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Tool on Depression: Assessment and Treatment For Older Adults CANADIAN COALITION FOR SENIORS MENTAL HEALTH To promote seniors mental health by connecting.

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Presentation on theme: "Tool on Depression: Assessment and Treatment For Older Adults CANADIAN COALITION FOR SENIORS MENTAL HEALTH To promote seniors mental health by connecting."— Presentation transcript:

1 Tool on Depression: Assessment and Treatment For Older Adults CANADIAN COALITION FOR SENIORS MENTAL HEALTH To promote seniors mental health by connecting people, ideas and resources COALITION CANADIENNE POUR LA SANTÉ MENTALE DES PERSONNES ÂGÉES Promouvoir la santé mentale des personnes agées en reliant les personnes, les idées et les ressource

2 Reality: Defining Seniors Mental Health Mood DisordersMood Disorders Anxiety DisordersAnxiety Disorders Dementia – Alzheimers DiseaseDementia – Alzheimers Disease Personality DisordersPersonality Disorders Concurrent DisordersConcurrent Disorders Schizophrenia; AutismSchizophrenia; Autism Suicidal BehaviourSuicidal Behaviour

3 Mental Illness is NOT a normal consequence of aging! Depression: 14.7% – 20% in the communityDepression: 14.7% – 20% in the community LTC: % of residentsLTC: % of residents Alzheimers: 1 in 3 over 85Alzheimers: 1 in 3 over 85 DeliriumDelirium up to 50% up to 50% Suicide:Suicide: Suicide rate for older Canadian men nearly 2x that of the nation as a whole Suicide rate for older Canadian men nearly 2x that of the nation as a whole

4 Mental Illness is NOT a normal consequence of aging! Major Depression 2-4%Major Depression 2-4% Depressive symptoms 14 – 20%Depressive symptoms 14 – 20% Schizophrenia 0.5%Schizophrenia 0.5% Dementia 8% (rising to 34% in those >85)Dementia 8% (rising to 34% in those >85) Paranoid thoughts: 10%Paranoid thoughts: 10% Anxiety Disorders: 19%Anxiety Disorders: 19% Alcohol dependence 1-3%Alcohol dependence 1-3% (problem drinking 4-23%) (problem drinking 4-23%)

5 Who should be screened for depression? Recently bereaved with symptoms 3-6 months after the lossRecently bereaved with symptoms 3-6 months after the loss Socially isolatedSocially isolated Persistent complaints of memory difficultiesPersistent complaints of memory difficulties Chronic disabilitiesChronic disabilities Recent major illness (e.g., within 3 months)Recent major illness (e.g., within 3 months) Persistent sleep difficultiesPersistent sleep difficulties Somatic concerns or anxietySomatic concerns or anxiety Refusal to eat or neglect of personal careRefusal to eat or neglect of personal care Recurrent or prolonged hospitalizationRecurrent or prolonged hospitalization Diagnosis of dementia, ParkinsonsDiagnosis of dementia, Parkinsons Recent placement in a nursing/LTC homeRecent placement in a nursing/LTC home

6 Health care providers should have knowledge and skills in the application of age-appropriate screening and assessment tools for depression in older adults. Recommended Screening Tools for Depression

7 Screening Tools for Depression Without significant cognitive impairment in general medical or geriatric settings include: Geriatric Depression Scale (GDS)Geriatric Depression Scale (GDS) SELFCARESELFCARE Brief Assessment Schedule Depression Cards (BASDEC) for hospitalized patients.Brief Assessment Schedule Depression Cards (BASDEC) for hospitalized patients. Moderate to severe cognitive impairment: Cornell Scale for Depression in DementiaCornell Scale for Depression in Dementia

8 Are my older patients at higher risk of depression? (laminate) Risk factors: socially isolatedsocially isolated persistent complaints of memory difficultiespersistent complaints of memory difficulties chronic disabling illnesschronic disabling illness major physical illness within the last 3 monthsmajor physical illness within the last 3 months persistent sleep difficultiespersistent sleep difficulties somatic concerns or recent-onset anxietysomatic concerns or recent-onset anxiety refusal to eat or neglect of personal carerefusal to eat or neglect of personal care recurrent or prolonged hospitalizationrecurrent or prolonged hospitalization diagnosis of dementia, Parkinsons disease, or strokediagnosis of dementia, Parkinsons disease, or stroke recent placement in a nursing/LTC homerecent placement in a nursing/LTC home

9 If your patient is recently bereaved: active suicidal ideationactive suicidal ideation guilt not related to the deceasedguilt not related to the deceased psychomotor retardationpsychomotor retardation mood congruent delusionsmood congruent delusions marked functional impairment (2 months after loss)marked functional impairment (2 months after loss) reaction that seems out of proportion to the lossreaction that seems out of proportion to the loss Continued

