4DepressionDepression is a spectrum of mood disorders characterized by a sustained disturbance in emotional, cognitive, behavioral, or somatic regulation and associated with significant functional impairment and a reduction in the capacity for pleasure and enjoyment.The American Psychiatric Association’s Diagnostic and Statistical Manual of Psychiatric Disorders1 (DSM-IV) defines both major depressive disorder (MDD) and other disorders that do not meet criteria for MDD but that may nevertheless, in the long term care (LTC) setting, be associated with morbidity and mortality. These disorder, described in the literature as minor depression or subsyndromal depression, may have a particularly negative impact on the ability of the LTC patient to achieve or maintain maximum functioning.Depressive disorders should not be confused with depressed or sad mood, which may be a normal, transient response to specific losses or disappointments or to loneliness or boredom.
5IntroductionMaintain a high index of suspicion for the presence of depression or depressive symptoms in long term care (LTC) patientsLate-life depression may be overlooked or inadequately treatedAll health care workers in the LTC setting should maintain a high index of suspicion for the presence of depression or depressive symptoms in their patients. It has been estimated that between 12 percent and 16 percent of older adults living in LTC facilities have major depression, 50 percent may have a minor depressive disorder, and up to 70 percent may at one time experience depressed, sad, or blue mood.2Late-life depression may be overlooked or inadequately treated. Possible reasons for this include practitioners’ and patients’ focus on medical illnesses and the incorrect belief that increasing sadness is part of normal aging. In addition, symptoms of medical illness may be very similar to those of depression, making accurate diagnosis of depression more difficult.3 Cognitive decline also interferes with the recognition of depression.In the elderly, depression with medical comorbidity is the norm rather than the exception.Depression is known to increase disability and mortality and increase use of health care services.4
6IntroductionThe relationship between medical conditions and depression is complexDepression may exacerbate coexisting medical illnessSome medications may cause or contribute to depressionThe relationship between medical conditions and depression is complex. Medical conditions (e.g., stroke) can predispose to or trigger depression.Conversely, medical or neurological conditions may mask or imitate depression.5Many medical illnesses or conditions can cause symptoms such as apathy or lethargy that may suggest depression. However, the presence of such symptoms does not necessarily mean that an individual is suffering from depression.In many situations, depression may exacerbate coexisting medical illness. As a rule, when medical illness and depression coexist, both conditions should be treated.6Some medications may cause or contribute to depression.
7Federal Regulations and Depression F157-§483.10(b)(11) -- Notification of changes(i) A facility must immediately inform the resident; consult with the resident’s physician; and if known, notify the resident’s legal representative or an interested family member when there is:(B) A significant change in the resident’s physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications)For purposes of §483.10(b)(11)(i)(B), Clinical complications are such things as … or onset of depression
8Federal Regulations and Depression F250-§483.15(g)(1) The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident“Medically-related social services” means services provided by the facility’s staff to assist residents in maintaining or improving their ability to manage their everyday physical, mental, and psychosocial needsTypes of conditions to which the facility should respond with social services by staff or referral include:Depression
9Federal Regulations and Depression EATING-§483.25(a)(1)(iv)If the resident’s eating abilities have declined, is there any evidence that the decline was unavoidable?1. What risk factors for decline of eating skills did the facility identify?d. Depression or confused mental state is responsible for 50% or eating problems or weight loss in SeniorsAnorexiaThe facility, in consultation with the practitioner, identifies and addresses treatable causes of anorexiaWhere psychosis or a mood disorder such as depression has been identified as a cause of anorexia or weight change, treatment of the underlying disorder (based on an appropriate diagnostic evaluation) may improve appetite. However, other coexisting conditions or factors instead of, or in addition to, depression, may cause or contribute to anorexia. In addition, the use of antidepressants is not generally considered to be an adequate substitute for appropriately investigating and addressing modifiable risk factors or other underlying causes of anorexia and weight loss.
10Federal Regulations and Depression 42 CFR (f)(1)&(2), F319, F320, Mental and Psychosocial FunctioningSurveyors are instructed to review whether the facility had identified, evaluated, and responded to a change in behavior and/or psychosocial changes, including depression
11RecognitionRecognition is the first stage of the care processRecognition” means identifying the presence of a risk or conditionHow: PHQ-2 shows that only 14-25% of residents in LTC have depressionCaregivers identify depression poorlyThe PHQ-2 identifies 85% of patients with depressionReference: Practical Depression Screening in Residential Care. Am. J. Geriatrics Psychiatry. 17:7. July
12RecognitionDoes the patient have a history of depression or a positive depression screening test?Review available transfer information, referral data and patient and family historyLook for history of depression, psychiatric disorder(s), treatment of hospitalizationDocument the presence of these conditions in the medical recordAvailable transfer information, including summaries and other referral data, as well as a patient and family history, can help to identify individuals who have a history of depression, other psychiatric disorder(s), psychiatric treatment or hospitalizations, or suicide attempts.Document in the admission medical record the presence of any of these conditions or events in the patient’s history.
13Recognition Depression is common among patients in the LTC setting Treatment is effectiveAdopt a policy encouraging formal screening of all patients for depressionAppropriate screening tools include:Geriatric Depression ScaleCornell Scale for Depression in DementiaCenter for Epidemiologic Studies of Depression ScalePatient Health Questionnaire 9Clinical InterviewDo you feel life is worth living?What makes you happy?Because depression is common among patients in the LTC setting and treatment is effective, facilities may consider adopting a policy that encourages formal screening of all patients for depression on admission and at any time a significant change occurs in a patient’s functional or medical status.Appropriate screening tools include:Geriatric Depression Scale (GDS)Cornell Scale for Depression in Dementia (CSDD)Center for Epidemiologic Studies of Depression Scale (CES-D)Patient Health Questionnaire 9 (PHQ-9)The GDS can be used to screen patients with dementia who score 15 or higher on the Mini-Mental State Exam.7The CES-D may be especially useful for evaluating depression in African Americans and Native Americans.
14Recognition Does the patient have signs or symptoms of depression? Nursing staff are in a good position to recognize signs and symptoms (S&S) of depression (Behavior – not subjective)Look for S&S in RAI. MDS, RAPs, progress notes, family interaction notesIf the patient has a history of depression, other psychiatric disorder(s), or a screening test result that indicates possible depression, members of the interdisciplinary team and direct care staff should observe him or her for current signs and symptoms of depression.Nurses and nursing assistants are in a particularly good position to recognize day-to-day signs and symptoms of depression.Relevant signs and symptoms can also be found in the Resident Assessment Instrument (RAI), which consists of the Minimum Data Set (MDS) and Resident Assessment Protocols (RAPs), and in other parts of the medical record, such as family interaction notes and assessments and progress notes by practitioners; nurse practitioners; physician assistants; social workers; dietitians; activities staff; chaplains; and physical, occupational, and speech therapists.Another sign may be sudden improvement in mood and behavior signaling that the patient has resolved his or her feelings of conflict and has a plan to commit suicide.
