depression clinical practice guideline

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DepressionDepressionClinical Practice GuidelineClinical Practice Guideline

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DisclosuresDisclosures

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Learning ObjectivesLearning Objectives

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DepressionDepression

Depression is a spectrum of mood Depression is a spectrum of mood disorders characterized by a sustained disorders characterized by a sustained disturbance in emotional, cognitive, disturbance in emotional, cognitive, behavioral, or somatic regulation and behavioral, or somatic regulation and associated with significant functional associated with significant functional impairment and a reduction in the capacity impairment and a reduction in the capacity for pleasure and enjoyment. for pleasure and enjoyment.

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IntroductionIntroduction

Maintain a high index of suspicion for the Maintain a high index of suspicion for the presence of depression or depressive symptoms presence of depression or depressive symptoms in long term care (LTC) patientsin long term care (LTC) patients

Late-life depression may be overlooked or Late-life depression may be overlooked or inadequately treatedinadequately treated

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IntroductionIntroduction

The relationship between medical conditions and The relationship between medical conditions and depression is complexdepression is complex

Depression may exacerbate coexisting medical Depression may exacerbate coexisting medical illnessillness

Some medications may cause or contribute to Some medications may cause or contribute to depressiondepression

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Federal Regulations and DepressionFederal Regulations and Depression

F157-§483.10(b)(11) -- Notification of changesF157-§483.10(b)(11) -- Notification of changes (i) A facility must immediately inform the resident; (i) A facility must immediately inform the resident;

consult with the resident’s physician; and if known, consult with the resident’s physician; and if known, notify the resident’s legal representative or an notify the resident’s legal representative or an interested family member when there is:interested family member when there is:

• (B) A significant change in the resident’s physical, mental, or (B) A significant change in the resident’s physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or psychosocial status in either life-threatening conditions or clinical complications)clinical complications)

For purposes of §483.10(b)(11)(i)(B), Clinical complications are For purposes of §483.10(b)(11)(i)(B), Clinical complications are such things as … or onset of depressionsuch things as … or onset of depression

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F250-§483.15(g)(1)F250-§483.15(g)(1) The facility must provide The facility must provide medically-related social services to attain or medically-related social services to attain or maintain the highest practicable physical, maintain the highest practicable physical, mental, and psychosocial well-being of each mental, and psychosocial well-being of each residentresident ““Medically-related social services” means services Medically-related social services” means services

provided by the facility’s staff to assist residents in provided by the facility’s staff to assist residents in maintaining or improving their ability to manage their maintaining or improving their ability to manage their everyday physical, mental, and psychosocial needseveryday physical, mental, and psychosocial needs

• Types of conditions to which the facility should respond with Types of conditions to which the facility should respond with social services by staff or referral include:social services by staff or referral include:

DepressionDepression

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EATING-§483.25(a)(1)(iv)EATING-§483.25(a)(1)(iv) If the resident’s eating abilities have declined, If the resident’s eating abilities have declined,

is there any evidence that the decline was is there any evidence that the decline was unavoidable?unavoidable?1. What risk factors for decline of eating skills did the 1. What risk factors for decline of eating skills did the

facility identify?facility identify? d. Depression or confused mental state is responsible for d. Depression or confused mental state is responsible for

50% or eating problems or weight loss in Seniors50% or eating problems or weight loss in Seniors

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42 CFR 483.25(f)(1)&(2), F319, F320, Mental 42 CFR 483.25(f)(1)&(2), F319, F320, Mental and Psychosocial Functioningand Psychosocial Functioning

Surveyors are instructed to review whether the facility had Surveyors are instructed to review whether the facility had identified, evaluated, and responded to a change in behavior identified, evaluated, and responded to a change in behavior and/or psychosocial changes, including depressionand/or psychosocial changes, including depression

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RecognitionRecognition

Recognition is the first stage of the care processRecognition is the first stage of the care process RecognitionRecognition” means identifying the presence of a ” means identifying the presence of a

risk or conditionrisk or condition

How: PHQ-2 shows that only 14-25% of How: PHQ-2 shows that only 14-25% of residents in LTC have depressionresidents in LTC have depression

Caregivers identify depression poorlyCaregivers identify depression poorly The PHQ-2 identifies 85% of patients with depressionThe PHQ-2 identifies 85% of patients with depression

Reference: Practical Depression Screening in Residential Care. Am. J. Geriatrics Psychiatry. 17:7. July 2009. 556-564Reference: Practical Depression Screening in Residential Care. Am. J. Geriatrics Psychiatry. 17:7. July 2009. 556-564

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Does the patient have a history of depression or Does the patient have a history of depression or a positive depression screening test?a positive depression screening test? Review available transfer information, referral data and Review available transfer information, referral data and

patient and family historypatient and family history Look for history of depression, psychiatric disorder(s), Look for history of depression, psychiatric disorder(s),

treatment of hospitalizationtreatment of hospitalization Document the presence of these conditions in the medical Document the presence of these conditions in the medical

recordrecord

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RecognitionRecognition Depression is common among patients in the LTC Depression is common among patients in the LTC

setting setting Treatment is effective Treatment is effective Adopt a policy encouraging formal screening of all Adopt a policy encouraging formal screening of all

patients for depression 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 9Patient Health Questionnaire 9 Clinical InterviewClinical Interview

Do you feel life is worth living?Do you feel life is worth living? What makes you happy?What makes you happy?

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Does the patient have signs or symptoms of Does the patient have signs or symptoms of

depression?depression? Nursing staff are in a good position to recognize signs Nursing staff are in a good position to recognize signs

and symptoms (S&S) of depression (Behavior – not and symptoms (S&S) of depression (Behavior – not subjective)subjective)

Look for S&S in RAI. MDS, RAPs, progress notes, Look for S&S in RAI. MDS, RAPs, progress notes, family interaction notesfamily interaction notes

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Symptoms Of Depression Symptoms Of Depression 33

Most Most importantimportant

Depressed mood most of the day, almost every day (by either subjective Depressed mood most of the day, almost every day (by either subjective report or observation made by others , Diminished interest or pleasure in report or observation made by others , Diminished interest or pleasure in most activities, most of the time, Thoughts of death or suicide. most activities, most of the time, Thoughts of death or suicide.

ImportantImportant Difficulty making decisions, Feelings of helplessness, Feelings of Difficulty making decisions, Feelings of helplessness, Feelings of worthlessness or hopelessness, Inappropriate feelings of guilt, worthlessness or hopelessness, Inappropriate feelings of guilt, Psychomotor agitation or retardation not attributable to other causes, Social Psychomotor agitation or retardation not attributable to other causes, Social withdrawal, avoidance of social interactions, going out, activities and/or withdrawal, avoidance of social interactions, going out, activities and/or participationparticipation

Sometimes Sometimes helpfulhelpful

Appetite change, Change in ability to think or concentrate, Change in Appetite change, Change in ability to think or concentrate, Change in activities of daily living (ADLs), Family history of mood disorders, Fatigue or activities of daily living (ADLs), Family history of mood disorders, Fatigue or loss of energy, worse than baseline, Insomnia or hypersomnia nearly every loss of energy, worse than baseline, Insomnia or hypersomnia nearly every day. Increased complaints of pain, Preoccupation with poor health or day. Increased complaints of pain, Preoccupation with poor health or physical limitations, Weight loss or gain.physical limitations, Weight loss or gain.

