Presentation is loading. Please wait.

Presentation is loading. Please wait.

1 Depression Clinical Practice Guideline. 2 Disclosures.

Similar presentations


Presentation on theme: "1 Depression Clinical Practice Guideline. 2 Disclosures."— Presentation transcript:

1 1 Depression Clinical Practice Guideline

2 2 Disclosures

3 3 Learning Objectives

4 4 Depression Depression 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. Depression 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.

5 5 Introduction Maintain a high index of suspicion for the presence of depression or depressive symptoms in long term care (LTC) patients Maintain a high index of suspicion for the presence of depression or depressive symptoms in long term care (LTC) patients Late-life depression may be overlooked or inadequately treated Late-life depression may be overlooked or inadequately treated

6 6 Introduction The relationship between medical conditions and depression is complex The relationship between medical conditions and depression is complex Depression may exacerbate coexisting medical illness Depression may exacerbate coexisting medical illness Some medications may cause or contribute to depression Some medications may cause or contribute to depression

7 7 Federal Regulations and Depression F157-§483.10(b)(11) -- Notification of changes F157-§483.10(b)(11) -- Notification of changes (i) A facility must immediately inform the resident; consult with the residents physician; and if known, notify the residents legal representative or an interested family member when there is: (i) A facility must immediately inform the resident; consult with the residents physician; and if known, notify the residents legal representative or an interested family member when there is: (B) A significant change in the residents physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications)(B) A significant change in the residents 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 For purposes of §483.10(b)(11)(i)(B), Clinical complications are such things as … or onset of depression

8 8 Federal 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 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 facilitys staff to assist residents in maintaining or improving their ability to manage their everyday physical, mental, and psychosocial needs Medically-related social services means services provided by the facilitys staff to assist residents in maintaining or improving their ability to manage their everyday physical, mental, and psychosocial needs Types of conditions to which the facility should respond with social services by staff or referral include:Types of conditions to which the facility should respond with social services by staff or referral include: Depression Depression

9 9 Federal Regulations and Depression EATING-§483.25(a)(1)(iv) EATING-§483.25(a)(1)(iv) If the residents eating abilities have declined, is there any evidence that the decline was unavoidable? If the residents 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 Seniors d. Depression or confused mental state is responsible for 50% or eating problems or weight loss in Seniors

10 10 Federal Regulations and Depression 42 CFR (f)(1)&(2), F319, F320, Mental and Psychosocial Functioning 42 CFR (f)(1)&(2), F319, F320, Mental and Psychosocial Functioning Surveyors are instructed to review whether the facility had identified, evaluated, and responded to a change in behavior and/or psychosocial changes, including depression Surveyors are instructed to review whether the facility had identified, evaluated, and responded to a change in behavior and/or psychosocial changes, including depression

11 11 Recognition Recognition is the first stage of the care process Recognition is the first stage of the care process Recognition means identifying the presence of a risk or condition Recognition means identifying the presence of a risk or condition How: PHQ-2 shows that only 14-25% of residents in LTC have depression How: PHQ-2 shows that only 14-25% of residents in LTC have depression Caregivers identify depression poorly Caregivers identify depression poorly The PHQ-2 identifies 85% of patients with depression The PHQ-2 identifies 85% of patients with depression Reference: Practical Depression Screening in Residential Care. Am. J. Geriatrics Psychiatry. 17:7. July

12 12 Recognition Does the patient have a history of depression or a positive depression screening test? Does the patient have a history of depression or a positive depression screening test? Review available transfer information, referral data and patient and family history Review available transfer information, referral data and patient and family history Look for history of depression, psychiatric disorder(s), treatment of hospitalization Look for history of depression, psychiatric disorder(s), treatment of hospitalization Document the presence of these conditions in the medical record Document the presence of these conditions in the medical record

13 13 Recognition Depression is common among patients in the LTC setting Depression is common among patients in the LTC setting Treatment is effective Treatment is effective Adopt a policy encouraging formal screening of all patients for depression Adopt a policy encouraging formal screening of all patients for depression Appropriate screening tools include: Appropriate screening tools include: Geriatric Depression Scale Geriatric Depression Scale Cornell Scale for Depression in Dementia Cornell Scale for Depression in Dementia Center for Epidemiologic Studies of Depression Scale Center for Epidemiologic Studies of Depression Scale Patient Health Questionnaire 9 Patient Health Questionnaire 9 Clinical Interview Clinical Interview Do you feel life is worth living? Do you feel life is worth living? What makes you happy? What makes you happy?

