1. XIII Update in Psychogeriatrics, May 8th 2008 1 Recognition & treatment of depression in elderly What is the power of nurses and nursing assistants? Karel G. Brühl, MD

2. XIII Update in Psychogeriatrics, May 8th 2008 2 Depression in elderly & the role of nurses and nursing assistants... Nurses and all health care professionals can make a big difference for depressed elderly Update to help you use knowledge of 2008 for your patients & family

3. XIII Update in Psychogeriatrics, May 8th 2008 3 Depression in elderly & the role of nurses and nursing assistants... I.In psycho geriatric care, NL II.In recognition III.In treatment IV.‘things to do’

4. XIII Update in Psychogeriatrics, May 8th 2008 4 Role of nurses in Psycho geriatric care from a dutch perspective Psycho geriatric care = Long Term Care and Dementia Care Outside Nursing Homes:  Assisted Living Facilities  or at Home In Nursing Homes I.

5. XIII Update in Psychogeriatrics, May 8th 2008 5 Dementia patients: most live at Home, 1 of 6 in Nursing Home I. Dutch perspective

6. XIII Update in Psychogeriatrics, May 8th 2008 6 IN NURSING HOMES Multidisciplinary team: Several therapists/paramedical nursing assistants  coordinate care nursing home physician = Medical Doctor + 3 years geriatric education = staff member, not consultant 1 doctor: 100 patients in nursing home I. Dutch perspective

7. XIII Update in Psychogeriatrics, May 8th 2008 7 IN Nursing Homes Netherlands Few registered nurses, many nursing assistants Quantity of nursing assistants: 40 nursing assistants: 1 doctor I. Dutch perspective

8. XIII Update in Psychogeriatrics, May 8th 2008 8 Dementia care at Home Netherlands Family Home care nurses and nursing assistants general practitioner & - Clinical geriatrician in hospital - Social geriatrician at home: case- management I.

9. XIII Update in Psychogeriatrics, May 8th 2008 9 Dementia care at home: Casemanagement New: Geriant Foundation 100 professionals, 1500 patients Aim: improve functioning and Quality of Life in people living with dementia 2001: 300 new patients 2007: 1000 new patients I. Dutch perspective

10. XIII Update in Psychogeriatrics, May 8th 2008 10.52.595.29495.29 4. In the Netherlands yet some areas offer casemanagement at home The Netherlands

11. XIII Update in Psychogeriatrics, May 8th 2008 11 Casemanager = specialized nurse Registered Nurse + 2 years psycho geriatric education 50 - 70 patients Central role: first assessment till death or nursing home Most face to face contacts with patients: 15.000 in 2007 I. Dutch perspective

12. XIII Update in Psychogeriatrics, May 8th 2008 12 Patient contacts 2007 I. Geriant Foundation

13. XIII Update in Psychogeriatrics, May 8th 2008 13 Casemanagers had over 15.000 contacts in 2007 I.

14. XIII Update in Psychogeriatrics, May 8th 2008 14 400.000 nurses in NL 8 Nurses: 1 doctor I.

15. XIII Update in Psychogeriatrics, May 8th 2008 15 Nurses’ power All times, all over the world: Number of nurses and nursing assistants high Amount of contacts with patients high We rely on nurses’ observations, also for symptoms of depression in Long Term Care I.

16. XIII Update in Psychogeriatrics, May 8th 2008 16 How well do nurses recognize depression? 3 questions come first: 1. What is depression in elderly? 2. What is depression in dementia? 3. What is its prevalence? II.

17. XIII Update in Psychogeriatrics, May 8th 2008 17 Prevalence depression elderly living in the community: 15 % II. Beekman et al, Br J Psychiat. 1999

18. XIII Update in Psychogeriatrics, May 8th 2008 18 prevalence in elderly depending on long term care: 30% II. recognition Alexopoulos, Lancet 2005

19. XIII Update in Psychogeriatrics, May 8th 2008 19 What is depression in Elderly? Minor depression and Major depression = depressive episode DSM-IV: international ‘standard’ in high quality research seems simple, is not simple II. recognition

20. XIII Update in Psychogeriatrics, May 8th 2008 20 About 50% of depressions, in elderly who seek help, are recognized II. recognition Hoogendijk, VUmc 2006