Sleep problems occur in 40%-68% of all patients, with only 19% Sleep problems occur in 40%-68% of all patients, with only 19% documenteddocumented

Reference: Sleep: A Marker of Physical and Mental Health in the Elderly. Am. J. Geriatric Psychiatry. 14:16. 860-866. Oct. 2006

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Does the patient have risk factors for Does the patient have risk factors for depression?depression? Evaluate for risk factorsEvaluate for risk factors

• If risk factors are present, develop an interdisciplinary (IDT) If risk factors are present, develop an interdisciplinary (IDT) care plancare plan

• If no risk factors are found, monitor periodically (every 3 If no risk factors are found, monitor periodically (every 3 months)months)

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Some Risk Factors for DepressionSome Risk Factors for Depression Alcohol or substance abuseAlcohol or substance abuse Current use of a medication associated with a high risk of Current use of a medication associated with a high risk of

depression depression Hearing or vision impairment severe enough to affect function – Hearing or vision impairment severe enough to affect function –

30% increase rate of depression30% increase rate of depression History of attempted suicideHistory of attempted suicide History of psychiatric hospitalizationHistory of psychiatric hospitalization Medical diagnosis or diagnoses associated with a high risk of Medical diagnosis or diagnoses associated with a high risk of

depression depression New admission or change in environmentNew admission or change in environment New stressful losses, including loss of autonomy, loss of privacy, New stressful losses, including loss of autonomy, loss of privacy,

loss of functional status, loss of body part, or loss of family member, loss of functional status, loss of body part, or loss of family member, friend or petfriend or pet

Personal or family history of depression or mood disorderPersonal or family history of depression or mood disorder Personality Anxiety Disorder – Sleep problem (day time)Personality Anxiety Disorder – Sleep problem (day time)

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AssessmentAssessment

Assessment is the second stage of the Assessment is the second stage of the care processcare process “Assessment” means clarifying the nature

and causes of a condition or situation and identifying its impact on the individual

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Has the patient had a persistently depressed Has the patient had a persistently depressed mood or loss of interest or pleasure for at least 2 mood or loss of interest or pleasure for at least 2 weeks? weeks?

Has depressed mood (dysphoria) or loss of interest or pleasure Has depressed mood (dysphoria) or loss of interest or pleasure (anhedonia) been present for at least 2 weeks; (anhedonia) been present for at least 2 weeks; andand

has dysphoria or anhedonia contributed to the patient’s has dysphoria or anhedonia contributed to the patient’s functional or social impairment or decline functional or social impairment or decline

Is substance abuse or bereavement Is substance abuse or bereavement notnot present present Personality DisorderPersonality 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. 17. 335-344. April 2009.

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Is it appropriate to perform a medical work-up for Is it appropriate to perform a medical work-up for factors contributing to signs and symptoms of factors contributing to signs and symptoms of possible depression?possible depression? Will depend upon:Will depend upon:

• patient’s conditionpatient’s condition

• prognosis prognosis

• advance care directives advance care directives

• expressed preferences of the patient or familyexpressed preferences of the patient or family

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Laboratory Tests For Evaluating Laboratory Tests For Evaluating Possible DepressionPossible Depression33

Preferred TestsPreferred Tests Other Tests That May Be Other Tests That May Be ConsideredConsidered

Chemistry profile (electrolytes, Chemistry profile (electrolytes, blood urea nitrogen, creatinine, blood urea nitrogen, creatinine, glucose)glucose) Complete blood countComplete blood count Serum levels of anticonvulsant Serum levels of anticonvulsant or tricyclic antidepressant, if taking or tricyclic antidepressant, if taking either type of medicationeither type of medication Thyroid function (T3, T4, TSH)Thyroid function (T3, T4, TSH)

ElectrocardiogramElectrocardiogram Folate levelFolate level Serum calcium levelSerum calcium level Serum level of digoxin or Serum level of digoxin or theophylline, if taking either theophylline, if taking either medicationmedication UrinalysisUrinalysis Vitamin B12 level Vitamin B12 level

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Is the patient taking medications that might Is the patient taking medications that might cause or contribute to depression?cause or contribute to depression?

• Many medications can affect:Many medications can affect: moodmood affect affect level of consciousness level of consciousness

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Medications That May Cause Medications That May Cause Symptoms of DepressionSymptoms of Depression

Alpha-methyl dopaAlpha-methyl dopa Anabolic steroidsAnabolic steroids Anti-arrhythmic Anti-arrhythmic

medicationsmedications Anticonvulsant Anticonvulsant

medicationsmedications AntidementiaAntidementia BarbituratesBarbiturates Benzodiazepines (i.e., Benzodiazepines (i.e.,

long acting)long acting)

Carbidopa or levodopaCarbidopa or levodopa Certain beta-adrenergic Certain beta-adrenergic

antagonists (propranolol)antagonists (propranolol) ClonidineClonidine Cytokines (specifically IL-Cytokines (specifically IL-

2)2) Digitalis preparations Digitalis preparations GlucocorticoidsGlucocorticoids H2 blockersH2 blockers MetoclopramideMetoclopramide Opioids Opioids

References:

D. Rogers et. al. General Drug Associated with Depression. Psychiatry. 5, Dec. 2008. 28-41.

Sidhuk et. al. Watch for Psychotropics Causing Psychiatric Side Effects. Current Psychiatry. August 2009. 61-74.

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

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Important Comorbid Conditions*Important Comorbid Conditions* Most importantMost important

Alcohol dependencyAlcohol dependency Cerebrovascular Cerebrovascular

diseases diseases Medications that can Medications that can

cause mood disorders cause mood disorders Neurodegenerative Neurodegenerative

disorders (e.g., disorders (e.g., Alzheimer’s disease, Alzheimer’s disease, Parkinson’s disease, Parkinson’s disease, multiple sclerosis)multiple sclerosis)

Substance abuseSubstance abuse Sleep apnea (40%-60% Sleep apnea (40%-60%

of patients with of patients with dementia)dementia)

ImportantImportant CancerCancer Chronic obstructive pulmonary disorderChronic obstructive pulmonary disorder Chronic painChronic pain Congestive heart failureCongestive heart failure Coronary artery diseaseCoronary artery disease DiabetesDiabetes Electrolyte imbalanceElectrolyte imbalance Endocrine disorders (thyroid)Endocrine disorders (thyroid) Head traumaHead trauma Metabolic problems Metabolic problems Myocardial infarctionMyocardial infarction Orthostatic hypotensionOrthostatic hypotension Physical, verbal, emotional abusePhysical, verbal, emotional abuse SchizophreniaSchizophrenia AnxietyAnxiety

*Reference: Is a Medical Illness Causing your Patients Depression. Current Psychiatry. 8. 2009. 43-54.

