. (1998). Non-Drug Therapies for Depression Available online at http://www.depression.com/good/good_08_nondrug.htm.

Sheikh, J. I., & Yesavage, J. A. (1986). Geriatric Depression Scale (GDS) recent evidence and development of a shorter version. Clinical Gerontologist, 5, 165-173.

Tueth, M. J. (1994). Diagnosing psychiatric emergencies in the elderly. American Journal of Emergency Medicine, 12(3), 364-369.

Waintraub, L. (1998). Depression in the aged: diagnosis and treatment. Press Med 27(40), 2129-44.

TABLE 1

TABLE 2

(t-test for independent samples)

Therapy biking protocol for nursing home residents

Name of Program: Easy Rider

Staff requirements: One therapist or nurse plus one aide for each session

Entrance criteria: Enjoyed biking in the past or expresses a desire to ride plus symptoms minor depression (as evidenced by Geriatric Depression Scale or Cornell Depression Scale)

Exit criteria: No longer enjoys biking program (or) and free of symptoms of depression.

Group size: Therapeutic biking program will be completed in groups of four residents.

Duration: Each resident will receive 15 minutes of riding time for a total session of one-hour (4 residents at 15 minutes each).

Safety considerations: Each participant will have medical clearance to participate in the therapeutic biking program. Each participant will wear a safety helmet and H-Harness while on the Duet bike. Residents will be assisted on and off the wheelchair bike when boarding and de-boarding the bike.

Methods: The program will have two components. In part one residents will have a small group discussion program about bike riding and related events. In part two each resident will take a 15-minute ride. Residents will be escorted outdoors in a small group (4) for participation in this program, during inclement weather the group will be held indoors.

Part I: The aide will sit with those residents who are waiting for their turn to ride. During this time the small group will discuss bike riding in the past. Discussion questions will tap into long term memory and might be: "Do you remember your first bike? What color was it? What was it like?" "How old were you when you learned to ride a two-wheeler?" Did you ever ride a bicycle built for two?" "Where did you ride your bike when you were young?" "Did you ever get hurt riding your bike?" "Did you ever teach anyone else to ride a bike?" "What was the best thing about bike riding?"

Part II: Lock bike brakes. The Duet wheelchair will be lowered for boarding and the footrest will be swung away. Each resident will be assisted to board the wheelchair bike. Each resident will put on the helmet and attach the safety harness for comfort. The therapist will double check the harness and helmet before raising the chair to biking position and beginning the ride. The ride will take place on the flat driveway areas surrounding the nursing facility for 10-15 minutes. When ride ends the resident will remove harness, helmet, and footrest. The resident will be encouraged to tell the others in the group about the ride.

Possible Objectives:

• To improve small group socialization as evidenced by verbalizing with at least one other person in the group during each session.

• To improve mood as evidenced by positive comments about riding and by a happy expression.

• To increase appetite as evidenced by improved nutritional intake

• To improve sleep as evidenced by reducing nighttime rising.

• To improve concentration as evidenced by staying in the group and remaining on topic during discussions.

• To improve self-esteem as evidenced by positive descriptions of experience on bike.

• Reduce feelings of hopelessness as evidenced by an expression of looking forward to another ride in the future.

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