15Symptoms Of Depression 3 Most importantDepressed mood most of the day, almost every day (by either subjective report or observation made by others , Diminished interest or pleasure in most activities, most of the time, Thoughts of death or suicide.ImportantDifficulty making decisions, Feelings of helplessness, Feelings of worthlessness or hopelessness, Inappropriate feelings of guilt, Psychomotor agitation or retardation not attributable to other causes, Social withdrawal, avoidance of social interactions, going out, activities and/or participationSometimes helpfulAppetite change, Change in ability to think or concentrate, Change in activities of daily living (ADLs), Family history of mood disorders, Fatigue or loss of energy, worse than baseline, Insomnia or hypersomnia nearly every day. Increased complaints of pain, Preoccupation with poor health or physical limitations, Weight loss or gain.Sleep problems occur in 40%-68% of all patients, with only 19% documentedReference: Sleep: A Marker of Physical and Mental Health in the Elderly. Am. J. Geriatric Psychiatry. 14: Oct. 2006Weight loss, or anorexia was found to be the most common sign and symptom of depression in LTC in one study.In addition to the symptoms listed in Table 2 from the American Medical Directors Association (AMDA) guideline, depressed patients in LTC facilities may exhibit changes in socialization patterns or attendance at social or recreational activities, apathy, anger, irritability, combative or resistive behaviors, preoccupation with life review, somatization, or increased use of health services and resources.Delusions may occur in a subset of patients who have MDD with psychotic features. However, none of these findings alone verifies the diagnosis of depression. Combinations of symptoms may be caused by one or more other conditions or by the combination of depression and one or more other conditions. A health care practitioner should always be involved in differentiating these possibilities.A member of the interdisciplinary team should document the presence and severity of any signs and symptoms of depression in the patient’s record. Whoever is designated for this task should be capable of describing and documenting findings (e.g., mood, affect, function) objectively, accurately, and in sufficient detail, and should be able to distinguish description from premature diagnosis (e.g., do not make statements such as “the resident acts depressed”).Members of the interdisciplinary care team should be familiar with the subtle signs of patient suicidal intent. Staff may more readily recognize active suicidal behaviors, such as hoarding pills or plastic wastebasket liners (for the purpose of suffocation), than passive behaviors such as refusing medications, nutrition, and care.
16Recognition Does the patient have risk factors for depression? Evaluate for risk factorsIf risk factors are present, develop an interdisciplinary (IDT) care planIf no risk factors are found, monitor periodically (every 3 months)If the patient does not have current signs or symptoms of depression, evaluate him or her for risk factors (see next slide) and document the findings in the patient’s medical record.If the patient has risk factors, develop an interdisciplinary care plan that takes those risk factors into account and maintain a high index of suspicion for depression.If no risk factors are found, continue to monitor the patient periodically for the development of risk factors as well as for signs or symptoms of depression. The involvement of the patient and family and the provision of in-service training and other activities to educate facility staff about the risk factors for and signs and symptoms of depression can help to ensure that depression is not overlooked in the LTC setting.
17Some Risk Factors for Depression Alcohol or substance abuseCurrent use of a medication associated with a high risk of depressionHearing or vision impairment severe enough to affect function – 30% increase rate of depressionHistory of attempted suicideHistory of psychiatric hospitalizationMedical diagnosis or diagnoses associated with a high risk of depressionNew admission or change in environmentNew stressful losses, including loss of autonomy, loss of privacy, loss of functional status, loss of body part, or loss of family member, friend or petPersonal or family history of depression or mood disorderPersonality Anxiety Disorder – Sleep problem (day time)This slide represents table 3 from the AMDA Depression guideline
18Assessment Assessment is the second stage of the care process “Assessment” means clarifying the nature and causes of a condition or situation and identifying its impact on the individual
19AssessmentHas the patient had a persistently depressed mood or loss of interest or pleasure for at least 2 weeks?Has depressed mood (dysphoria) or loss of interest or pleasure (anhedonia) been present for at least 2 weeks; andhas dysphoria or anhedonia contributed to the patient’s functional or social impairment or declineIs substance abuse or bereavement not presentPersonality DisorderPersonality traits influence clinical outcomes in a day hospitalReference: Treatment of Elderly Depressed Patients. Am. J. Geriatric Psychiatry April 2009.If the patient’s depressed mood (dysphoria) or loss of interest or pleasure (anhedonia) has been present for at least 2 weeks and if either dysphoria or anhedonia has contributed to the patient’s functional or social impairment or decline and if substance abuse or bereavement is not present, it is likely that the patient is suffering from a depressive disorder.Before this conclusion is reached, however, a health care practitioner should be consulted to distinguish a depressive disorder from other conditions or combinations of conditions, as discussed above.
20AssessmentIs it appropriate to perform a medical work-up for factors contributing to signs and symptoms of possible depression?Will depend upon:patient’s conditionprognosisadvance care directivesexpressed preferences of the patient or familyAlthough it is important to determine whether coexisting medical conditions or current medications may be contributing to the patient’s depressive symptoms, the nature and extent of an appropriate medical work-up will depend on the patient’s condition, prognosis, and advance care directives, as well as on the expressed preferences of the patient or family.For most patients in the LTC setting, a pertinent history and physical examination by the practitioner, the laboratory studies listed on the next slide, and the standard interdisciplinary RAI process may yield findings that help with decision making.The selection of additional studies to be performed will depend on coexisting medical conditions, availability of recent diagnostic data, and findings from previous assessments and consultations.In certain circumstances (e.g., a patient who is expected to die within a week or so), even a limited workup may not be indicated. In such cases, clearly document in the patient’s medical record the reasons why the work-up was not carried out.
21Laboratory Tests For Evaluating Possible Depression3 Preferred TestsOther Tests That May Be ConsideredChemistry profile (electrolytes, blood urea nitrogen, creatinine, glucose)Complete blood countSerum levels of anticonvulsant or tricyclic antidepressant, if taking either type of medicationThyroid function (T3, T4, TSH)ElectrocardiogramFolate levelSerum calcium levelSerum level of digoxin or theophylline, if taking either medicationUrinalysisVitamin B12 levelThis slide represents table 4 from the AMDA Depression guideline
22AssessmentIs the patient taking medications that might cause or contribute to depression?Many medications can affect:moodaffectlevel of consciousnessMany medications can affect mood, affect, and level of consciousness (see next slide).If a drug used to treat a coexisting condition is suspected of contributing to depressive symptoms, consider switching to an alternative medication that is less likely to have this adverse effect. For example, if a patient who is receiving clonidine for hypertension develops depressive symptoms, consider switching him or her to another antihypertensive medication.