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Do the patient’s signs and symptoms Do the patient’s signs and symptoms resolve with treatment of comorbid resolve with treatment of comorbid condition(s)?condition(s)?

Take appropriate action if medical diagnoses or conditions are Take appropriate action if medical diagnoses or conditions are suspected of contributing to depressive symptoms suspected of contributing to depressive symptoms

When depression and a medical condition coexist, both When depression and a medical condition coexist, both conditions are likely to require treatment conditions are likely to require treatment

To the extent possible, address underlying causes and evaluate To the extent possible, address underlying causes and evaluate the impact of such measures the impact of such measures

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AssessmentAssessment Clarify the diagnosis Clarify the diagnosis

The DSM-IV defines the following types of depressive The DSM-IV defines the following types of depressive disorders:disorders:

• Mild episode of major depression Mild episode of major depression • Moderate episode of major depression Moderate episode of major depression • Severe episode of major depression Severe episode of major depression • Severe episode of major depression with psychotic features Severe episode of major depression with psychotic features • Minor depression disorder – 80% convert to MDD (Major Minor depression disorder – 80% convert to MDD (Major

Depression Disorder)Depression Disorder) • Bipolar type II Bipolar type II • Dysthymic disorder Dysthymic disorder • Adjustment disorder with depressed mood or with mixed Adjustment disorder with depressed mood or with mixed

anxiety and depressed moodanxiety and depressed mood

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Major DepressionMajor Depression

Depressed Depressed Mood Mood + + 4 symptoms4 symptomsxx2 weeks2 weeks

•Weight loss or gainWeight loss or gain•Insomnia or hypersomniaInsomnia or hypersomnia•Psychomotor retardationPsychomotor retardation•Agitation Agitation (irritability, anxiety, fatigue)(irritability, anxiety, fatigue)

•Decreased energyDecreased energy•Guilt feelingsGuilt feelings•Inability to concentrateInability to concentrate•Thoughts of death or suicide (life Thoughts of death or suicide (life not worth living)not worth living)

Loss ofLoss of interest or interest or pleasurepleasure++4 symptoms4 symptomsxx2 weeks2 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 2009. 565-575.

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Rating ScalesRating Scales

Use at the beginning of treatmentUse at the beginning of treatment Only reliable way to obtain an objective Only reliable way to obtain an objective

measuremeasure Essential to monitoring the effectiveness Essential to monitoring the effectiveness

of treatmentof 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 Center for Epidemiologic Studies of Depression Scale

(CES-D) (CES-D) Patient Health Questionnaire 9 (PHQ-9)Patient Health Questionnaire 9 (PHQ-9)

Most reliable and efficientMost reliable and efficient

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Does the situation warrant additional psychiatric Does the situation warrant additional psychiatric support? support?

• Depression is often managed readily by primary Depression is often managed readily by primary care practitioners (80/20) care practitioners (80/20)

• Effective psychiatric support may not be readily Effective psychiatric support may not be readily available in the LTC settingavailable in the LTC setting

• In some cases, however, psychiatric support is In some cases, however, psychiatric support is helpfulhelpful

25% improve with medication, while 58% improve with 25% improve with medication, while 58% improve with counseling and medicationcounseling and medication

Post-stroke depression resolves in 6 months regardless Post-stroke depression resolves in 6 months regardless of treatment (20-40% have behavioral symptoms)of treatment (20-40% have behavioral symptoms)

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Does the patient’s depression exhibit Does the patient’s depression exhibit complications that may pose a risk to the patient complications that may pose a risk to the patient or to others? or to others? Determine if the patient is psychotic, severely Determine if the patient is psychotic, severely

agitated, aggressive, neurovegetative, or suicidalagitated, aggressive, neurovegetative, or suicidal Suicide risk increases with the severity of depressionSuicide risk increases with the severity of depression

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TreatmentTreatment

Treatment is the third stage of the care processTreatment is the third stage of the care process “Treatment” means selecting and providing

appropriate interventions for that individual

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TreatmentTreatment

Depression usually responds to treatment with Depression usually responds to treatment with psychotherapy, medications, or a combination of the psychotherapy, medications, or a combination of the twotwo

An effective individualized care plan includes both An effective individualized care plan includes both nonpharmacologic and pharmacologic interventionsnonpharmacologic and pharmacologic interventions

Pharmacologic:Pharmacologic:1.1. Antianxiety, antipsychotic, antidepressive and antidementiaAntianxiety, antipsychotic, antidepressive and antidementia

Non-PharmacologicNon-Pharmacologic (other psychotherapies) (other psychotherapies)::1.1. Emotion-oriented, interpersonal therapy, sensory stimulation Emotion-oriented, interpersonal therapy, sensory stimulation

therapytherapy2.2. Cognitive Behavioral Therapy (CBT) – (art, music, massage) Cognitive Behavioral Therapy (CBT) – (art, music, massage)

only in early stage, Problem Solving Therapy, Environmental only in early stage, Problem Solving Therapy, Environmental Activity – (exercise)Activity – (exercise)

3.3. Supportive TherapiesSupportive Therapies

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Phases of Depression TreatmentPhases of Depression Treatment33 PhasePhase DurationDuration GoalGoal

AcuteAcute Approx. 3 monthsApprox. 3 months To achieve complete To achieve complete recovery from signs and recovery from signs and symptoms of acute symptoms of acute depressive episode (i.e., depressive episode (i.e., remission) remission)

ContinuationContinuation 4-6 months4-6 months To prevent relapse as To prevent relapse as patient’s depressive patient’s depressive symptoms continue to symptoms continue to decline and his or her decline and his or her functionality improves functionality improves

MaintenanceMaintenance • 3 months or longer, 3 months or longer, depending on patient’s needsdepending on patient’s needs• Over the age of 70, usually Over the age of 70, usually 12-24 months or lifetime if 12-24 months or lifetime if more than 2 episodesmore than 2 episodes

• To prevent recurrence of To prevent recurrence of a new depressive episodea new depressive episode• Relapse occurs in 40-Relapse occurs in 40-60%60%

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TreatmentTreatment

Implement appropriate treatment for the patient’s Implement appropriate treatment for the patient’s depression depression Minimize institutional aspects of the environmentMinimize institutional aspects of the environment Facilitate interaction with family members and friendsFacilitate interaction with family members and friends Provide opportunities for spiritual activity (50% of LTC Provide opportunities for spiritual activity (50% of LTC

residents have an interest)residents have an interest) Provide socialization interventionsProvide socialization interventions

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PsychotherapyPsychotherapy

Considerable advances have occurredConsiderable advances have occurred

Both cognitive-behavioral therapy and learning-Both cognitive-behavioral therapy and learning-based therapy have a significant impact on based therapy have a significant impact on depression symptoms in older adults depression symptoms in older adults

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Pharmacologic TreatmentPharmacologic Treatment

All antidepressants approved by the U.S. Food All antidepressants approved by the U.S. Food and Drug Administration have been shown to be and Drug Administration have been shown to be relatively safe in most populationsrelatively safe in most populations