14 14 Recognition Does the patient have signs or symptoms of depression? 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) 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 notes Look for S&S in RAI. MDS, RAPs, progress notes, family interaction notes

15 15 Symptoms Of Depression 3 Most important Depressed 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. Depressed 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. Important Difficulty 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 participation Difficulty 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 participation Sometimes helpful Appetite 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. Appetite 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% documented Sleep problems occur in 40%-68% of all patients, with only 19% documented Reference: Sleep: A Marker of Physical and Mental Health in the Elderly. Am. J. Geriatric Psychiatry. 14: Oct. 2006

16 16 Recognition Does the patient have risk factors for depression? Does the patient have risk factors for depression? Evaluate for risk factors Evaluate for risk factors If risk factors are present, develop an interdisciplinary (IDT) care planIf risk factors are present, develop an interdisciplinary (IDT) care plan If no risk factors are found, monitor periodically (every 3 months)If no risk factors are found, monitor periodically (every 3 months)

17 17 Some Risk Factors for Depression Alcohol or substance abuse Alcohol or substance abuse Current use of a medication associated with a high risk of depression Current use of a medication associated with a high risk of depression Hearing or vision impairment severe enough to affect function – 30% increase rate of depression Hearing or vision impairment severe enough to affect function – 30% increase rate of depression History of attempted suicide History of attempted suicide History of psychiatric hospitalization History of psychiatric hospitalization Medical diagnosis or diagnoses associated with a high risk of depression Medical diagnosis or diagnoses associated with a high risk of depression New admission or change in environment New admission or change in environment New stressful losses, including loss of autonomy, loss of privacy, loss of functional status, loss of body part, or loss of family member, friend or pet New stressful losses, including loss of autonomy, loss of privacy, loss of functional status, loss of body part, or loss of family member, friend or pet Personal or family history of depression or mood disorder Personal or family history of depression or mood disorder Personality Anxiety Disorder – Sleep problem (day time) Personality Anxiety Disorder – Sleep problem (day time)

18 18 Assessment Assessment is the second stage of the care process 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

19 19 Assessment Has the patient had a persistently depressed mood or loss of interest or pleasure for at least 2 weeks? Has 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; and Has depressed mood (dysphoria) or loss of interest or pleasure (anhedonia) been present for at least 2 weeks; and has dysphoria or anhedonia contributed to the patients functional or social impairment or decline has dysphoria or anhedonia contributed to the patients functional or social impairment or decline Is substance abuse or bereavement not present Is substance abuse or bereavement not present Personality Disorder Personality Disorder Personality traits influence clinical outcomes in a day hospitalPersonality traits influence clinical outcomes in a day hospital Reference: Treatment of Elderly Depressed Patients. Am. J. Geriatric Psychiatry April 2009.

20 20 Assessment Is it appropriate to perform a medical work-up for factors contributing to signs and symptoms of possible depression? Is it appropriate to perform a medical work-up for factors contributing to signs and symptoms of possible depression? Will depend upon: Will depend upon: patients conditionpatients condition prognosisprognosis advance care directivesadvance care directives expressed preferences of the patient or familyexpressed preferences of the patient or family

21 21 Laboratory Tests For Evaluating Possible Depression 3 Preferred Tests Other Tests That May Be Considered Chemistry profile (electrolytes, blood urea nitrogen, creatinine, glucose) Chemistry profile (electrolytes, blood urea nitrogen, creatinine, glucose) Complete blood count Complete blood count Serum levels of anticonvulsant or tricyclic antidepressant, if taking either type of medication Serum levels of anticonvulsant or tricyclic antidepressant, if taking either type of medication Thyroid function (T3, T4, TSH) Thyroid function (T3, T4, TSH) Electrocardiogram Electrocardiogram Folate level Folate level Serum calcium level Serum calcium level Serum level of digoxin or theophylline, if taking either medication Serum level of digoxin or theophylline, if taking either medication Urinalysis Urinalysis Vitamin B12 level Vitamin B12 level

22 22 Assessment Is the patient taking medications that might cause or contribute to depression? Is the patient taking medications that might cause or contribute to depression? Many medications can affect:Many medications can affect: mood mood affect affect level of consciousness level of consciousness

23 23 Medications That May Cause Symptoms of Depression Alpha-methyl dopa Alpha-methyl dopa Anabolic steroids Anabolic steroids Anti-arrhythmic medications Anti-arrhythmic medications Anticonvulsant medications Anticonvulsant medications Antidementia Antidementia Barbiturates Barbiturates Benzodiazepines (i.e., long acting) Benzodiazepines (i.e., long acting) Carbidopa or levodopa Carbidopa or levodopa Certain beta-adrenergic antagonists (propranolol) Certain beta-adrenergic antagonists (propranolol) Clonidine Clonidine Cytokines (specifically IL- 2) Cytokines (specifically IL- 2) Digitalis preparations Digitalis preparations Glucocorticoids Glucocorticoids H2 blockers H2 blockers Metoclopramide Metoclopramide Opioids Opioids References: D. Rogers et. al. General Drug Associated with Depression. Psychiatry. 5, Dec Sidhuk et. al. Watch for Psychotropics Causing Psychiatric Side Effects. Current Psychiatry. August