23Medications That May Cause Symptoms of Depression Alpha-methyl dopaAnabolic steroidsAnti-arrhythmic medicationsAnticonvulsant medicationsAntidementiaBarbituratesBenzodiazepines (i.e., long acting)Carbidopa or levodopaCertain beta-adrenergic antagonists (propranolol)ClonidineCytokines (specifically IL-2)Digitalis preparationsGlucocorticoidsH2 blockersMetoclopramideOpioidsThis slide represents table 5 from the AMDA Depression guidelineReferences:D. Rogers et. al. General Drug Associated with Depression. Psychiatry. 5, DecSidhuk et. al. Watch for Psychotropics Causing Psychiatric Side Effects. Current Psychiatry. August
24AssessmentDoes the patient have one or more conditions that may increase the likelihood of depression or that may cause depressive symptomsMany medical and psychiatric diseases and conditions produce depressive symptoms or carry an independent risk for causing depression.These conditions need to be taken into account when a patient is assessed for depression (next slide).
25Important Comorbid Conditions* CancerChronic obstructive pulmonary disorderChronic painCongestive heart failureCoronary artery diseaseDiabetesElectrolyte imbalanceEndocrine disorders (thyroid)Head traumaMetabolic problemsMyocardial infarctionOrthostatic hypotensionPhysical, verbal, emotional abuseSchizophreniaAnxietyMost importantAlcohol dependencyCerebrovascular diseasesMedications that can cause mood disordersNeurodegenerative disorders (e.g., Alzheimer’s disease, Parkinson’s disease, multiple sclerosis)Substance abuseSleep apnea (40%-60% of patients with dementia)This slide represents table 6 from the AMDA Depression guideline*Reference: Is a Medical Illness Causing your Patients Depression. Current Psychiatry
26AssessmentDo the patient’s signs and symptoms resolve with treatment of comorbid condition(s)?Take appropriate action if medical diagnoses or conditions are suspected of contributing to depressive symptomsWhen depression and a medical condition coexist, both conditions are likely to require treatmentTo the extent possible, address underlying causes and evaluate the impact of such measuresTake appropriate action if medical diagnoses or conditions are suspected of contributing to depressive symptoms or increasing the likelihood of depression. For example, initiate treatment if either hypothyroidism or vitamin B12 deficiency is found. However, be aware that doing so may not resolve the patient’s depressive symptoms.When depression and a medical condition coexist, both conditions are likely to require treatment. It is often more difficult to resolve depression if coexisting conditions, such as diabetes or congestive heart failure, are not treated. Conversely, depression may contribute to worsening of a comorbid condition such as dementia or chronic pain.To the extent possible, address underlying causes and evaluate the impact of such measures before adding more medications to the patient’s regimen. If these measures fail to improve symptoms, assess the patient for treatment of the depression itself.
27Assessment Clarify the diagnosis The DSM-IV defines the following types of depressive disorders:Mild episode of major depressionModerate episode of major depressionSevere episode of major depressionSevere episode of major depression with psychotic featuresMinor depression disorder – 80% convert to MDD (Major Depression Disorder)Bipolar type IIDysthymic disorderAdjustment disorder with depressed mood or with mixed anxiety and depressed moodThe DSM-IV defines the following types of depressive disorders:Mild episode of major depression. Minor impairment in social activities, relationships, and overall functioning that persists for at least 2 weeks. Patient does not have more than five diagnostic symptoms.Moderate episode of major depression. Symptoms or functional impairment between mild and severe, persisting for at least 2 weeks.Severe episode of major depression. Marked interference with and impairment of social activities, relationships, and overall functioning, persisting for at least 2 weeks. Patient has more than five diagnostic symptoms.Severe episode of major depression with psychotic features. Symptoms include delusions and hallucinations.Minor depression disorder (subsyndromal depression). A less severe degree of impairment (two or three symptoms), but the duration of symptoms is the same as in major depression.Bipolar type II (recurrent major depressive disorder with hypomanic features). Meets the criteria for major depressive disorder with at least one hypomanic episode.Dysthymic disorder. Less severe depressive symptoms present for at least 2 years; symptoms are chronic, not episodic.Adjustment disorder with depressed mood or with mixed anxiety and depressed mood. The development of emotional or behavioral symptoms in response to an identifiable stressor(s) and occurring within 3 months of the onset of the stressor. The symptoms or behaviors represent marked distress in excess of what would be expected from exposure to the stressor and cause significant social impairment. The symptoms do not represent bereavement.
28Major Depression Weight loss or gain Insomnia or hypersomnia Psychomotor retardationAgitation (irritability, anxiety, fatigue)Decreased energyGuilt feelingsInability to concentrateThoughts of death or suicide (life not worth living)Loss of interest or pleasure+4 symptomsx2 weeksDepressedMood+4 symptomsx2 weeksThis figure helps the attending practitioner and interdisciplinary team to discern whether the patient may have a depressive disorder.If at least five of the symptoms listed in this figure are present for at least 2 weeks and if the patient has no history of a prior manic episode, then major depression is likely to be a correct diagnosisA substantial proportion of patients may fall slightly short of the criteria for major depression in the DSM-IV.These patients, especially those who clinically do not appear to be achieving their “highest practicable” level of function as required by the Omnibus Budget Reconciliation Act of 1987, may have minor depression, also called subsyndromal or subclinical depression.8It is important to recognize these DSM-IV “near misses” because evidence suggests that some patients with minor depression and its functional and social consequences may benefit from some of the same kinds of interventions that are helpful for patients with major depression.9AND these symptoms:Produce social impairmentAre not related to substance abuse.Are not related to bereavementReference: Comorbid Depression in Psychogeriatric Nursing Homes Wards which Symptoms are Prominent. Am. J. Geriatric Psychiatry. 17:7. July
29Rating Scales Use at the beginning of treatment Only reliable way to obtain an objective measureEssential to monitoring the effectiveness of treatmentGeriatric Depression Scale (GDS)Cornell Scale for Depression in Dementia (CSDD)Center for Epidemiologic Studies of Depression Scale (CES-D)Patient Health Questionnaire 9 (PHQ-9)Most reliable and efficientThe use of a depression rating scale at the beginning of treatment is the only reliable way to obtain an objective measure of the severity of a patient’s depression. Such information is essential to monitoring the effectiveness of treatment and to decisions about whether to continue, change, or terminate treatment.The following scales (listed as screening tools in Step 1) may also be used to diagnose and monitor depression:Geriatric Depression Scale (GDS)Cornell Scale for Depression in Dementia (CSDD)Center for Epidemiologic Studies of Depression Scale (CES-D)Patient Health Questionnaire 9 (PHQ-9)
30Assessment Does the situation warrant additional psychiatric support? Depression is often managed readily by primary care practitioners (80/20)Effective psychiatric support may not be readily available in the LTC settingIn some cases, however, psychiatric support is helpful25% improve with medication, while 58% improve with counseling and medicationPost-stroke depression resolves in 6 months regardless of treatment (20-40% have behavioral symptoms)Depression can often be managed readily by primary care practitioners who follow appropriate protocols and guidelines.Effective psychiatric support may not be readily available in the LTC setting. In some cases, however, psychiatric support is helpful, for example, to distinguish depression from other conditions, to assess the type and severity of depression, to identify underlying causes, or to manage complications.).Some clinical situations in which consultation with a psychiatric specialist may be helpful:Bipolar depressionDepression with comorbid alcohol dependency or substance abuseDepression with comorbid dementiaDepression with suicide ideationDouble depression (major depression and dysthymia)Dysthymic disorderEvaluation to determine if depression requires treatmentSevere, uncomplicated, nonpsychotic unipolar depressionPsychotic depression
31AssessmentDoes the patient’s depression exhibit complications that may pose a risk to the patient or to others?Determine if the patient is psychotic, severely agitated, aggressive, neurovegetative, or suicidalSuicide risk increases with the severity of depressionSerious grief or bereavement issues and psychiatric disorders other than depression may complicate a depressive episode.Other complicating behavioral comorbidities may include alcohol dependency, substance abuse, and dementia.A consultant with specific expertise in the psychiatric disorders of older adults may be helpful in evaluating the patient for complications of depression.It is important to determine if the patient is psychotic, severely agitated, aggressive (i.e., potentially dangerous to self or others), neurovegetative, or suicidal. If any of these conditions are present, referral to a geriatric psychiatric unit or consultation with a psychiatrist who has expertise in the care of older adults may be considered, unless the facility’s interdisciplinary team has experience in dealing with such patients.Suicide risk increases for all elderly persons when depression is severe or is compounded by psychosis, a recent loss or bereavement, or a recent physical disability, as well as in patients with alcohol dependency or those who abuse sedatives or hypnotics.