However, they are effective in some, but not all, However, they are effective in some, but not all, populationspopulations

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Electroconvulsive Therapy (ECT)Electroconvulsive Therapy (ECT)

(ECT) should be considered if:(ECT) should be considered if: The patient’s condition is rapidly deteriorating or,The patient’s condition is rapidly deteriorating or, If antidepressant medication is not tolerated or has If antidepressant medication is not tolerated or has

failedfailed • Mild depression – failure of 4-6 antidepressantsMild depression – failure of 4-6 antidepressants• Moderate depression – failure of 2-4 antidepressantsModerate depression – failure of 2-4 antidepressants• Sever depression – failure of 1-2 antidepressants or Sever depression – failure of 1-2 antidepressants or

suicidal riskssuicidal risks

• 50% effective50% effective• Transitional Stimulation (limited studies in seniors)Transitional Stimulation (limited studies in seniors)

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Assessing Treatment ResponseAssessing Treatment Response

Treatment response can vary widely among Treatment response can vary widely among depressed elderly patientsdepressed elderly patients

Patient response is generally not predictable Patient response is generally not predictable

before the initiation of treatmentbefore the initiation of treatment

Beliefs that older patients in general respond Beliefs that older patients in general respond more slowly to antidepressant treatment are more slowly to antidepressant treatment are unsubstantiatedunsubstantiated12-1512-15

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Most Common Psychosocial Most Common Psychosocial Interventions for DepressionInterventions for Depression

Intervention Intervention Preferred TechniquesPreferred Techniques

PsychotherapyPsychotherapy Cognitive-behavioral therapyCognitive-behavioral therapy Interpersonal therapyInterpersonal therapy Problem-solving therapyProblem-solving therapy Supportive therapy Supportive therapy

PsychosocialPsychosocial

interventionintervention

Activities and exercise Activities and exercise Bereavement groupsBereavement groups Family counselingFamily counseling Participation in social eventsParticipation in social events PsychoeducationPsychoeducation Celebrate past and present positive life eventsCelebrate past and present positive life events

References: L. Volicer. Effects of Continuous Activity Program on Behavior Symptoms of Dementia. AMDA. Sept. 2006. 7: 426-431.M. Smith et. al. Beyond Bingo: Meaningful Activities for Persons with Dementia. Annals of Long-Term Care. July 2009.

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F329 - §483.25(l) Unnecessary DrugsF329 - §483.25(l) Unnecessary Drugs 1. General. Each resident’s drug regimen must be 1. General. Each resident’s drug regimen must be

free from unnecessary drugs.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 (v) In the presence of adverse consequences which indicate

the dose should be reduced or discontinued; orthe dose should be reduced or discontinued; or• (vi) Any combinations of the reasons above.(vi) Any combinations of the reasons above.

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Federal Regulations and Depression (F 329)Federal Regulations and Depression (F 329)

INTENT: §483.25(l) Unnecessary drugsINTENT: §483.25(l) Unnecessary drugs The intent of this requirement is that each resident’s entire The intent of this requirement is that each resident’s entire

drug/medication regimen be managed and monitored to achieve drug/medication regimen be managed and monitored to achieve the following goals:the following goals:

• The medication regimen helps promote or maintain the resident’s The medication regimen helps promote or maintain the resident’s highest practicable mental, physical, and psychosocial well-being, highest practicable mental, physical, and psychosocial well-being, as identified by the resident and/or representative(s) in collaboration as identified by the resident and/or representative(s) in collaboration with the attending physician and facility staff with the attending physician and facility staff

Risk/Benefit (Just document in progress note);Risk/Benefit (Just document in progress note); Pharmacists must notifyPharmacists must notify MD can ignoreMD can ignore

• Non-pharmacological interventions (such as behavioral Non-pharmacological interventions (such as behavioral interventions) are considered and used when indicated, instead of, interventions) are considered and used when indicated, instead of, or in addition to, medication;or in addition to, medication;

• Clinically significant adverse consequences are minimized; andClinically significant adverse consequences are minimized; and

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Determining the frequency of monitoring. The frequency and Determining the frequency of monitoring. The frequency and duration of monitoring needed to identify therapeutic duration of monitoring needed to identify therapeutic effectiveness and adverse consequences will depend on effectiveness and adverse consequences will depend on factors such as clinical standards of practice, facility policies factors such as clinical standards of practice, facility policies and procedures, manufacturer’s specifications, and the and procedures, manufacturer’s specifications, and the resident’s clinical conditionresident’s clinical condition

Monitoring involves three aspects:Monitoring involves three aspects:• Periodic planned evaluation of progress toward the therapeutic Periodic planned evaluation of progress toward the therapeutic

goals;goals;

• Continued vigilance for adverse consequences; andContinued vigilance for adverse consequences; and

• Evaluation of identified adverse consequenceEvaluation of identified adverse consequence

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Tapering of a Medication Dose/Gradual Dose Tapering of a Medication Dose/Gradual Dose Reduction (GDR)Reduction (GDR)

There are various opportunities during the care process to There are various opportunities during the care process to evaluate the effects of medications on a resident’s function and evaluate the effects of medications on a resident’s function and behavior, and to consider whether the medications should be behavior, and to consider whether the medications should be continued, reduced, discontinued, or otherwise modifiedcontinued, reduced, discontinued, or otherwise modified

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For any individual who is receiving an antipsychotic For any individual who is receiving an antipsychotic medication to treat a psychiatric disorder other than medication to treat a psychiatric disorder other than behavioral symptoms related to dementia (for example, behavioral symptoms related to dementia (for example, depression with psychotic features), the GDR may be depression with psychotic features), the GDR may be considered contraindicated, if:considered contraindicated, if:

The continued use is in accordance with relevant current standards of The continued use is in accordance with relevant current standards of practice and the physician has documented the clinical rationale for why practice and the physician has documented the clinical rationale for why any attempted dose reduction would be likely to impair the resident’s any attempted dose reduction would be likely to impair the resident’s function or cause psychiatric instability by exacerbating an underlying function or cause psychiatric instability by exacerbating an underlying psychiatric disorder; orpsychiatric disorder; or

The resident’s target symptoms returned or worsened after the most The resident’s target symptoms returned or worsened after the most recent attempt at a GDR within the facility and the physician has recent attempt at a GDR within the facility and the physician has documented the clinical rationale for why any additional attempted dose documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident’s function or reduction at that time would be likely to impair the resident’s function or cause psychiatric instability by exacerbating an underlying medical or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorderpsychiatric disorder

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F 329F 329AntidepressantsAntidepressants All antidepressants classes, All antidepressants classes,

e.g.,e.g., Alpha - adrenoceptor Alpha - adrenoceptor

antagonist, e.g., mirtazapineantagonist, e.g., mirtazapine Dopamine-reuptake blocking Dopamine-reuptake blocking

compounds, e.g., bupropioncompounds, e.g., bupropion Monoamine oxidase inhibitors Monoamine oxidase inhibitors