21. XIII Update in Psychogeriatrics, May 8th 2008 21 Symptoms of depressive episode: Not simple II. recognition

22. XIII Update in Psychogeriatrics, May 8th 2008 22 Depressive episode DSM-IV At least 5 symptoms Most of the day 2 weeks or longer The 2 most important or ‘gateway symptoms’: Depressed mood or appears depressed Decreased Interest or pleasure II. recognition

23. XIII Update in Psychogeriatrics, May 8th 2008 23 DSM-IV gateway symptoms: 1. Depressed mood 2. Loss of interest or pleasure 3. Weight and appetite  4.Sleep disturbance 5.Motor activity: agitated or slowed 6.Loss of energy 7.Feeling worthless or guilty 8.Indecisive, loss concentration 9. Thoughts of death or suicide or suicide attempt Other symptoms:

24. XIII Update in Psychogeriatrics, May 8th 2008 24 Depressive episode in elderly 5 symptoms often too many minor depression: 2 - 4 symptoms Impact on work, social or personal functioning Not caused by medication or other general medical condition (like dementia...) II. recognition

25. XIII Update in Psychogeriatrics, May 8th 2008 25 In dementia: even harder to recognize Less verbal abilities Some symptoms due to dementia itself: e.g. loss of interest in cooking or biking because it is not possible anymore Mood symptoms change fast from situation to situation & from moment to moment II. recognition

26. XIII Update in Psychogeriatrics, May 8th 2008 26 Irritability also symptom of depression in dementia? not in DSM-IV depressive episode II. recognition

27. XIII Update in Psychogeriatrics, May 8th 2008 27 Depression in Alzheimer's disease New criteria, by Olin et al, 2002 differences with DSM-IV: reduced pleasure in response to usually pleasant activities  can be noticed by others (nurses) ! ‘New’: Irritability & Social withdrawal 3 instead of 5 symptoms Should be easier to recognize II. recognition

28. XIII Update in Psychogeriatrics, May 8th 2008 28 Back to what is the power of nurses and nursing assistants In mental health care for elderly who are depending on long term care number of studies is rising.... II. recognition

29. XIII Update in Psychogeriatrics, May 8th 2008 29 2007 pub med: over 400 studies on elderly depression and nurses II. recognition

30. XIII Update in Psychogeriatrics, May 8th 2008 30 Review : Recognition of depression by nurses The Question: how well do nurses and nursing assistants recognize depression? II. recognition

31. XIII Update in Psychogeriatrics, May 8th 2008 31 4 high quality studies 2 in USA nursing homes 1 in USA home health care 1 in the Netherlands: nursing home II. review

32. XIII Update in Psychogeriatrics, May 8th 2008 32 Study in nursing homes Baltimore USA Rovner, 1991 Recognition: Nursing assistants: 65% Nursing home physicians: 14% Family members: 70% !  Doctors not part of staff: consultants and specificity of doctors was high: 95 % (nurses 68%)  advise doctors: ask nurse assistant first 4 x better recognition! II. review

33. XIII Update in Psychogeriatrics, May 8th 2008 33 Study in Nursing Homes New York Teresi, 2001 42 % recognition by nurses 45 % recognition by nursing assistants 44 % recognition by psychiatrists 55-65% with screening scales for depressive symptoms (GDS or HAMD) II. review

34. XIII Update in Psychogeriatrics, May 8th 2008 34 = about 50% of depressions in elderly who seek help are recognized II. review

35. XIII Update in Psychogeriatrics, May 8th 2008 35 USA study, New York in Home health care, Brown, 2002 Recognition nurses 45 % new study with staff training (Bruce, Brown, JAGS 2007) in depression assessment and referral: recognition higher, appropriate referral rate, improvement of depressive symptoms and cure rate of depression higher II. review

36. XIII Update in Psychogeriatrics, May 8th 2008 36 Study in Nursing Home Amsterdam, Falck, 1999 Nursing assistants: 78% Nursing home physicians: 68% If nursing home physician & NAs both answered YES depressed: recognition was almost 90%! !!Nursing assistants talked in groups of 4 before answering yes or no depressed Doctors here are staff members, not consultants II. review

37. XIII Update in Psychogeriatrics, May 8th 2008 37 4 High Quality studies: How well do Nurses and NAs recognize depression? studyrecognition Brown45% Teresi44% Falck78% Rovner65% II. review