32Treatment Treatment is the third stage of the care process “Treatment” means selecting and providing appropriate interventions for that individual
33TreatmentDepression usually responds to treatment with psychotherapy, medications, or a combination of the twoAn effective individualized care plan includes both nonpharmacologic and pharmacologic interventionsPharmacologic:Antianxiety, antipsychotic, antidepressive and antidementiaNon-Pharmacologic (other psychotherapies):Emotion-oriented, interpersonal therapy, sensory stimulation therapyCognitive Behavioral Therapy (CBT) – (art, music, massage) only in early stage, Problem Solving Therapy, Environmental Activity – (exercise)Supportive TherapiesOnce diagnosed, depression usually responds to treatment with psychotherapy, medications, or a combination of the two. However, the implementation of an effective individualized care plan that includes both nonpharmacologic and pharmacologic interventions hinges on an accurate interpretation of depressive symptoms.The overall goals of treatment of an acute depressive episode are to achieve recovery and prevent future episodes of depression. The intended outcome should be complete resolution of symptoms, not simply a reduction in depressive symptoms.The overall goal for treatment of ongoing depression is to prevent a relapse as patient’s depressive symptoms continue to decline and his or her functionality improves and to prevent recurrence of a new depressive episode.
34Phases of Depression Treatment3 DurationGoalAcuteApprox. 3 monthsTo achieve complete recovery from signs and symptoms of acute depressive episode (i.e., remission)Continuation4-6 monthsTo prevent relapse as patient’s depressive symptoms continue to decline and his or her functionality improvesMaintenance3 months or longer, depending on patient’s needsOver the age of 70, usually months or lifetime if more than 2 episodesTo prevent recurrence of a new depressive episodeRelapse occurs in 40-60%This slide represents table 9 from the AMDA Depression guideline
35Treatment Implement appropriate treatment for the patient’s depression Minimize institutional aspects of the environmentFacilitate interaction with family members and friendsProvide opportunities for spiritual activity (50% of LTC residents have an interest)Provide socialization interventionsGeneral facility-wide approaches that should be available to all patients who can participate include the following:Minimize institutional aspects of the environment (e.g., encourage patients to decorate their living space with personal items).Facilitate interaction with family members and friends important to the patient.Provide opportunities for patients to engage in spiritual or religious activities if they so desire.Provide socialization interventions and structured, meaningful physical and intellectual activities that are age- and gender-appropriate.In some cases, a patient who has a depressive disorder may be unable to make an informed decision about treatment options. Under these circumstances, family members or significant others, patient advocates, and members of the interdisciplinary team may need to work together to ensure that the best decision is made for the patient.If it is decided to proceed with specific treatment for depression, the interdisciplanary team (IDT) should generate a care plan that identifies target symptoms and timetables for follow-up.The team should also ensure that steps are taken to address related environmental, spiritual, family, and cultural issues.If it is decided to forego psychotherapy or pharmacotherapy, document the rationale for this decision in the patient’s medical record.
36Psychotherapy Considerable advances have occurred Both cognitive-behavioral therapy and learning-based therapy have a significant impact on depression symptoms in older adultsDuring the past 25 years, considerable advances have occurred in the psychological treatment of late-life depression.10Whereas the early literature focused on reminiscence and containment of symptoms, recent research has demonstrated that both cognitive-behavioral therapy11 and learning-based therapy12 have a significant impact on depression symptoms in older adults.When considering psychotherapy, keep in mind that a variety of psychotherapeutic techniques exist. The patient’s cognitive status and previous experiences with therapists, as well as the availability of therapists, will influence the effectiveness of psychotherapy.
37Pharmacologic Treatment All antidepressants approved by the U.S. Food and Drug Administration have been shown to be relatively safe in most populationsHowever, they are effective in some, but not all, populationsWhen considering pharmacotherapy, keep in mind that all antidepressants approved by the U.S. Food and Drug Administration have been shown to be relatively safe in most populations and effective in some, but not all, populations. For many patients with depression in the LTC setting, the choice of an antidepressant usually depends on one or more of the following factors:AgeCoexisting medical conditionsConcomitant medications for other diagnoses or conditions and potential drug interactionsMedication costsPrior response to or failure of a particular drugSide-effect profileTarget signs and symptomsTraining and experience of the prescribing practitioner, especially with regard to psychiatric complications
38Electroconvulsive Therapy (ECT) (ECT) should be considered if:The patient’s condition is rapidly deteriorating or,If antidepressant medication is not tolerated or has failedMild depression – failure of 4-6 antidepressantsModerate depression – failure of 2-4 antidepressantsSever depression – failure of 1-2 antidepressants or suicidal risks50% effectiveTransitional Stimulation (limited studies in seniors)Two recent reviews suggest that ECT is both safe and effective in older adults and that this technique may be considered when a rapid response is desired.It need not be reserved for cases of depression-associated psychosis, rapid deterioration, high suicide risk, or failed pharmacotherapy.13,14ECT should be conducted only in an appropriately equipped setting under the supervision of an experienced psychiatrist and anesthesiologist.