24 24 Assessment Does the patient have one or more conditions that may increase the likelihood of depression or that may cause depressive symptoms Does the patient have one or more conditions that may increase the likelihood of depression or that may cause depressive symptoms

25 25 Important Comorbid Conditions* Most important Most important Alcohol dependency Alcohol dependency Cerebrovascular diseases Cerebrovascular diseases Medications that can cause mood disorders Medications that can cause mood disorders Neurodegenerative disorders (e.g., Alzheimers disease, Parkinsons disease, multiple sclerosis) Neurodegenerative disorders (e.g., Alzheimers disease, Parkinsons disease, multiple sclerosis) Substance abuse Substance abuse Sleep apnea (40%-60% of patients with dementia) Sleep apnea (40%-60% of patients with dementia) Important Important Cancer Chronic obstructive pulmonary disorder Chronic pain Congestive heart failure Coronary artery disease Diabetes Electrolyte imbalance Endocrine disorders (thyroid) Head trauma Metabolic problems Myocardial infarction Orthostatic hypotension Physical, verbal, emotional abuse Schizophrenia Anxiety *Reference: Is a Medical Illness Causing your Patients Depression. Current Psychiatry

26 26 Assessment Do the patients signs and symptoms resolve with treatment of comorbid condition(s)? Do the patients signs and symptoms resolve with treatment of comorbid condition(s)? Take appropriate action if medical diagnoses or conditions are suspected of contributing to depressive symptoms Take appropriate action if medical diagnoses or conditions are suspected of contributing to depressive symptoms When depression and a medical condition coexist, both conditions are likely to require treatment When depression and a medical condition coexist, both conditions are likely to require treatment To the extent possible, address underlying causes and evaluate the impact of such measures To the extent possible, address underlying causes and evaluate the impact of such measures

27 27 Assessment Clarify the diagnosis Clarify the diagnosis The DSM-IV defines the following types of depressive disorders: The DSM-IV defines the following types of depressive disorders: Mild episode of major depressionMild episode of major depression Moderate episode of major depressionModerate episode of major depression Severe episode of major depressionSevere episode of major depression Severe episode of major depression with psychotic featuresSevere episode of major depression with psychotic features Minor depression disorder – 80% convert to MDD (Major Depression Disorder)Minor depression disorder – 80% convert to MDD (Major Depression Disorder) Bipolar type IIBipolar type II Dysthymic disorderDysthymic disorder Adjustment disorder with depressed mood or with mixed anxiety and depressed moodAdjustment disorder with depressed mood or with mixed anxiety and depressed mood

28 28 Major Depression DepressedMood+ 4 symptoms x 2 weeks Weight loss or gainWeight loss or gain Insomnia or hypersomniaInsomnia or hypersomnia Psychomotor retardationPsychomotor retardation Agitation (irritability, anxiety, fatigue)Agitation (irritability, anxiety, fatigue) Decreased energyDecreased energy Guilt feelingsGuilt feelings Inability to concentrateInability to concentrate Thoughts of death or suicide (life not worth living)Thoughts of death or suicide (life not worth living) Loss of interest or pleasure + 4 symptoms x 2 weeks AND these symptoms: Produce social impairment Are not related to substance abuse. Are not related to bereavement Reference: Comorbid Depression in Psychogeriatric Nursing Homes Wards which Symptoms are Prominent. Am. J. Geriatric Psychiatry. 17:7. July

29 29 Rating Scales Use at the beginning of treatment Use at the beginning of treatment Only reliable way to obtain an objective measure Only reliable way to obtain an objective measure Essential to monitoring the effectiveness of treatment Essential to monitoring the effectiveness of treatment Geriatric Depression Scale (GDS) Geriatric Depression Scale (GDS) Cornell Scale for Depression in Dementia (CSDD) Cornell Scale for Depression in Dementia (CSDD) Center for Epidemiologic Studies of Depression Scale (CES-D) Center for Epidemiologic Studies of Depression Scale (CES-D) Patient Health Questionnaire 9 (PHQ-9) Patient Health Questionnaire 9 (PHQ-9) Most reliable and efficient Most reliable and efficient

30 30 Assessment Does the situation warrant additional psychiatric support? Does the situation warrant additional psychiatric support? Depression is often managed readily by primary care practitioners (80/20)Depression is often managed readily by primary care practitioners (80/20) Effective psychiatric support may not be readily available in the LTC settingEffective psychiatric support may not be readily available in the LTC setting In some cases, however, psychiatric support is helpfulIn some cases, however, psychiatric support is helpful 25% improve with medication, while 58% improve with counseling and medication 25% improve with medication, while 58% improve with counseling and medication Post-stroke depression resolves in 6 months regardless of treatment (20-40% have behavioral symptoms) Post-stroke depression resolves in 6 months regardless of treatment (20-40% have behavioral symptoms)