10 Tool development on Depression Assessment For Older Adults Developed by NICE Mental Health Team

11

12 Part 1: RISK, SCREENING

13 1 IS MY PATIENT AT RISK FOR DEPRESSION? National Guidelines for Seniors Mental Health: Part 2: PREDISPOSING FACTORS Female Widowed or divorced Previous depression history Brain changes due to vascular problems Major physical and chronic disabling illnesses Medications or Polypharmacy Excessive alcohol use Social disadvantage & low social support Caregiver for person with a major disease (e.g.,dementia) Personality type (e.g., relationship or dependence problems) PRECIPITATING FACTORS Recent bereavement Move from home to other places (e.g., nursing home) Adverse life events (e.g., losses, separation, financial crisis) Chronic stress with declining health, family or marital problems Social isolation Persistent sleep difficulties Part 1: Risk Screening

14 2 RECOMMENDED ASSESSMENT OPTIONS National Guidelines for Seniors Mental Health: Part 2: A structured interview using one of the following tools: TOOLS DEVELOPED TO REFLECT DEPRESSION OLDER ADULTS WITH AVAILABLE WEBSITES In general medical practice, nursing/residential homes or inpatient settings SIG E CAPS- (http://webmedia.unmc.edu/intmed/geriatics/reynolds/pearlcards/depression/depressionindex.htm) The Geriatric Depression Scale (http://www.stanford.edu/~yesavage/GDS.html) Brief Assessment Schedule for the Elderly (BASDEC) (http://www.medalreg.com/www/sheets/ch18/depression%20Koenig%20scale.xls) In community surveys Center for Epidemiological Studies – Depression Scale The Geriatric Mental State Schedule (GMSS) For depression in the presence of dementia or significant cognitive difficulties The Cornell Scale for Depression in Dementia (http://www.emoryhealthcare.org/departments/fuqua/CornellScale.pdf )

15 3 DIAGNOSTIC CRITERIA National Guidelines for Seniors Mental Health: Part 2: 2.2 DIAGNOSTIC CRITERIA FOR DEPRESSION - DSM 1+V ) A cluster of symptoms present on most days, most of the time, for at least 2 weeks Depressed mood Loss of interest or pleasure in normal, previously enjoyed activities Decreased energy and increased fatigue Sleep disturbance Inappropriate feelings of guilt Diminished ability to think or concentrate Appetite change (i.e., usually loss of appetite in the elderly) Psychomotor agitation or retardation Suicidal ideation or recurrent thoughts of death

16 DSM IV-TR CLASSIFICATION (APA, 2000) Make a clear DSM-IV diagnosis & document Different types of depressive disorders Major depressive episodes (i.e., part of unipolar, bipolar mood disorder or secondary to a medical condition) Dysthymic disorder Depressive disorders not otherwise specified: A group of disorders including minor depressive disorder, post psychotic depressive disorder of schizophrenia and depressive disorders of unclear etiology (e.g., may be primary or secondary to a medical condition or substance induced)

17 4 SUICIDE RISK National Guidelines for Seniors Mental Health: Part 2: 2.1 Non-modifiable risk factors Old age Male gender Being widowed or divorced Previous attempt at self-harm Losses (e.g., health status, role, independence, significant relations) Potentially modifiable risk factors Social isolation Presence of chronic pain Abuse/misuse of alcohol or other medications Presence & severity of depression Presence of hopelessness and suicidal ideation Access to means, especially firearms Behaviors to alert clinicians to potential suicide Agitation Giving personal possessions away Reviewing ones will Increase in alcohol use Non-compliance with medical treatment Taking unnecessary risk Preoccupation with death

18 Part 2: WHEN TO TREAT, REFER, & MONITORING & LONG TERM TREATMENT

19 Commonly-used Antidepressant Medications- National Guidelines for Seniors Mental Health: Part 5 Generic Name Trade Name Starting dose mg/dayAverageDose Maximum recommended dose (CPS) Comments/Caution SSRI SSRI Citalopram Citalopram Celexa Celexa mg 40 mg Escitalopram Escitalopram Cipralex Cipralex mg 20 mg Sertraline Sertraline Zoloft Zoloft mg 200 mg Other Agents Other Agents Buproprion Buproprion Wellbutrin Wellbutrin mg BID 100 mg BID 150 mg BID 150 mg BID May cause seizures May cause seizures Mirtazapine Mirtazapine Remeron Remeron mg 45 mg Moclobemide Moclobemide Manerix Manerix BID BID 300 mg BID 300 mg BID Do not combine with MAO-B Do not combine with MAO-B inhibitors or Tricyclics inhibitors or Tricyclics Venlafaxine Venlafaxine Effexor Effexor *375 mg *375 mg * For severe depression; May * For severe depression; May increase blood pressure increase blood pressure Tricyclic Antidepressants Tricyclic Antidepressants Desipramine Desipramine Norpramin Norpramin mg 300 mg Anticholinergic properties Anticholinergic properties cardiovascular side-effects; cardiovascular side-effects; Monitor blood levels Monitor blood levels Nortriptyline Nortriptyline Aventyl Aventyl mg 200 mg Anticholinergic properties; Anticholinergic properties; cardiovascular side-effects; cardiovascular side-effects; Monitor blood levels Monitor blood levels