39Assessing Treatment Response Treatment response can vary widely among depressed elderly patientsPatient response is generally not predictable before the initiation of treatmentBeliefs that older patients in general respond more slowly to antidepressant treatment are unsubstantiated12-15Treatment response can vary widely among depressed elderly patients who present with similar diagnostic profiles and receive similar treatment.13Although patient response is generally not predictable before the initiation of treatment, the following factors are often associated with poorer outcomes5Older agepresence of multiple acute or chronic stressors (e.g., medical illnesses, difficult life situations)difficulty with activities of daily livingfirst episode of depression occurring at a younger agehigher level of anxiety associated with depressionpoor sleep patternspoor social supportBeliefs that older patients in general respond more slowly to antidepressant treatment and that it takes at least 12 weeks to identify nonresponders are unsubstantiated.Four recent studies suggest that older patients do not respond to treatment more slowly.12-15Another common belief is that a lower starting dose and slower dose escalation will improve drug tolerability in geriatric patients. The “start low, go slow” paradigm evolved when tricyclic antidepressants (TCAs) were the primary pharmacologic treatment for depression.Furthermore, the “start low, go slow” strategy is essentially untested for the selective serotonin reuptake inhibitors (SSRIs). Nevertheless, doses should be increased gradually.Caregiving staff should be aware that it may take several weeks to see an appreciable response to an antidepressant medication and should not advocate for a dose increase prematurely.The practitioner should assess the patient’s response 2-4 weeks after initiating therapy. Informed decisions about changing or continuing treatment may be made after 4 weeks and again after 6 weeks.Relapse is more common and more difficult to treat in older patients with comorbid disease. Therefore antidepressant therapy in low does may need to be considered indefinitely depending on the patient’s risk factors and degree of symptoms.
40Most Common Psychosocial Interventions for Depression Preferred TechniquesPsychotherapyCognitive-behavioral therapyInterpersonal therapyProblem-solving therapySupportive therapyPsychosocialinterventionActivities and exerciseBereavement groupsFamily counselingParticipation in social eventsPsychoeducationCelebrate past and present positive life eventsThis slide represents table 10 from the AMDA Depression guidelineReferences:L. Volicer. Effects of Continuous Activity Program on Behavior Symptoms of Dementia. AMDA. Sept :M. Smith et. al. Beyond Bingo: Meaningful Activities for Persons with Dementia. Annals of Long-Term Care. July 2009.
41Federal Regulations and Depression F329 - §483.25(l) Unnecessary Drugs1. General. Each resident’s drug regimen must be free from unnecessary drugs.An unnecessary drug is any drug when used:(i) In excessive dose (including duplicate therapy); or(ii) For excessive duration; or(iii) Without adequate monitoring; or(iv) Without adequate indications for its use; or(v) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or(vi) Any combinations of the reasons above.
42Federal Regulations and Depression (F 329) INTENT: §483.25(l) Unnecessary drugsThe intent of this requirement is that each resident’s entire drug/medication regimen be managed and monitored to achieve the following goals:The medication regimen helps promote or maintain the resident’s highest practicable mental, physical, and psychosocial well-being, as identified by the resident and/or representative(s) in collaboration with the attending physician and facility staffRisk/Benefit (Just document in progress note);Pharmacists must notifyMD can ignoreNon-pharmacological interventions (such as behavioral interventions) are considered and used when indicated, instead of, or in addition to, medication;Clinically significant adverse consequences are minimized; and“Behavioral interventions” are individualized non-pharmacological approaches (including direct care and activities) that are provided as part of a supportive physical and psychosocial environment, and are directed toward preventing, relieving, and/or accommodating a resident’s distressed behavior.“Clinically significant” refers to effects, results, or consequences that materially affect or are likely to affect an individual’s mental, physical, or psychosocial well-being either positively by preventing, stabilizing, or improving a condition or reducing a risk, or negatively by exacerbating, causing, or contributing to a symptom, illness, or decline in status.
43Federal Regulations and Depression (F 329) Determining the frequency of monitoring. The frequency and duration of monitoring needed to identify therapeutic effectiveness and adverse consequences will depend on factors such as clinical standards of practice, facility policies and procedures, manufacturer’s specifications, and the resident’s clinical conditionMonitoring involves three aspects:Periodic planned evaluation of progress toward the therapeutic goals;Continued vigilance for adverse consequences; andEvaluation of identified adverse consequenceSurveyors are instructed to see whether the physician and staff have noted and acted upon possible medication related causes of recent or persistent changes in the resident’s condition such as worsening of an existing problem or the emergence of new signs or symptoms. [including depression, mood disturbance]
44Federal Regulations and Depression (F 329) Tapering of a Medication Dose/Gradual Dose Reduction (GDR)There are various opportunities during the care process to evaluate the effects of medications on a resident’s function and behavior, and to consider whether the medications should be continued, reduced, discontinued, or otherwise modifiedSometimes, the decision about whether to continue a medication is clear; for example, someone with a history of multiple episodes of depression or recurrent seizures may need an antidepressant or anticonvulsant medication indefinitely. Often, however, the only way to know whether a medication is needed indefinitely and whether the dose remains appropriate is to try reducing the dose and to monitor the resident closely for improvement, stabilization, or decline.The time frames and duration of attempts to taper any medication depend on factors including the coexisting medication regimen, the underlying causes of symptoms, individual risk factors, and pharmacologic characteristics of the medications. Some medications (e.g., antidepressants, sedative/hypnotics, opioids) require more gradual tapering so as to minimize or prevent withdrawal symptoms or other adverse consequences.If the resident’s condition has not responded to treatment or has declined despite treatment, it is important to evaluate both the medication and the dose to determine whether the medication should be discontinued or the dosing should be altered, whether or not the facility has implemented GDR as required, or tapering.