31 31 Assessment Does the patients depression exhibit complications that may pose a risk to the patient or to others? Does the patients 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 suicidal Determine if the patient is psychotic, severely agitated, aggressive, neurovegetative, or suicidal Suicide risk increases with the severity of depression Suicide risk increases with the severity of depression

32 32 Treatment Treatment is the third stage of the care process Treatment is the third stage of the care process Treatment means selecting and providing appropriate interventions for that individual

33 33 Treatment Depression usually responds to treatment with psychotherapy, medications, or a combination of the two Depression usually responds to treatment with psychotherapy, medications, or a combination of the two An effective individualized care plan includes both nonpharmacologic and pharmacologic interventions An effective individualized care plan includes both nonpharmacologic and pharmacologic interventions Pharmacologic: Pharmacologic: 1. Antianxiety, antipsychotic, antidepressive and antidementia Non-Pharmacologic (other psychotherapies): Non-Pharmacologic (other psychotherapies): 1. Emotion-oriented, interpersonal therapy, sensory stimulation therapy 2. Cognitive Behavioral Therapy (CBT) – (art, music, massage) only in early stage, Problem Solving Therapy, Environmental Activity – (exercise) 3. Supportive Therapies

34 34 Phases of Depression Treatment 3 PhaseDurationGoal Acute Approx. 3 months To achieve complete recovery from signs and symptoms of acute depressive episode (i.e., remission) Continuation 4-6 months To prevent relapse as patients depressive symptoms continue to decline and his or her functionality improves Maintenance 3 months or longer, depending on patients needs 3 months or longer, depending on patients needs Over the age of 70, usually months or lifetime if more than 2 episodes Over the age of 70, usually months or lifetime if more than 2 episodes To prevent recurrence of a new depressive episode To prevent recurrence of a new depressive episode Relapse occurs in % Relapse occurs in %

35 35 Treatment Implement appropriate treatment for the patients depression Implement appropriate treatment for the patients depression Minimize institutional aspects of the environment Minimize institutional aspects of the environment Facilitate interaction with family members and friends Facilitate interaction with family members and friends Provide opportunities for spiritual activity (50% of LTC residents have an interest) Provide opportunities for spiritual activity (50% of LTC residents have an interest) Provide socialization interventions Provide socialization interventions

36 36 Psychotherapy Considerable advances have occurred Considerable advances have occurred Both cognitive-behavioral therapy and learning- based therapy have a significant impact on depression symptoms in older adults Both cognitive-behavioral therapy and learning- based therapy have a significant impact on depression symptoms in older adults

37 37 Pharmacologic Treatment All antidepressants approved by the U.S. Food and Drug Administration have been shown to be relatively safe in most populations All antidepressants approved by the U.S. Food and Drug Administration have been shown to be relatively safe in most populations However, they are effective in some, but not all, populations However, they are effective in some, but not all, populations

38 38 Electroconvulsive Therapy (ECT) (ECT) should be considered if: (ECT) should be considered if: The patients condition is rapidly deteriorating or, The patients condition is rapidly deteriorating or, If antidepressant medication is not tolerated or has failed If antidepressant medication is not tolerated or has failed Mild depression – failure of 4-6 antidepressants Mild depression – failure of 4-6 antidepressants Moderate depression – failure of 2-4 antidepressants Moderate depression – failure of 2-4 antidepressants Sever depression – failure of 1-2 antidepressants or suicidal risks Sever depression – failure of 1-2 antidepressants or suicidal risks 50% effective50% effective Transitional Stimulation (limited studies in seniors)Transitional Stimulation (limited studies in seniors)

39 39 Assessing Treatment Response Treatment response can vary widely among depressed elderly patients Treatment response can vary widely among depressed elderly patients Patient response is generally not predictable before the initiation of treatment Patient response is generally not predictable before the initiation of treatment Beliefs that older patients in general respond more slowly to antidepressant treatment are unsubstantiated Beliefs that older patients in general respond more slowly to antidepressant treatment are unsubstantiated 12-15

40 40 Most Common Psychosocial Interventions for Depression Intervention Preferred Techniques Psychotherapy Cognitive-behavioral therapy Cognitive-behavioral therapy Interpersonal therapy Interpersonal therapy Problem-solving therapy Problem-solving therapy Supportive therapy Supportive therapy Psychosocial intervention intervention Activities and exercise Activities and exercise Bereavement groups Bereavement groups Family counseling Family counseling Participation in social events Participation in social events Psychoeducation Psychoeducation Celebrate past and present positive life events Celebrate past and present positive life events References: 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.

41 41 Federal Regulations and Depression F329 - §483.25(l) Unnecessary Drugs F329 - §483.25(l) Unnecessary Drugs 1. General. Each residents drug regimen must be free from unnecessary drugs. 1. General. Each residents drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used:An unnecessary drug is any drug when used: (i) In excessive dose (including duplicate therapy); or(i) In excessive dose (including duplicate therapy); or (ii) For excessive duration; or(ii) For excessive duration; or (iii) Without adequate monitoring; or(iii) Without adequate monitoring; or (iv) Without adequate indications for its use; 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(v) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (vi) Any combinations of the reasons above.(vi) Any combinations of the reasons above.