(MAOIs)(MAOIs) Serotonin (5-HT 2) Serotonin (5-HT 2)

antagonists, e.g., nefazodone, antagonists, e.g., nefazodone, trazodonetrazodone

Selective Selective serotoninnorepinephrine serotoninnorepinephrine reuptake inhibitors (SNRIs), reuptake inhibitors (SNRIs), e.g., duloxetine, venlafaxinee.g., duloxetine, venlafaxine

IndicationsIndications Agents usually classified as Agents usually classified as

“antidepressants” are prescribed “antidepressants” are prescribed for conditions other than for conditions other than depression including anxiety depression including anxiety disorders, post-traumatic stress disorders, post-traumatic stress disorder, obsessive compulsive disorder, obsessive compulsive disorder, insomnia, neuropathic disorder, insomnia, neuropathic pain (e.g., diabetic peripheral pain (e.g., diabetic peripheral neuropathy), migraine headaches, neuropathy), migraine headaches, urinary incontinence, and othersurinary incontinence, and others

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F 329F 329

AntidepressantsAntidepressants

Selective serotonin reuptake Selective serotonin reuptake inhibitors (SSRIs), e.g., inhibitors (SSRIs), e.g., citalopram, escitalopram, citalopram, escitalopram, fluoxetine, fluvoxamine, fluoxetine, fluvoxamine, paroxetine, sertralineparoxetine, sertraline

Tricyclic (TCA) and related Tricyclic (TCA) and related compoundscompounds

DosageDosage

Use of two or more Use of two or more antidepressants antidepressants simultaneously may increase simultaneously may increase risk of side effects; in such risk of side effects; in such cases, there should be cases, there should be documentation of expected documentation of expected benefits that outweigh the benefits that outweigh the associated risks and associated risks and monitoring for any increase in monitoring for any increase in side effectsside effects

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F 329F 329DurationDuration Duration should be in accordance with pertinent literature, including clinical Duration should be in accordance with pertinent literature, including clinical

practice guidelinespractice guidelines Prior to discontinuation, many antidepressants may need a gradual dose Prior to discontinuation, many antidepressants may need a gradual dose

reduction or tapering to avoid a withdrawal syndrome (e.g., SSRIs, TCAs)reduction or tapering to avoid a withdrawal syndrome (e.g., SSRIs, TCAs) If used to manage behavior, stabilize mood, or treat a psychiatric disorder, If used to manage behavior, stabilize mood, or treat a psychiatric disorder,

refer to Section V –Tapering of a Medication Dose/Gradual Dose Reduction refer to Section V –Tapering of a Medication Dose/Gradual Dose Reduction (GDR) in the guidance(GDR) in the guidance

MonitoringMonitoring All residents being treated for depression with any antidepressant should be All residents being treated for depression with any antidepressant should be

monitored closely for worsening of depression and/or suicidal behavior or monitored closely for worsening of depression and/or suicidal behavior or thinking, especially during initiation of therapy and during any change in thinking, especially during initiation of therapy and during any change in dosage dosage

Weekly for 1-3 months and quarterly thereafter (Do Not give 3 month Weekly for 1-3 months and quarterly thereafter (Do Not give 3 month prescription if requested by PBM - Pharmacy Benefit Manager)prescription if requested by PBM - Pharmacy Benefit Manager)

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F 329F 329

Interactions/Adverse Consequences/Positive BenefitsInteractions/Adverse Consequences/Positive Benefits May cause dizziness, nausea, diarrhea, anxiety, nervousness, May cause dizziness, nausea, diarrhea, anxiety, nervousness,

insomnia, somnolence, weight gain, anorexia, or increased appetite. insomnia, somnolence, weight gain, anorexia, or increased appetite. Many of these effects can increase the risk for fallsMany of these effects can increase the risk for falls

Bupropion may increase seizure risk and be associated with Bupropion may increase seizure risk and be associated with seizures in susceptible individualsseizures in susceptible individuals

SSRIs in combination with other medications affecting serotonin SSRIs in combination with other medications affecting serotonin (e.g., tramadol, St. John’s Wort, linezolid, other SSRI’s) may (e.g., tramadol, St. John’s Wort, linezolid, other SSRI’s) may increase the risk for serotonin syndrome and seizuresincrease the risk for serotonin syndrome and seizures

Augmentation with Buspirone, Aripiprazole, or Lithium – limited Augmentation with Buspirone, Aripiprazole, or Lithium – limited benefits in 4-6 weeksbenefits in 4-6 weeks

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F 329F 329

AntidepressantsAntidepressants Monoamine oxidase inhibitors Monoamine oxidase inhibitors

(MAOIs), e.g., isocarboxazid, (MAOIs), e.g., isocarboxazid, phenelzine, tranylcyprominephenelzine, tranylcypromine

Indications/ContraindicationsIndications/Contraindications Should not be administered to Should not be administered to

anyone with a confirmed or anyone with a confirmed or suspected cerebrovascular defect suspected cerebrovascular defect or to anyone with confirmed or to anyone with confirmed cardiovascular disease or cardiovascular disease or hypertensionhypertension

Should not be used in the presence Should not be used in the presence

of pheochromocytomaof pheochromocytoma

MAO Inhibitors are rarely utilized MAO Inhibitors are rarely utilized due to their potential interactions due to their potential interactions with tyramine or with tyramine or tryptophancontaining foods, other tryptophancontaining foods, other medications, and their profound medications, and their profound effect on blood pressureeffect on blood pressure

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F 329F 329

MAOIs (cont.)MAOIs (cont.)

Adverse ConsequencesAdverse Consequences May cause hypertensive crisis if combined with certain foods, May cause hypertensive crisis if combined with certain foods,

cheese, winecheese, wine Exception: Monoamine oxidase inhibitors such as selegiline Exception: Monoamine oxidase inhibitors such as selegiline

(MAO-B inhibitors) utilized for Parkinson’s Disease, unless used (MAO-B inhibitors) utilized for Parkinson’s Disease, unless used in doses greater than 10 mg per dayin doses greater than 10 mg per day

InteractionsInteractions Should not be administered together or in rapid succession with Should not be administered together or in rapid succession with

other MAO inhibitors, tricyclic antidepressants, bupropion, SSRIs, other MAO inhibitors, tricyclic antidepressants, bupropion, SSRIs, buspirone, sympathomimetics, meperidine, triptans, and other buspirone, sympathomimetics, meperidine, triptans, and other medications that affect serotonin or norepinephrinemedications that affect serotonin or norepinephrine

5252

F 329F 329AntidepressantsAntidepressants Tricyclic antidepressants Tricyclic antidepressants

(TCAs), e.g., amitriptyline, (TCAs), e.g., amitriptyline, amoxapine, doxepin, amoxapine, doxepin, arrhythmias (low doses are arrhythmias (low doses are appropriate for pain – Less appropriate for pain – Less than 25mg)than 25mg)

Combination products, e.g., Combination products, e.g., amitriptyline and amitriptyline and chlordiazepoxide, amitripytline chlordiazepoxide, amitripytline and perphenazineand perphenazine

IndicationsIndications TCAs and combination TCAs and combination

products are rarely the products are rarely the medication of choice in older medication of choice in older individualsindividuals