45Federal Regulations and Depression (F 329) For any individual who is receiving an antipsychotic medication to treat a psychiatric disorder other than behavioral symptoms related to dementia (for example, depression with psychotic features), the GDR may be considered contraindicated, if:The continued use is in accordance with relevant current standards of practice and the physician has documented the clinical rationale for why any attempted dose reduction would be likely to impair the resident’s function or cause psychiatric instability by exacerbating an underlying psychiatric disorder; orThe resident’s target symptoms returned or worsened after the most recent attempt at a GDR within the facility and the physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident’s function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder
46F 329 Antidepressants Indications All antidepressants classes, e.g., Alpha - adrenoceptor antagonist, e.g., mirtazapineDopamine-reuptake blocking compounds, e.g., bupropionMonoamine oxidase inhibitors (MAOIs)Serotonin (5-HT 2) antagonists, e.g., nefazodone, trazodoneSelective serotoninnorepinephrine reuptake inhibitors (SNRIs), e.g., duloxetine, venlafaxineIndicationsAgents usually classified as “antidepressants” are prescribed for conditions other than depression including anxiety disorders, post-traumatic stress disorder, obsessive compulsive disorder, insomnia, neuropathic pain (e.g., diabetic peripheral neuropathy), migraine headaches, urinary incontinence, and others
47F 329 Antidepressants Dosage Selective serotonin reuptake inhibitors (SSRIs), e.g., citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertralineTricyclic (TCA) and related compoundsDosageUse of two or more antidepressants simultaneously may increase risk of side effects; in such cases, there should be documentation of expected benefits that outweigh the associated risks and monitoring for any increase in side effects
48F 329DurationDuration should be in accordance with pertinent literature, including clinical practice guidelinesPrior to discontinuation, many antidepressants may need a gradual dose reduction or tapering to avoid a withdrawal syndrome (e.g., SSRIs, TCAs)If used to manage behavior, stabilize mood, or treat a psychiatric disorder, refer to Section V –Tapering of a Medication Dose/Gradual Dose Reduction (GDR) in the guidanceMonitoringAll residents being treated for depression with any antidepressant should be monitored closely for worsening of depression and/or suicidal behavior or thinking, especially during initiation of therapy and during any change in dosageWeekly for 1-3 months and quarterly thereafter (Do Not give 3 month prescription if requested by PBM - Pharmacy Benefit Manager)
49F 329 Interactions/Adverse Consequences/Positive Benefits May cause dizziness, nausea, diarrhea, anxiety, nervousness, insomnia, somnolence, weight gain, anorexia, or increased appetite. Many of these effects can increase the risk for fallsBupropion may increase seizure risk and be associated with seizures in susceptible individualsSSRIs in combination with other medications affecting serotonin (e.g., tramadol, St. John’s Wort, linezolid, other SSRI’s) may increase the risk for serotonin syndrome and seizuresAugmentation with Buspirone, Aripiprazole, or Lithium – limited benefits in 4-6 weeks
50F 329 Antidepressants Indications/Contraindications Monoamine oxidase inhibitors (MAOIs), e.g., isocarboxazid, phenelzine, tranylcypromineIndications/ContraindicationsShould not be administered to anyone with a confirmed or suspected cerebrovascular defect or to anyone with confirmed cardiovascular disease or hypertensionShould not be used in the presence of pheochromocytomaMAO Inhibitors are rarely utilized due to their potential interactions with tyramine or tryptophancontaining foods, other medications, and their profound effect on blood pressure
51F 329 Adverse Consequences Interactions MAOIs (cont.) May cause hypertensive crisis if combined with certain foods, cheese, wineException: Monoamine oxidase inhibitors such as selegiline (MAO-B inhibitors) utilized for Parkinson’s Disease, unless used in doses greater than 10 mg per dayInteractionsShould not be administered together or in rapid succession with other MAO inhibitors, tricyclic antidepressants, bupropion, SSRIs, buspirone, sympathomimetics, meperidine, triptans, and other medications that affect serotonin or norepinephrine
52F 329 Antidepressants Indications Adverse Consequences Tricyclic antidepressants (TCAs), e.g., amitriptyline, amoxapine, doxepin, arrhythmias (low doses are appropriate for pain – Less than 25mg)Combination products, e.g., amitriptyline and chlordiazepoxide, amitripytline and perphenazineIndicationsTCAs and combination products are rarely the medication of choice in older individualsAdverse ConsequencesCompared to other categories of antidepressants, TCAs cause significant anticholinergic side effects and sedation (nortriptyline and desipramine are less problematic)Exception:Use of TCAs may be appropriate if:The resident is being treated for neurogenic pain based on documented evidence to support the diagnosis; andThe relative benefits outweigh the risks and other, safer agents including nonpharmacological interventions or alternative therapies are not indicated or have been considered, attempted, and failed
53Monitoring Monitoring is the fourth phase of the care process “Monitoring” means reviewing the course of a condition or situation as the basis for deciding to continue, change, or stop interventions
54Monitoring Monitor the patient’s response to treatment for depression Goals of treatment may include, but need not be limited to, the following:Resolution of signs and symptoms of depressionImprovement of scores on the GDS, CSDD, or CES-DImprovement in attendance at and participation in usual activitiesImprovement in sleep patternDocument approaches, timetables, and goals of treatment in the interdisciplinary care plan and progress notes.Monitor the patient carefully for side effects specific to each class of medication as well as for interactions between antidepressants and other classes of medications.Establish and document drug dosages, titration schedules, and frequency of testing to check drug levels as appropriate.
55Pharmacotherapy Considerations Pharmacokinetics and Drug InteractionsPharmacokinetic differences among older patients produce differing drug concentrations than in younger and healthier groupsPatients taking multiple drugs are at risk for drug-drug interactions and subsequent adverse events.Most antidepressants are susceptible to drug interactions,May be necessary to adjust doses of a patient’s other medicationsAntidepressant use in the LTC setting has increased significantly in recent years. This next few slides outlines a systematic approach to antidepressant selection. The use of such an approach is important so that the success of the chosen treatment can be evaluated and changes or adjustments to treatment made as appropriate.Because LTC patients are more likely to be taking multiple medications, drug interactions and side effects are a concern. Along with anticoagulants, psychoactive medications, including antidepressants, are the medications most commonly associated with preventable adverse drug events in LTC facilities.16Older patients in general are more sensitive than younger adults to the adverse effects of antidepressant medications. However, to obtain a therapeutic response, older patients require drug concentrations similar to those that generally produce a therapeutic response in younger patients.17Pharmacokinetic differences among older patients produce differing drug concentrations than in younger and healthier groups. For various reasons, including age-related reduction in renal clearance, liver volume, blood flow, and drug metabolizing enzymes18, the choice of an antidepressant for elderly patients should be based on the drug’s side-effect profile and on how the drug is affected by reduced renal and hepatic function.Because most antidepressants are susceptible to drug interactions, it may be necessary to adjust doses of a patient’s other medications in order to achieve therapeutics effects from antidepressants without intolerable side effects.
56Pharmacotherapy Considerations Treatment StrategiesNo single class of antidepressant has been found to be more effective than another in the acute treatment of late-life depression, however side effects vary.Therapeutic drug-level monitoring maybe useful initially depending on the agent used (tricyclic)Routine drug monitoring is not necessary except when:depressive symptoms do not respond to treatment or when adverse side effects of treatment are apparentFollowing the era of TCAs, SSRIs quickly became the preferred agents because of their safety profile: relatively high tolerability, relatively low incidence of adverse events, and lower potential for drug-drug interactions.However, although members of the SSRI class vary in their side-effect profiles, all, especially fluoxetine, have been associated with anxiety, insomnia, sexual dysfunction, weight loss, gastrointestinal side effects, dizziness, and other problematic side effects.SSRIs should be used with extreme caution in cachetic, malnourished elderly patients.Although therapeutic drug-level monitoring is useful initially, routine monitoring is not necessary except when depressive symptoms do not respond to treatment or when adverse side effects of treatment are apparent.
57Pharmacotherapy Considerations Tricyclic tertiary amines at therapeutic doses frequently are not tolerated in the LTC populationMonoamine oxidase inhibitors are not acceptable first-line drugs in the LTC settingTricyclic tertiary amines such as amitriptyline, imipramine, and doxepin at therapeutic doses frequently are not tolerated in the LTC population because of their anticholinergic, sedating, or autonomic side effects. Anticholinergic agents have been shown to worsen cognitive impairment and should not be used in patients with any degree of dementia (even mild cognitive impairment).Monoamine oxidase inhibitors (MAOIs) are not acceptable first-line drugs in the LTC setting, primarily because of their hypotensive, urinary tract effects, and the need for dietary restrictions of tyramine-containing foods (certain chesses and wines). They increase the risks of hypertension crisis secondary to interacting with tryamine containing foods.