42 42 Federal Regulations and Depression (F 329) INTENT: §483.25(l) Unnecessary drugs INTENT: §483.25(l) Unnecessary drugs The intent of this requirement is that each residents entire drug/medication regimen be managed and monitored to achieve the following goals: The intent of this requirement is that each residents entire drug/medication regimen be managed and monitored to achieve the following goals: The medication regimen helps promote or maintain the residents 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 staffThe medication regimen helps promote or maintain the residents 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 staff Risk/Benefit (Just document in progress note); Risk/Benefit (Just document in progress note); Pharmacists must notify Pharmacists must notify MD can ignore MD can ignore Non-pharmacological interventions (such as behavioral interventions) are considered and used when indicated, instead of, or in addition to, medication;Non-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; andClinically significant adverse consequences are minimized; and

43 43 Federal 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, manufacturers specifications, and the residents clinical condition 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, manufacturers specifications, and the residents clinical condition Monitoring involves three aspects: Monitoring involves three aspects: Periodic planned evaluation of progress toward the therapeutic goals;Periodic planned evaluation of progress toward the therapeutic goals; Continued vigilance for adverse consequences; andContinued vigilance for adverse consequences; and Evaluation of identified adverse consequenceEvaluation of identified adverse consequence

44 44 Federal Regulations and Depression (F 329) Tapering of a Medication Dose/Gradual Dose Reduction (GDR) 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 residents function and behavior, and to consider whether the medications should be continued, reduced, discontinued, or otherwise modified There are various opportunities during the care process to evaluate the effects of medications on a residents function and behavior, and to consider whether the medications should be continued, reduced, discontinued, or otherwise modified

45 45 Federal 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: 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 residents function or cause psychiatric instability by exacerbating an underlying psychiatric disorder; or 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 residents function or cause psychiatric instability by exacerbating an underlying psychiatric disorder; or The residents 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 residents function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder The residents 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 residents function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder

46 46 F 329 Antidepressants All antidepressants classes, e.g., All antidepressants classes, e.g., Alpha - adrenoceptor antagonist, e.g., mirtazapine Alpha - adrenoceptor antagonist, e.g., mirtazapine Dopamine-reuptake blocking compounds, e.g., bupropion Dopamine-reuptake blocking compounds, e.g., bupropion Monoamine oxidase inhibitors (MAOIs) Monoamine oxidase inhibitors (MAOIs) Serotonin (5-HT 2) antagonists, e.g., nefazodone, trazodone Serotonin (5-HT 2) antagonists, e.g., nefazodone, trazodone Selective serotoninnorepinephrine reuptake inhibitors (SNRIs), e.g., duloxetine, venlafaxine Selective serotoninnorepinephrine reuptake inhibitors (SNRIs), e.g., duloxetine, venlafaxineIndications Agents 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 Agents 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

47 47 F 329 Antidepressants Selective serotonin reuptake inhibitors (SSRIs), e.g., citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline Selective serotonin reuptake inhibitors (SSRIs), e.g., citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline Tricyclic (TCA) and related compounds Tricyclic (TCA) and related compoundsDosage Use 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 Use 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

48 48 F 329 Duration Duration should be in accordance with pertinent literature, including clinical practice guidelines Duration should be in accordance with pertinent literature, including clinical practice guidelines Prior to discontinuation, many antidepressants may need a gradual dose reduction or tapering to avoid a withdrawal syndrome (e.g., SSRIs, TCAs) Prior 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 guidance 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 guidanceMonitoring All 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 dosage All 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 dosage Weekly for 1-3 months and quarterly thereafter (Do Not give 3 month prescription if requested by PBM - Pharmacy Benefit Manager) Weekly for 1-3 months and quarterly thereafter (Do Not give 3 month prescription if requested by PBM - Pharmacy Benefit Manager)

49 49 F 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 falls May cause dizziness, nausea, diarrhea, anxiety, nervousness, insomnia, somnolence, weight gain, anorexia, or increased appetite. Many of these effects can increase the risk for falls Bupropion may increase seizure risk and be associated with seizures in susceptible individuals Bupropion may increase seizure risk and be associated with seizures in susceptible individuals SSRIs in combination with other medications affecting serotonin (e.g., tramadol, St. Johns Wort, linezolid, other SSRIs) may increase the risk for serotonin syndrome and seizures SSRIs in combination with other medications affecting serotonin (e.g., tramadol, St. Johns Wort, linezolid, other SSRIs) may increase the risk for serotonin syndrome and seizures Augmentation with Buspirone, Aripiprazole, or Lithium – limited benefits in 4-6 weeks Augmentation with Buspirone, Aripiprazole, or Lithium – limited benefits in 4-6 weeks