38. XIII Update in Psychogeriatrics, May 8th 2008 38 So: recognition of depression by nurses and nursing assistants Few studies, compared to importance nurses and nursing assistants in mental health care of elderly Screening scales higher recognition e.g Geriatric Depression Scale in Nursing homes, Jongenelis 2006: over 85% recognition ! Staff training helps to improve recognition as well II. review

39. XIII Update in Psychogeriatrics, May 8th 2008 39 Treatment of depression What evidence is there for a positive effect of interventions or treatment by nurses? Treatment = non-pharmaceutical and pharmaceutical treatment Non-pharmaceutical treatment = psychological and psycho-social interventions III. ‘the good part’ Making elderly Feel better

40. XIII Update in Psychogeriatrics, May 8th 2008 40 Small talk improves quality of life nursing home residents NIVEL, Beek et al, 2008 III. Treatment

41. XIII Update in Psychogeriatrics, May 8th 2008 41 International reviews*: effect of psychosocial interventions for depression in dementia * Verkaik et al, 2005; Livingstone et al, 2005, Verhey 2006 Proved Effective : Emotion oriented care Behavior therapy (25 studies) Snoezelen Exercise Music therapy !! Combinations Proved NOT effective: Reality orientation Validation Not yet enough high quality studies: Activities without behavior therapy (5) Reminiscence (5) Antidepressants *(4) * Bains ea, cochrane 2006 III. Treatment

42. XIII Update in Psychogeriatrics, May 8th 2008 42 Antidepressive medication Currently debate about effectivity and side effects 30-35% placebo effect might be a psycho-social effect as well ! If nurses believe in it: even a better effect? In practise medication helpful, especially for the more severe depressions Yet not enough studies in elderly in general III. Treatment

43. XIII Update in Psychogeriatrics, May 8th 2008 43 Exercise helps against depression enough studies show evidence for that  “Appropriate Exercise” III. treatment

44. XIII Update in Psychogeriatrics, May 8th 2008 44 Help with exercise works too III. Treatment

45. XIII Update in Psychogeriatrics, May 8th 2008 45 Other help? Pimp my ride... III. Treatment

46. XIII Update in Psychogeriatrics, May 8th 2008 46 Duo bike: a combination of interventions

47. XIII Update in Psychogeriatrics, May 8th 2008 47 Another combined intervention? Admission to nursing home Prevalence of depressive symptoms after 6 months in nursing home decreased from 41 % - 29 % Smalbrugge, JAGS 2006 III. treatment

48. XIII Update in Psychogeriatrics, May 8th 2008 48 Staff training positive effect on depression evidence found in studies all over the world Care intervention late life depression in residential care Australia, Llewellyn Jones, 1999 Staff training based on behavior therapy combined with exercise program USA, Teri et al, 2003 Emotion oriented care training & pleasant events, care plan by nursing assistants: study in Dutch nursing homes preliminary data PhD study, Verkaik III. treatment

49. XIII Update in Psychogeriatrics, May 8th 2008 49 ‘Things to do’ Admit it: we all miss a lot of depressions in elderly Communication is the key. Talk in your team about symptoms, doubts, failures and successes in recognition and treatment Use screening scale for depression e.g. GDS: around 85% recognition in Nursing Homes Ask for staff training in depression management IV.

50. XIII Update in Psychogeriatrics, May 8th 2008 50 Things to do (2) Nurses and nursing assistants: speak out! allway have the doctor or psychologist included your observation and opinion in a depression diagnose Doctors, psychologists e.o: never just examine the patient, always examine other staff members opinion as well Always ask family: they know best ! IV.

51. XIII Update in Psychogeriatrics, May 8th 2008 51 Things to do (3) Freely use DSM-IV criteria depressive episode, it will save many patients a lot of suffering In Alzheimer’s: you might want to use the ‘provisional diagnostic criteria’ from Olin et al IV.

52. XIII Update in Psychogeriatrics, May 8th 2008 52 Things to do (4) Include exercise, emotion oriented care, daily activity programs, medication options in your care planning

53. XIII Update in Psychogeriatrics, May 8th 2008 53 Finally Effective use of the power of nurses and nursing assistants in mental health care improves the quality of life of elderly And will improve everybody’s work satisfaction as well

54. XIII Update in Psychogeriatrics, May 8th 2008 54 Thank you! k.bruhl@mac.com