58CHOICE OF ANTIDEPRESSANT 3 Drug ClassPreferred AgentsAlternate AgentsNot RecommendedSSRIsCitalopramEscitalopramMirtazapineParoxetineSertralineVenlafaxine XR/ DuloxatineBupropionFluoxetineNefazodoneTrazodoneTCAsDesipramineNortriptylineAmitriptylineAmoxapineDoxepinImipramineIsocarboxazidMaprotilineTranylcypromineThis slide represents table 14 from the AMDA Depression guidelineFluoxetine has side effects of anorexia and weight loss.Trazodone may be given for augmentation therapy only, at bedtime for side effects of insomnia secondary to depression (SSRI).
59Doses of Antidepressants That Are Likely to be Adequate3 Average Starting Dose (mg/day)Average Target Dose After 6 Weeks (mg/day)Usual Final Acute Dose (mg/day)Bupropion SR100150 – 300300 – 400Citalopram10 – 2020 – 3030 – 40Desipramine10 – 4050 – 100100 – 150Escitalopram10Fluoxetine2020 – 40Fluvoxamine25 – 5050 – 200100 – 300Mirtazapine7.5 – 1515 – 3030 – 45Nortriptyline10 – 3040 – 10075 – 125ParoxetineSertraline100 – 200Venlafaxine XR25 – 7575 – 200This slide represents table 15 from the AMDA Depression guideline
60Preferred Treatment Option Other Options That May Be Considered Treatment of Depression That Coexists with Mild to Moderate DementiaPreferred Treatment OptionOther Options That May Be ConsideredPsychosocial interventionsCaregiver-focused treatmentSupportive psychotherapyPharmacologic treatmentMedication alone (citalopram, escitalopram, sertraline, venlafaxine XR)Medication plus psychosocial interventionCholinesterase inhibitorBupropion SRMirtazapineParoxetineThis slide represents table 17 from the AMDA Depression guideline
61Summary Depressive symptoms are: common among older adultscan have a major effect on their quality of lifeAccurate diagnosis of depression is importantDepression usually responds to treatment with psychotherapy, medications, or a combination of the twoTreatment options should be consistent with the patient’s and family’s wishes and advanced directivesDepressive symptoms are common among older adults and can have a major effect on their quality of life.All health care workers in the LTC setting should maintain a high index of suspicion for the presence of depression in their patients.Accurate diagnosis of depression is important because many of the symptoms of depression may also be found in other conditions.Once diagnosed, depression usually responds to treatment with psychotherapy, medications, or a combination of the two.When depression and a medical condition coexist as explanations for signs and symptoms of depression, both conditions may require treatment.Treatment options should be consistent with the patient’s and family’s wishes and with the patient’s advance care directives.
62Case Study:In this example, a 65-year old woman spends most of her day either asleep or awake and developed a habit of leaving her room at night.Possible interventions:Dimming a light in her room rather than leaving it on (the light was left on for safety reasons)Having a caregiver walk with her and then guiding her back to bedLimiting naps to 30 minutesOffering her warm milk or soothing snacks prior to going to bed
63Case Study: Wrong Psychotherapy and Right Psychotropics Mrs. Jones is a 75 y. female with chronic anxiety and long history of physical abuse as a child and as an adult. She was recently married for 4 years. Because of increasing anxiety, depression and acrophobia she was disabled and admitted herself to a nursing home. She was in psychotherapy for 6 months with benefits but suddenly became increasingly critical of nursing staff and uncooperative with treatment as discharge was planned. MMSE confirmed that her cognitive function was intact. After the therapist began to explore a history of sexual abuse, she became uncooperative.
64Outcomes of this Case Study: Wrong Psychotherapy and Right Psychotropics Talking about past abuse was too painful and she preferred to focus on the present.The therapist was encouraged to be more reality oriented and supportive, so she was.She suddenly left, after refusing medication for two weeks and was readmitted 6 months later due to depression and impulsively divorcing her husband.Mrs. Jones said that she had life-long paranoia, which was hidden by obsessive compulsive symptoms and acrophobia.She was given depakote and her paranoia and anxiety reduced to levels that were tolerable.
65Case Study: Depression, Dementia, and Psychosocial Issues Carlos was a 72 year-old Mexican American who was admitted for dementia 3 years after his wife passed away. He was friendly and adjusted well. The family was extremely attentive and guilty that they could not managed him at home, as was the custom in their culture. Each family took turns initially on weekends visiting or taking him home for a few hours. After several months, the visits and outings gradually and unpredictably decreased. Carlos was reported to have increasing isolation, which escalated to disruptive behavior and sleep problems. I was consulted after 3 months of increasing dysfunctional behavior because of sexually inappropriate behavior with other patients and staff that led to a state site visit.
66Outcomes of this Case Study: Depression, Dementia, and Psychosocial Issues Carlos denied any knowledge of events and denied any symptoms, which resulted in the initiation of Lexapro and Aricept.A family conference was held with the weekend nursing staff and they stopped their flirtatious behavior, separated Carlos from the females, and now must confirm passes when they are scheduled.The problems continued and after 3 months Carlos was transferred to another nursing home.
67Case Study: Is there a Psychiatrist in the House? I had been consulting with the Nursing Home, Happy Springs, sporadically for several years. After several emergency consultations and the patient eloping, I had a conference with the new DON, Administrator, and Social Worker about the evaluation of evolving psychiatric behavior problems. They said they did not admit patients with mental health problems because most of the problems were resolved, initially, after treatment with Xanax, PRN, or Benadryl for sleep. Because the census was low, they wanted help with patients who had psychiatric problems. The DON believed that senior citizens had a right to be depressed and would be overmedicated if seen by a psychiatrist and the Social Worker discouraged psychotherapy consults because she thought she would not be needed if outside therapists started seeing the residents.
68Nonpharmalogic Treatments for Depression in Dementia Emotion-Oriented TherapiesBrief PsychotherapiesSensory Stimulation TherapiesGellis Zvi D., PhD, McClive-Reed, Kimberly P., PhD, and Brown, Ellen L., EdD, MS, ARNP. Treatments for Depression in Older Persons with Dementia. Annals of Long-Term Care: , Vol. 17. Feb. 01, 2009.
69Emotion-Oriented Therapies Validation TherapySimulated Presence TherapyGellis Zvi D., PhD, McClive-Reed, Kimberly P., PhD, and Brown, Ellen L., EdD, MS, ARNP. Treatments for Depression in Older Persons with Dementia. Annals of Long-Term Care: , Vol. 17. Feb. 01, 2009.
70Brief Psychotherapies Cognitive Behavioral TherapiesEarlier Stages of Cognitive DeclineProblem Solving TherapyGellis Zvi D., PhD, McClive-Reed, Kimberly P., PhD, and Brown, Ellen L., EdD, MS, ARNP. Treatments for Depression in Older Persons with Dementia. Annals of Long-Term Care: , Vol. 17. Feb. 01, 2009.
71Sensory Stimulation Therapy Art/Music TherapyAromatherapyAnimal-Assisted/Pet TherapyActivity TherapiesMassage/Touch TherapiesMultisensory ApproachesGellis Zvi D., PhD, McClive-Reed, Kimberly P., PhD, and Brown, Ellen L., EdD, MS, ARNP. Treatments for Depression in Older Persons with Dementia. Annals of Long-Term Care: , Vol. 17. Feb. 01, 2009.