50 50 F 329 Antidepressants Monoamine oxidase inhibitors (MAOIs), e.g., isocarboxazid, phenelzine, tranylcypromine Monoamine oxidase inhibitors (MAOIs), e.g., isocarboxazid, phenelzine, tranylcypromineIndications/Contraindications Should not be administered to anyone with a confirmed or suspected cerebrovascular defect or to anyone with confirmed cardiovascular disease or hypertension Should not be administered to anyone with a confirmed or suspected cerebrovascular defect or to anyone with confirmed cardiovascular disease or hypertension Should not be used in the presence of pheochromocytoma Should not be used in the presence of pheochromocytoma MAO Inhibitors are rarely utilized due to their potential interactions with tyramine or tryptophancontaining foods, other medications, and their profound effect on blood pressure MAO Inhibitors are rarely utilized due to their potential interactions with tyramine or tryptophancontaining foods, other medications, and their profound effect on blood pressure

51 51 F 329 MAOIs (cont.) Adverse Consequences May cause hypertensive crisis if combined with certain foods, cheese, wine May cause hypertensive crisis if combined with certain foods, cheese, wine Exception: Monoamine oxidase inhibitors such as selegiline (MAO-B inhibitors) utilized for Parkinsons Disease, unless used in doses greater than 10 mg per day Exception: Monoamine oxidase inhibitors such as selegiline (MAO-B inhibitors) utilized for Parkinsons Disease, unless used in doses greater than 10 mg per dayInteractions Should 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 Should 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

52 52 F 329 Antidepressants Tricyclic antidepressants (TCAs), e.g., amitriptyline, amoxapine, doxepin, arrhythmias (low doses are appropriate for pain – Less than 25mg) 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 perphenazine Combination products, e.g., amitriptyline and chlordiazepoxide, amitripytline and perphenazineIndications TCAs and combination products are rarely the medication of choice in older individuals TCAs and combination products are rarely the medication of choice in older individuals Adverse Consequences Compared to other categories of antidepressants, TCAs cause significant anticholinergic side effects and sedation (nortriptyline and desipramine are less problematic) Compared to other categories of antidepressants, TCAs cause significant anticholinergic side effects and sedation (nortriptyline and desipramine are less problematic)

53 53 Monitoring Monitoring is the fourth phase of the care process 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 interventionsMonitoring means reviewing the course of a condition or situation as the basis for deciding to continue, change, or stop interventions

54 54 Monitoring Monitor the patients response to treatment for depression Monitor the patients response to treatment for depression Goals of treatment may include, but need not be limited to, the following: Goals of treatment may include, but need not be limited to, the following: Resolution of signs and symptoms of depressionResolution of signs and symptoms of depression Improvement of scores on the GDS, CSDD, or CES-DImprovement of scores on the GDS, CSDD, or CES-D Improvement in attendance at and participation in usual activitiesImprovement in attendance at and participation in usual activities Improvement in sleep patternImprovement in sleep pattern

55 55 Pharmacotherapy Considerations Pharmacokinetics and Drug Interactions Pharmacokinetics and Drug Interactions Pharmacokinetic differences among older patients produce differing drug concentrations than in younger and healthier groups Pharmacokinetic differences among older patients produce differing drug concentrations than in younger and healthier groups Patients taking multiple drugs are at risk for drug-drug interactions and subsequent adverse events. Patients taking multiple drugs are at risk for drug-drug interactions and subsequent adverse events. Most antidepressants are susceptible to drug interactions, Most antidepressants are susceptible to drug interactions, May be necessary to adjust doses of a patients other medications May be necessary to adjust doses of a patients other medications

56 56 Pharmacotherapy Considerations Treatment Strategies Treatment Strategies No 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. No 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) Therapeutic drug-level monitoring maybe useful initially depending on the agent used (tricyclic) Routine drug monitoring is not necessary except when: Routine drug monitoring is not necessary except when: depressive symptoms do not respond to treatment or when adverse side effects of treatment are apparentdepressive symptoms do not respond to treatment or when adverse side effects of treatment are apparent

57 57 Pharmacotherapy Considerations Tricyclic tertiary amines at therapeutic doses frequently are not tolerated in the LTC population Tricyclic tertiary amines at therapeutic doses frequently are not tolerated in the LTC population Monoamine oxidase inhibitors are not acceptable first- line drugs in the LTC setting Monoamine oxidase inhibitors are not acceptable first- line drugs in the LTC setting

58 58 Drug Class Preferred Agents Alternate Agents Not Recommended SSRIs Citalopram Citalopram Escitalopram Escitalopram Mirtazapine Mirtazapine Paroxetine Paroxetine Sertraline Sertraline Venlafaxine XR/ Duloxatine Venlafaxine XR/ Duloxatine Bupropion Bupropion Fluoxetine Fluoxetine Nefazodone Nefazodone Trazodone Trazodone TCAs Desipramine Desipramine Nortriptyline Nortriptyline Amitriptyline Amitriptyline Amoxapine Amoxapine Doxepin Doxepin Imipramine Imipramine Isocarboxazid Isocarboxazid Maprotiline Maprotiline Tranylcypromine Tranylcypromine CHOICE OF ANTIDEPRESSANT CHOICE OF ANTIDEPRESSANT 3