Adverse ConsequencesAdverse Consequences Compared to other categories Compared to other categories

of antidepressants, TCAs of antidepressants, TCAs cause significant cause significant anticholinergic side effects and anticholinergic side effects and sedation (nortriptyline and sedation (nortriptyline and desipramine are less desipramine are less problematic)problematic)

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MonitoringMonitoring

Monitoring is the fourth phase of the care Monitoring is the fourth phase of the care processprocess ““MonitoringMonitoring” means reviewing the course of a ” means reviewing the course of a

condition or situation as the basis for deciding to condition or situation as the basis for deciding to continue, change, or stop interventionscontinue, change, or stop interventions

5454

MonitoringMonitoring

Monitor the patient’s response to Monitor the patient’s response to treatment for depressiontreatment for depression Goals of treatment may include, but need not be Goals of treatment may include, but need not be

limited to, the following: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 Improvement in attendance at and participation in usual

activitiesactivities• Improvement in sleep patternImprovement in sleep pattern

5555

Pharmacotherapy ConsiderationsPharmacotherapy Considerations

Pharmacokinetics and Drug InteractionsPharmacokinetics and Drug Interactions Pharmacokinetic differences among older patients produce Pharmacokinetic differences among older patients produce

differing drug concentrations than in younger and healthier differing drug concentrations than in younger and healthier groupsgroups

Patients taking multiple drugs are at risk for drug-drug Patients taking multiple drugs are at risk for drug-drug interactions and subsequent adverse events. 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 patient’s other May be necessary to adjust doses of a patient’s other medications medications

5656


Treatment StrategiesTreatment Strategies No single class of antidepressant has been found to be more No single class of antidepressant has been found to be more

effective than another in the acute treatment of late-life effective than another in the acute treatment of late-life depression, however side effects vary.depression, however side effects vary.

Therapeutic drug-level monitoring maybe useful initially Therapeutic drug-level monitoring maybe useful initially depending on the agent used (tricyclic)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 depressive symptoms do not respond to treatment or when

adverse side effects of treatment are apparentadverse side effects of treatment are apparent

5757


Tricyclic tertiary amines at therapeutic doses frequently Tricyclic tertiary amines at therapeutic doses frequently are not tolerated in the LTC populationare not tolerated in the LTC population

Monoamine oxidase inhibitors are not acceptable first-Monoamine oxidase inhibitors are not acceptable first-

line drugs in the LTC settingline drugs in the LTC setting

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Drug Drug ClassClass

Preferred AgentsPreferred Agents Alternate Alternate AgentsAgents

Not RecommendedNot Recommended

SSRIsSSRIs CitalopramCitalopram EscitalopramEscitalopram MirtazapineMirtazapine ParoxetineParoxetine SertralineSertraline Venlafaxine XR/ DuloxatineVenlafaxine XR/ Duloxatine

BupropionBupropion FluoxetineFluoxetine

NefazodoneNefazodone TrazodoneTrazodone

TCAsTCAs DesipramineDesipramine NortriptylineNortriptyline

AmitriptylineAmitriptyline AmoxapineAmoxapine DoxepinDoxepin ImipramineImipramine IsocarboxazidIsocarboxazid MaprotilineMaprotiline TranylcypromineTranylcypromine

CHOICE OF ANTIDEPRESSANTCHOICE OF ANTIDEPRESSANT 3

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AntidepressantAntidepressantAverage Average

Starting Dose Starting Dose (mg/day)(mg/day)

Average Target Average Target Dose After Dose After

6 Weeks 6 Weeks (mg/day)(mg/day)

Usual Final Acute Usual Final Acute Dose (mg/day)Dose (mg/day)

Bupropion SRBupropion SR 100100 150 – 300150 – 300 300 – 400300 – 400

CitalopramCitalopram 10 – 2010 – 20 20 – 3020 – 30 30 – 4030 – 40

DesipramineDesipramine 10 – 4010 – 40 50 – 10050 – 100 100 – 150100 – 150

EscitalopramEscitalopram 1010 1010 10 – 2010 – 20

FluoxetineFluoxetine 1010 2020 20 – 4020 – 40

FluvoxamineFluvoxamine 25 – 5025 – 50 50 – 20050 – 200 100 – 300100 – 300

MirtazapineMirtazapine 7.5 – 157.5 – 15 15 – 3015 – 30 30 – 4530 – 45

NortriptylineNortriptyline 10 – 3010 – 30 40 – 10040 – 100 75 – 12575 – 125

ParoxetineParoxetine 10 – 2010 – 20 20 – 3020 – 30 30 – 4030 – 40

SertralineSertraline 25 – 5025 – 50 50 – 10050 – 100 100 – 200100 – 200

Venlafaxine XRVenlafaxine XR 25 – 7525 – 75 75 – 20075 – 200 150 – 300150 – 300

Doses of Antidepressants That Are Likely to be AdequateDoses of Antidepressants That Are Likely to be Adequate33

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Preferred Treatment OptionPreferred Treatment Option Other Options Other Options That May Be That May Be ConsideredConsidered

Psychosocial Psychosocial interventionsinterventions

Caregiver-focused treatmentCaregiver-focused treatment Supportive psychotherapySupportive psychotherapy

Pharmacologic Pharmacologic treatmenttreatment

Medication alone (citalopram, Medication alone (citalopram, escitalopram, sertraline, venlafaxine escitalopram, sertraline, venlafaxine XR)XR) Medication plus psychosocial Medication plus psychosocial interventionintervention Cholinesterase inhibitorCholinesterase inhibitor

Bupropion SRBupropion SR MirtazapineMirtazapine ParoxetineParoxetine

Treatment of Depression That Coexists with Mild to Moderate Treatment of Depression That Coexists with Mild to Moderate DementiaDementia

6161

SummarySummary

Depressive symptoms are:Depressive symptoms are: common among older adultscommon among older adults can have a major effect on their quality of lifecan have a major effect on their quality of life

Accurate diagnosis of depression is importantAccurate diagnosis of depression is important

Depression usually responds to treatment with Depression usually responds to treatment with

psychotherapy, medications, or a combination of the twopsychotherapy, medications, or a combination of the two

Treatment options should be consistent with the patient’s Treatment options should be consistent with the patient’s and family’s wishes and advanced directivesand family’s wishes and advanced directives

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Case Study:Case Study:

In this example, a 65-year old woman spends most of In this example, a 65-year old woman spends most of her day either asleep or awake and developed a habit of her day either asleep or awake and developed a habit of leaving her room at night.leaving her room at night. Possible interventions:Possible interventions:

Dimming a light in her room rather than leaving it on (the light Dimming a light in her room rather than leaving it on (the light was left on for safety reasons)was left on for safety reasons)

Having a caregiver walk with her and then guiding her back Having a caregiver walk with her and then guiding her back to bedto bed

Limiting naps to 30 minutesLimiting naps to 30 minutes Offering her warm milk or soothing snacks prior to going to Offering her warm milk or soothing snacks prior to going to

bedbed

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Case Study:Case Study:Wrong Psychotherapy and Right PsychotropicsWrong Psychotherapy and Right Psychotropics

Mrs. Jones is a 75 y. female with chronic anxiety and long 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 history of physical abuse as a child and as an adult. She was recently married for 4 years. Because of increasing anxiety, recently married for 4 years. Because of increasing anxiety, depression and acrophobia she was disabled and admitted herself depression and acrophobia she was disabled and admitted herself to a nursing home. She was in psychotherapy for 6 months with to a nursing home. She was in psychotherapy for 6 months with benefits but suddenly became increasingly critical of nursing benefits but suddenly became increasingly critical of nursing staff and uncooperative with treatment as discharge was planned. staff and uncooperative with treatment as discharge was planned. MMSE confirmed that her cognitive function was intact. After MMSE confirmed that her cognitive function was intact. After the therapist began to explore a history of sexual abuse, she the therapist began to explore a history of sexual abuse, she became uncooperative.became uncooperative.