20 5 WHEN TO TREAT National Guidelines for Seniors Mental Health: Part 2: Following a positive screen for depression a complete bio-psycho-social assessment should be conducted including: A review of diagnostic criteria in the DSM 1V-TR or ICD 10 manuals An estimate of severity, including presence of psychotic or catatonic symptoms Risk of suicide, by directly asking patients about suicidal ideation, intent and plan Personal or family history of mood disorder Medication use and substance abuse Review of current stressors and life situation Level of functioning/disability Family situation, social integration/support Mental status exam, plus assessment of cognitive function Physical exam and lab tests to determine if medical issues contribute or mimic depressive symptoms Treatment can be divided into 3 main phases Acute treatment phase: to achieve remission of symptoms Continuation phase: to prevent recurrence or relapse of same episode of illness Maintenance or prophylaxis phase: to prevent future episodes or recurrence

21 6 GUIDELINES FOR TREATMENT National Guidelines for Seniors Mental Health: Part 4 & 5 Psychotherapies & Psychosocial Interventions Supportive care should be offered to all patients who are depressed Psychotherapy is a first line of treatment or in combination with antidepressant medication Based on type of depression, coping style, level of cognitive functioning Psychotherapy – provided by trained mental health professionals Pharmacological Treatment Medications are used in combination with psychosocial or psychotherapy treatments Part of overall treatment of depressed older adults See table for commonly used antidepressants See full guideline for details of prescribing and monitoring 7 WHEN TO REFER National Guidelines for Seniors Mental Health: Part 3: 3.5 Recommendations for clinicians to refer for Psychiatric Care at Time of Diagnosis Psychotic depression Bipolar disorder Depression with suicidal ideation

22 8 MONITORING AND LONG TERM TREATEMENT National Guidelines for Seniors Mental Health: Part 6: 3 Health care providers should monitor the older adult for re-occurrence of depression for the first 2 years after treatment Ongoing monitoring should focus on depressive symptoms present during initial episode Older adults in remission of their first episode should be treated for a minimum of one year and up to 2 years from time of improvement Older adults with recurrent episodes should receive indefinite maintenance therapy In LTC homes, response to therapy should be evaluated monthly after initial improvement and then every three months, as well as annual assessment after remission of symptoms

23 NICE – Mental Health Team Depression Assessment Tool, Evaluation

24 Evaluation Outline 1.Case Description (stakeholder consultation and tool development process) How many stakeholders were consulted? How many stakeholders were consulted? What disciplines / health care sectors / organizations were represented? What disciplines / health care sectors / organizations were represented? What is the geographical representation of stakeholders? What is the geographical representation of stakeholders? How were stakeholders recruited? How were stakeholders recruited? Describe process of consultation (i.e., teleconference calls, material distribution, survey monkey etc.). Describe process of consultation (i.e., teleconference calls, material distribution, survey monkey etc.). Describe limitations. Describe limitations. 2.Knowledge Transfer Survey To be collected at 3 weeks and 3 months post workshop session To be collected at 3 weeks and 3 months post workshop session Offered in both paper and survey monkey form Offered in both paper and survey monkey form Phone call reminders Phone call reminders Consent form Consent form 3.In-depth Qualitative Interviews Conducted 3 months after workshop – focus group or individual interviews depending on scenario (tape recorded / transcribed) Conducted 3 months after workshop – focus group or individual interviews depending on scenario (tape recorded / transcribed) Consent form Consent form 4.Evaluation of Workshop Sessions To be distributed and collected at end of each session To be distributed and collected at end of each session 5.Analysis – mid April – mid-May 6.Report- June 2008 NICE Conference

25 CANADIAN COALITION FOR SENIORS MENTAL HEALTH To promote seniors mental health by connecting people, ideas and resources COALITION CANADIENNE POUR LA SANTÉ MENTALE DES PERSONNES ÂGÉES Promouvoir la santé mentale des personnes agées en reliant les personnes, les idées et les ressource Disclaimer: This tool is intended for information purposes only and is not intended to be interpreted or used as a standard of medical/health practice.


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