59 59 Antidepressant Average Starting Dose (mg/day) Average Target Dose After 6 Weeks (mg/day) Usual Final Acute Dose (mg/day) Bupropion SR – – 400 Citalopram 10 – – – 40 Desipramine 10 – – – 150 Escitalopram – 20 Fluoxetine – 40 Fluvoxamine 25 – – – 300 Mirtazapine 7.5 – – – 45 Nortriptyline 10 – – – 125 Paroxetine 10 – – – 40 Sertraline 25 – – – 200 Venlafaxine XR 25 – – – 300 Doses of Antidepressants That Are Likely to be Adequate 3

60 60 Preferred Treatment Option Other Options That May Be Considered Psychosocial interventions Caregiver-focused treatment Caregiver-focused treatment Supportive psychotherapy Supportive psychotherapy Pharmacologic treatment Medication alone (citalopram, escitalopram, sertraline, venlafaxine XR) Medication alone (citalopram, escitalopram, sertraline, venlafaxine XR) Medication plus psychosocial intervention Medication plus psychosocial intervention Cholinesterase inhibitor Cholinesterase inhibitor Bupropion SR Bupropion SR Mirtazapine Mirtazapine Paroxetine Paroxetine Treatment of Depression That Coexists with Mild to Moderate Dementia

61 61 Summary Depressive symptoms are: Depressive symptoms are: common among older adults common among older adults can have a major effect on their quality of life can have a major effect on their quality of life Accurate diagnosis of depression is important Accurate diagnosis of depression is important Depression usually responds to treatment with psychotherapy, medications, or a combination of the two Depression usually responds to treatment with psychotherapy, medications, or a combination of the two Treatment options should be consistent with the patients and familys wishes and advanced directives Treatment options should be consistent with the patients and familys wishes and advanced directives

62 62 Case 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. 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: Possible interventions: Dimming a light in her room rather than leaving it on (the light was left on for safety reasons) 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 bed Having a caregiver walk with her and then guiding her back to bed Limiting naps to 30 minutes Limiting naps to 30 minutes Offering her warm milk or soothing snacks prior to going to bed Offering her warm milk or soothing snacks prior to going to bed

63 63 Case 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.

64 64 Outcomes of this Case Study: Wrong Psychotherapy and Right Psychotropics Talking about past abuse was too painful and she preferred to focus on the present. 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. 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. 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. 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. She was given depakote and her paranoia and anxiety reduced to levels that were tolerable.

65 65 Case 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.

66 66 Outcomes 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. 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. 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. The problems continued and after 3 months Carlos was transferred to another nursing home.

67 67 Case 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.

68 68 Nonpharmalogic Treatments for Depression in Dementia Emotion-Oriented Therapies Emotion-Oriented Therapies Brief Psychotherapies Brief Psychotherapies Sensory Stimulation Therapies Sensory Stimulation Therapies 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.

69 69 Emotion-Oriented Therapies Validation Therapy Validation Therapy Simulated Presence Therapy Simulated Presence Therapy 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.

70 70 Brief Psychotherapies Cognitive Behavioral Therapies Cognitive Behavioral Therapies Earlier Stages of Cognitive Decline Earlier Stages of Cognitive Decline Problem Solving Therapy Problem Solving Therapy 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.

71 71 Sensory Stimulation Therapy Art/Music Therapy Art/Music Therapy Aromatherapy Aromatherapy Animal-Assisted/Pet Therapy Animal-Assisted/Pet Therapy Activity Therapies Activity Therapies Massage/Touch Therapies Massage/Touch Therapies Multisensory Approaches Multisensory Approaches 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.

72 72 Activity Therapies Reports from these therapies have been very positive Reports from these therapies have been very positive Include things such as: Include things such as: Recreational activities Recreational activities Physical activity programs (improve mood) Physical 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.

73 73 Massage/Touch Therapies Even though evidence is limited, it still supports the use of massage and touch interventions for anxiety in dementia. 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 time Touch massages have been found to temporarily relieve agitated behavior for a short period of time 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.

74 74 Multisensory Approaches Effective in reducing apathy in dementia according to the Snoezelen/Multisensory Stimulation Effective in reducing apathy in dementia according to the Snoezelen/Multisensory Stimulation Types: Types: Light Light Texture Texture Smell Smell Sound Sound 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.