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Outcomes of this Case Study:Outcomes of this Case Study:

Wrong Psychotherapy and Right PsychotropicsWrong Psychotherapy and Right Psychotropics Talking about past abuse was too painful and she preferred to focus on the Talking about past abuse was too painful and she preferred to focus on the

present.present.

The therapist was encouraged to be more reality oriented and supportive, The therapist was encouraged to be more reality oriented and supportive, so she was.so she was.

She suddenly left, after refusing medication for two weeks and was She suddenly left, after refusing medication for two weeks and was readmitted 6 months later due to depression and impulsively divorcing her readmitted 6 months later due to depression and impulsively divorcing her husband.husband.

Mrs. Jones said that she had life-long paranoia, which was hidden by Mrs. Jones said that she had life-long paranoia, which was hidden by obsessive compulsive symptoms and acrophobia.obsessive compulsive symptoms and acrophobia.

She was given depakote and her paranoia and anxiety reduced to levels that She was given depakote and her paranoia and anxiety reduced to levels that were tolerable.were tolerable.

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Case Study:Case Study:Depression, Dementia, and Psychosocial IssuesDepression, Dementia, and Psychosocial Issues

Carlos was a 72 year-old Mexican American who was admitted Carlos was a 72 year-old Mexican American who was admitted for dementia 3 years after his wife passed away. He was friendly for dementia 3 years after his wife passed away. He was friendly and adjusted well. The family was extremely attentive and guilty and adjusted well. The family was extremely attentive and guilty that they could not managed him at home, as was the custom in that they could not managed him at home, as was the custom in their culture. Each family took turns initially on weekends their culture. Each family took turns initially on weekends visiting or taking him home for a few hours. After several visiting or taking him home for a few hours. After several months, the visits and outings gradually and unpredictably months, the visits and outings gradually and unpredictably decreased. Carlos was reported to have increasing isolation, decreased. Carlos was reported to have increasing isolation, which escalated to disruptive behavior and sleep problems. I was which escalated to disruptive behavior and sleep problems. I was consulted after 3 months of increasing dysfunctional behavior consulted after 3 months of increasing dysfunctional behavior because of sexually inappropriate behavior with other patients because of sexually inappropriate behavior with other patients and staff that led to a state site visit.and staff that led to a state site visit.

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Outcomes of this Case Study:Outcomes of this Case Study: Depression, Dementia, and Psychosocial IssuesDepression, Dementia, and Psychosocial Issues

Carlos denied any knowledge of events and denied any symptoms, which Carlos denied any knowledge of events and denied any symptoms, which resulted in the initiation of Lexapro and Aricept.resulted in the initiation of Lexapro and Aricept.

A family conference was held with the weekend nursing staff and they A family conference was held with the weekend nursing staff and they stopped their flirtatious behavior, separated Carlos from the females, and stopped their flirtatious behavior, separated Carlos from the females, and now must confirm passes when they are scheduled.now must confirm passes when they are scheduled.

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

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Case Study:Case Study:Is there a Psychiatrist in the House?Is there a Psychiatrist in the House?

I had been consulting with the Nursing Home, Happy Springs, I had been consulting with the Nursing Home, Happy Springs, sporadically for several years. After several emergency sporadically for several years. After several emergency consultations and the patient eloping, I had a conference with the consultations and the patient eloping, I had a conference with the new DON, Administrator, and Social Worker about the new DON, Administrator, and Social Worker about the evaluation of evolving psychiatric behavior problems. They said evaluation of evolving psychiatric behavior problems. They said they did not admit patients with mental health problems because they did not admit patients with mental health problems because most of the problems were resolved, initially, after treatment with most of the problems were resolved, initially, after treatment with Xanax, PRN, or Benadryl for sleep. Because the census was low, Xanax, PRN, or Benadryl for sleep. Because the census was low, they wanted help with patients who had psychiatric problems. they wanted help with patients who had psychiatric problems. The DON believed that senior citizens had a right to be depressed The DON believed that senior citizens had a right to be depressed and would be overmedicated if seen by a psychiatrist and the and would be overmedicated if seen by a psychiatrist and the Social Worker discouraged psychotherapy consults because she Social Worker discouraged psychotherapy consults because she thought she would not be needed if outside therapists started thought she would not be needed if outside therapists started seeing the residents.seeing the residents.

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Nonpharmalogic Treatments for Nonpharmalogic Treatments for Depression in DementiaDepression in Dementia

Emotion-Oriented TherapiesEmotion-Oriented Therapies

Brief PsychotherapiesBrief Psychotherapies

Sensory Stimulation TherapiesSensory 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: 1524-7929, Vol. 17. Feb. 01, 2009.

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Emotion-Oriented TherapiesEmotion-Oriented Therapies

Validation TherapyValidation Therapy

Simulated Presence TherapySimulated Presence Therapy


7070

Brief PsychotherapiesBrief Psychotherapies

Cognitive Behavioral TherapiesCognitive Behavioral Therapies

Earlier Stages of Cognitive DeclineEarlier Stages of Cognitive Decline

Problem Solving TherapyProblem Solving Therapy


7171

Sensory Stimulation TherapySensory Stimulation Therapy

Art/Music TherapyArt/Music Therapy

AromatherapyAromatherapy

Animal-Assisted/Pet TherapyAnimal-Assisted/Pet Therapy

Activity TherapiesActivity Therapies

Massage/Touch TherapiesMassage/Touch Therapies

Multisensory ApproachesMultisensory Approaches


7272

Activity TherapiesActivity Therapies

Reports from these therapies have been very Reports from these therapies have been very positivepositive

Include things such as:Include things such as: Recreational activitiesRecreational activities Physical activity programs (improve mood)Physical activity programs (improve mood)


7373

Massage/Touch TherapiesMassage/Touch Therapies

Even though evidence is limited, it still supports the use Even though evidence is limited, it still supports the use of massage and touch interventions for anxiety in of massage and touch interventions for anxiety in dementia.dementia.