72Activity TherapiesReports from these therapies have been very positiveInclude things such as:Recreational activitiesPhysical activity programs (improve mood)Gellis Zvi D., PhD, McClive-Reed, Kimberly P., PhD, and Brown, Ellen L., EdD, MS, ARNP. Treatments for Depression in Older Persons with Dementia. Annals of Long-Term Care: , Vol. 17. Feb. 01, 2009.
73Massage/Touch Therapies Even though evidence is limited, it still supports the use of massage and touch interventions for anxiety in dementia.Touch massages have been found to temporarily relieve agitated behavior for a short period of timeGellis Zvi D., PhD, McClive-Reed, Kimberly P., PhD, and Brown, Ellen L., EdD, MS, ARNP. Treatments for Depression in Older Persons with Dementia. Annals of Long-Term Care: , Vol. 17. Feb. 01, 2009.
74Multisensory Approaches Effective in reducing apathy in dementia according to the Snoezelen/Multisensory StimulationTypes:LightTextureSmellSoundGellis Zvi D., PhD, McClive-Reed, Kimberly P., PhD, and Brown, Ellen L., EdD, MS, ARNP. Treatments for Depression in Older Persons with Dementia. Annals of Long-Term Care: , Vol. 17. Feb. 01, 2009.
75Nonpharmacologic Interventions Have potential for successful treatment of depression in dementiaTypes:Emotion-Oriented TherapiesBehavioral Modification ProgramsCognitive-Behavioral ProgramsStructured Activity ProgramsGellis Zvi D., PhD, McClive-Reed, Kimberly P., PhD, and Brown, Ellen L., EdD, MS, ARNP. Treatments for Depression in Older Persons with Dementia. Annals of Long-Term Care: , Vol. 17. Feb. 01, 2009.
76Clinical Investigation Objectives: Examine the prevalence, correlates, and medication management of behavioral symptoms in elderly people living in residential care/assisted living (RC/AL) facilitiesDesign: Cross-Sectional StudySettings: Random sample of RC/AL facilities in four states (Florida, Maryland, New Jersey, North Carolina)Participants: Total of 2078 RC/AL residents 65 and olderMeasurement: Behavioral symptoms were classified using modified version of the Cohen-Mansfield Agitation InventoryGruber-Baldini, Ann L. PhD; Boustani, Malaz MD, MPH; Sloan, Philip D. MD, MPH; Zimmerman, Sheryl PhD. Behavioral Symptoms in Residential Care/Assisted Living Facilities: Prevalence, Risk Factors, and Medication Management – Clinical Investigations. Journal of the American Geriatrics Society. October Vol. 52: ,
77ResultsApproximately 34% exhibited one or more behavioral symptoms, once a week13% show aggressive behavioral symptoms20% demonstrated physically nonaggressive behavioral symptoms22% expressed verbal behavioral symptoms13% resisted taking medications or activities of daily living careMore than 50% of RC/AL residents were on psychotropic medicationsTwo-thirds had some mental health problem indicator, such as dementia depression, psychosis, or other psychiatric illnesses.Gruber-Baldini, Ann L. PhD; Boustani, Malaz MD, MPH; Sloan, Philip D. MD, MPH; Zimmerman, Sheryl PhD. Behavioral Symptoms in Residential Care/Assisted Living Facilities: Prevalence, Risk Factors, and Medication Management – Clinical Investigations. Journal of the American Geriatrics Society. October Vol. 52: ,
78ConclusionsIntegrating mental health services within the process of care in RC/AL is needed to manage and accommodate the high prevalence of behavioral symptoms in this evolving long-term settingGruber-Baldini, Ann L. PhD; Boustani, Malaz MD, MPH; Sloan, Philip D. MD, MPH; Zimmerman, Sheryl PhD. Behavioral Symptoms in Residential Care/Assisted Living Facilities: Prevalence, Risk Factors, and Medication Management – Clinical Investigations. Journal of the American Geriatrics Society. October Vol. 52: ,
79Clinical and Research News: Many Assisted-Living Residents Not Getting Depression Help Clinical Study: Duke University Medical Center – Lea Watson, MDCornell Scale for Depression and Dementia was the main test used to measure physical and mental healthEach item is scored on a three-point scale with a total possible score of 38.A score of 7 or more has been shown to signify significant depression.13% of all subjects in this study had a score of greater than 7At least a quarter of all subjects showed symptoms of depression, such as sadness, tearfulness, worrying, or irritabilityHowever, only 18% were diagnosed as being clinically depressedOnly 38% of patients with severe depression, a score of more than 12, were on antidepressantsLea Watson commented that her next phase of work will directly focus on depression in assisted-living facilities
80Study: When Should a Patient Discontinue Treatment for Elderly Depression? Address the risks and benefits of treating a patient with antidepressants when they have only experienced one episode of major depression in their life.The norm among experts has become treating a depressed elderly person until they have fully recovered.After the initial treatment they should be treated for 6-12 months after.“Most geriatric psychiatrists would not think that a 70 year-old or older patient with one incidence of depression would receive long-term treatment of up to 2 years.” Charles F. Reynolds III, MDMost psychiatrists agree that the elderly with two or more episodes should be appropriately prescribed maintenance treatment.Gruber - Baldini, Ann L. PhD; Boustani, Malaz MD, MPH; Sloan, Philip D. MD, MPH; Zimmerman, Sheryl PhD. Behavioral Symptoms in Residential Care/Assisted Living Facilities: Prevalence, Risk Factors, and Medication Management – Clinical Investigations. Journal of the American Geriatrics Society. October Vol. 52: ,
81Contraindications to Tapering and GDR GDR may be considered contraindicated for:Antipsychotic medications for psychiatric disorders that do not include behavioral symptoms related to dementiaPsychopharmacological medicationsIncluding antidementia agents and antidepressantsSedative/hypnoticsGDR can be considered contraindicated (without and failing first) if continued use:Is in accordance with current standards of practice, andThe physician documents clinical rationale for why GDR is likely to impair function or cause psychiatric instability due to exacerbation of an underlying psychiatric disorder
82Recurrence and Residual Symptoms in Geriatric Depression Recurrence rates of 50% - 90% over 2-3 yearsLower remission rates in geriatric depressionAfter 6-month remission, 20%-30% retain residual symptomsGreater distress and disabilityHigher relapse rates in elderly patients compared to younger patientsMaintenance therapy is important
83Empirically Supported Psychotherapies Cognitive Behavioral Therapy (CBT)Identify and modify negative beliefs and negative interpretations of the past, present and futureIncludes:EducationSymptom and stress management strategiesDesensitization to feared stimuliCognitive challenges to change beliefsInterpersonal Therapy (IPT)Focuses on 4 types of interpersonal problem categories viewed as causes of depressionGrief and morningInterpersonal disputesRole transitionsSocial skill deficits