75 75 Nonpharmacologic Interventions Have potential for successful treatment of depression in dementia Have potential for successful treatment of depression in dementia Types: Types: Emotion-Oriented Therapies Emotion-Oriented Therapies Behavioral Modification Programs Behavioral Modification Programs Cognitive-Behavioral Programs Cognitive-Behavioral Programs Structured Activity Programs Structured Activity Programs 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.

76 76 Clinical Investigation Objectives: Examine the prevalence, correlates, and medication management of behavioral symptoms in elderly people living in residential care/assisted living (RC/AL) facilities Design: Cross-Sectional Study Settings: Random sample of RC/AL facilities in four states (Florida, Maryland, New Jersey, North Carolina) Participants: Total of 2078 RC/AL residents 65 and older Measurement: Behavioral symptoms were classified using modified version of the Cohen-Mansfield Agitation Inventory 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: ,

77 77 Results Approximately 34% exhibited one or more behavioral symptoms, once a week Approximately 34% exhibited one or more behavioral symptoms, once a week 13% show aggressive behavioral symptoms 13% show aggressive behavioral symptoms 20% demonstrated physically nonaggressive behavioral symptoms 20% demonstrated physically nonaggressive behavioral symptoms 22% expressed verbal behavioral symptoms 22% expressed verbal behavioral symptoms 13% resisted taking medications or activities of daily living care 13% resisted taking medications or activities of daily living care More than 50% of RC/AL residents were on psychotropic medications More than 50% of RC/AL residents were on psychotropic medications Two-thirds had some mental health problem indicator, such as dementia depression, psychosis, or other psychiatric illnesses. Two-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: ,

78 78 Conclusions Integrating 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 setting Integrating 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 setting 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: ,

79 79 Clinical and Research News: Many Assisted-Living Residents Not Getting Depression Help Clinical Study: Duke University Medical Center – Lea Watson, MD Cornell Scale for Depression and Dementia was the main test used to measure physical and mental health Cornell Scale for Depression and Dementia was the main test used to measure physical and mental health Each item is scored on a three-point scale with a total possible score of 38. Each 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. 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 7 13% of all subjects in this study had a score of greater than 7 At least a quarter of all subjects showed symptoms of depression, such as sadness, tearfulness, worrying, or irritability At least a quarter of all subjects showed symptoms of depression, such as sadness, tearfulness, worrying, or irritability However, only 18% were diagnosed as being clinically depressed However, only 18% were diagnosed as being clinically depressed Only 38% of patients with severe depression, a score of more than 12, were on antidepressants Only 38% of patients with severe depression, a score of more than 12, were on antidepressants Lea Watson commented that her next phase of work will directly focus on depression in assisted-living facilities Lea Watson commented that her next phase of work will directly focus on depression in assisted-living facilities

80 80 Study: 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. 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. 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. 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, MD 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, MD Most psychiatrists agree that the elderly with two or more episodes should be appropriately prescribed maintenance treatment. Most 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: ,

81 81 Contraindications to Tapering and GDR GDR may be considered contraindicated for: GDR may be considered contraindicated for: Antipsychotic medications for psychiatric disorders that do not include behavioral symptoms related to dementia Antipsychotic medications for psychiatric disorders that do not include behavioral symptoms related to dementia Psychopharmacological medications Psychopharmacological medications Including antidementia agents and antidepressants Including antidementia agents and antidepressants Sedative/hypnotics Sedative/hypnotics GDR can be considered contraindicated (without and failing first) if continued use: GDR can be considered contraindicated (without and failing first) if continued use: Is in accordance with current standards of practice, and The physician documents clinical rationale for why GDR is likely to impair function or cause psychiatric instability due to exacerbation of an underlying psychiatric disorder

82 82 Recurrence and Residual Symptoms in Geriatric Depression Recurrence rates of 50% - 90% over 2-3 years Recurrence rates of 50% - 90% over 2-3 years Lower remission rates in geriatric depression Lower remission rates in geriatric depression After 6-month remission, 20%-30% retain residual symptoms After 6-month remission, 20%-30% retain residual symptoms Greater distress and disability Greater distress and disability Higher relapse rates in elderly patients compared to younger patients Higher relapse rates in elderly patients compared to younger patients Maintenance therapy is important Maintenance therapy is important

83 83 Empirically Supported Psychotherapies Cognitive Behavioral Therapy (CBT) Identify and modify negative beliefs and negative interpretations of the past, present and future Identify and modify negative beliefs and negative interpretations of the past, present and future Includes: Includes: Education Education Symptom and stress management strategies Symptom and stress management strategies Desensitization to feared stimuli Desensitization to feared stimuli Cognitive challenges to change beliefs Cognitive challenges to change beliefs Interpersonal Therapy (IPT) Focuses on 4 types of interpersonal problem categories viewed as causes of depression Focuses on 4 types of interpersonal problem categories viewed as causes of depression Grief and morning Interpersonal disputes Role transitions Social skill deficits


Download ppt "1 Depression Clinical Practice Guideline. 2 Disclosures."

Similar presentations


Ads by Google