Touch massages have been found to temporarily relieve Touch massages have been found to temporarily relieve agitated behavior for a short period of timeagitated behavior for a short period of time


7474

Multisensory ApproachesMultisensory Approaches

Effective in reducing apathy in dementia according to the Effective in reducing apathy in dementia according to the Snoezelen/Multisensory StimulationSnoezelen/Multisensory Stimulation

Types:Types: LightLight TextureTexture SmellSmell SoundSound


7575

Nonpharmacologic InterventionsNonpharmacologic Interventions

Have potential for successful treatment of Have potential for successful treatment of depression in dementiadepression in dementia

Types:Types: Emotion-Oriented TherapiesEmotion-Oriented Therapies Behavioral Modification ProgramsBehavioral Modification Programs Cognitive-Behavioral ProgramsCognitive-Behavioral Programs Structured Activity ProgramsStructured Activity Programs


7676

Clinical InvestigationClinical Investigation

Objectives:Objectives: Examine the prevalence, correlates, and medication Examine the prevalence, correlates, and medication

management of behavioral symptoms in elderly people living in residential management of behavioral symptoms in elderly people living in residential care/assisted living (RC/AL) facilitiescare/assisted living (RC/AL) facilities

Design:Design: Cross-Sectional StudyCross-Sectional Study

Settings:Settings: Random sample of RC/AL facilities in four states (Florida, Random sample of RC/AL facilities in four states (Florida,

Maryland, New Jersey, North Carolina)Maryland, New Jersey, North Carolina)

Participants:Participants: Total of 2078 RC/AL residents 65 and olderTotal of 2078 RC/AL residents 65 and older

Measurement:Measurement: Behavioral symptoms were classified using modified Behavioral symptoms were classified using modified

version of the Cohen-Mansfield Agitation Inventoryversion 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 2004. Vol. 52: 1610-1617,

7777

ResultsResults Approximately 34% exhibited one or more behavioral symptoms, once a Approximately 34% exhibited one or more behavioral symptoms, once a

weekweek

13% show aggressive behavioral symptoms13% show aggressive behavioral symptoms

20% demonstrated physically nonaggressive behavioral symptoms20% demonstrated physically nonaggressive behavioral symptoms

22% expressed verbal behavioral symptoms22% expressed verbal behavioral symptoms

13% resisted taking medications or activities of daily living care13% resisted taking medications or activities of daily living care

More than 50% of RC/AL residents were on psychotropic medicationsMore than 50% of RC/AL residents were on psychotropic medications

Two-thirds had some mental health problem indicator, such as dementia Two-thirds had some mental health problem indicator, such as dementia depression, psychosis, or other psychiatric illnesses.depression, psychosis, or other psychiatric illnesses.


7878

ConclusionsConclusions

Integrating mental health services within the Integrating mental health services within the process of care in RC/AL is needed to manage process of care in RC/AL is needed to manage and accommodate the high prevalence of and accommodate the high prevalence of behavioral symptoms in this evolving long-term behavioral symptoms in this evolving long-term settingsetting


7979

Clinical and Research News: Many Assisted-Living Residents Clinical and Research News: Many Assisted-Living Residents Not Getting Depression Help Not Getting Depression Help

Clinical Study: Duke University Medical Center – Lea Watson, MDClinical Study: Duke University Medical Center – Lea Watson, MD

Cornell Scale for Depression and Dementia was the main test used Cornell Scale for Depression and Dementia was the main test used to measure physical and mental healthto 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 713% of all subjects in this study had a score of greater than 7

At least a quarter of all subjects showed symptoms of depression, At least a quarter of all subjects showed symptoms of depression, such as sadness, tearfulness, worrying, or irritabilitysuch as sadness, tearfulness, worrying, or irritability

However, only 18% were diagnosed as being clinically depressedHowever, only 18% were diagnosed as being clinically depressed

Only 38% of patients with severe depression, a score of more than Only 38% of patients with severe depression, a score of more than 12, were on antidepressants12, were on antidepressants

Lea Watson commented that her next phase of work will directly Lea Watson commented that her next phase of work will directly focus on depression in assisted-living facilitiesfocus on depression in assisted-living facilities

8080

Study: When Should a Patient Discontinue Treatment Study: When Should a Patient Discontinue Treatment for Elderly Depression?for Elderly Depression?

Address the risks and benefits of treating a patient with Address the risks and benefits of treating a patient with antidepressants when they have only experienced one episode of antidepressants when they have only experienced one episode of major depression in their life.major depression in their life.

The norm among experts has become treating a depressed elderly The norm among experts has become treating a depressed elderly person until they have fully recovered.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 Most geriatric psychiatrists would not think that a 70 year-old or older patient with one incidence of depression would receive long-older patient with one incidence of depression would receive long-term treatment of up to 2 years.” Charles F. Reynolds term treatment of up to 2 years.” Charles F. Reynolds IIIIII, MD, MD

Most psychiatrists agree that the elderly with two or more episodes Most psychiatrists agree that the elderly with two or more episodes should be appropriately prescribed maintenance treatment.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 2004. Vol. 52: 1610-1617,

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Contraindications to Tapering and GDRContraindications 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 Antipsychotic medications for psychiatric disorders that do not include

behavioral symptoms related to dementiabehavioral symptoms related to dementia• Psychopharmacological medicationsPsychopharmacological medications

Including antidementia agents and antidepressantsIncluding antidementia agents and antidepressants• Sedative/hypnoticsSedative/hypnotics

GDR can be considered contraindicated (GDR can be considered contraindicated (without and failing first)without and failing first) if if continued use: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

8282

Recurrence and Residual Symptoms in Recurrence and Residual Symptoms in Geriatric DepressionGeriatric Depression

Recurrence rates of 50% - 90% over 2-3 yearsRecurrence rates of 50% - 90% over 2-3 years

Lower remission rates in geriatric depressionLower remission rates in geriatric depression

After 6-month remission, 20%-30% retain residual symptomsAfter 6-month remission, 20%-30% retain residual symptoms

• Greater distress and disabilityGreater distress and disability

Higher relapse rates in elderly patients compared to younger Higher relapse rates in elderly patients compared to younger patientspatients

• Maintenance therapy is importantMaintenance therapy is important

8383

Empirically Supported PsychotherapiesEmpirically Supported Psychotherapies

Cognitive Behavioral Cognitive Behavioral Therapy (CBT)Therapy (CBT)

Identify and modify negative Identify and modify negative beliefs and negative beliefs and negative interpretations of the past, interpretations of the past, present and futurepresent and future

Includes:Includes:• EducationEducation• Symptom and stress Symptom and stress

management strategiesmanagement strategies• Desensitization to feared Desensitization to feared

stimulistimuli• Cognitive challenges to Cognitive challenges to

change beliefschange beliefs

Interpersonal Therapy Interpersonal Therapy (IPT)(IPT)

Focuses on 4 types of Focuses on 4 types of interpersonal problem interpersonal problem categories viewed as causes categories viewed as causes of depressionof depression

• Grief and morningGrief and morning• Interpersonal disputesInterpersonal disputes• Role transitionsRole transitions• Social skill deficitsSocial skill deficits

depression clinical practice guideline

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