role of medications, therapy and education in the treatment of mood disorders of nursing homes jules...
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Role of Medications, Therapy and Education in the Treatment
of Mood Disorders of Nursing Homes
Jules Rosen M.D.
Professor, Psychiatry and Katz Graduate School of Business
University of Pittsburgh
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Disclosure
Financial interest in Fox Learning Systems, Inc.
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Goals
Understand the characteristics of late-life depression
Understand role of medications and therapy in treatment
Understand that depression in LTC may look different than in community
Role of environment critical in both causing depression and treating depression in LTC
New “f-tag” – Unnecessary Medications
Specific “milieu-oriented” therapy can be powerful
Understand the importance of staff education in depression recognition and treatment
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Mood Disorders of Late-life in Longterm Care
Phenomenology
Evidence for Continuum
Mood Disorder
Major Depressive Episode
Minor Depression
Dysthymia
Clinical Course Treatment Response
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Major Vs. Minor Depression Vs. Dysthymia
Major Depression
2 weeks duration
Depressed mood or loss of interest
5 of 9 symptoms
Significant distress or impaired functioning
Minor Depression
2 weeks duration
Depressed mood or loss of interest
2–4 of 9 symptoms
Significant distress or impaired functioning
Dysthymic Disorder
2 years duration
Depressed mood
2 of 6 symptoms
Significant distress or impaired functioning
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Prevalence of Depression
Community elders: 3-5% with major depression 8-15% with minor depression
Primary Care 5-10% with major depression 10-20% with minor depression
Nursing Homes 10-15% with major depression 25 – 40% with minor depression
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Biological Nonpsychiatric physical
illness Gene polymorphisms
ClinicalSymptom severityLifetime age of onsetComorbid anxiety Cognitive impairment
Psychosocial –Intrapersonal
Demographics Personality disorder Traits and dispositions
Psychosociall Environmental –
Social supports
Perceived chronic stress
Life events/acute stress
Physical environment
Nested Potential Predictors of Treatment Response in Late Life Depression
The
DepressedOlderAdult
Biological
ClinicalPsychosocial – Intrapersonal
Psychosocial – Environmental
Courtesy, Mary Amanda Dew, Ph.D.
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Presentations Depression
Somatic Presentation
Anxiety Symptoms
Associated with Medical Illness
Associated with Social Stressors of Nursing Home Placement
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Why to they complain “I’m Sick”
Infection Loss of interest Loss of pleasure Low energy, fatigue Negative mood
(irritable) Excessive sleep Loss of appetite
Depression Loss of interest Loss of pleasure Low energy, fatigue Negative mood
(irritable) Excessive or too little
sleep Loss of appetite
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3 Yr. incidence of most common complaints in primary care settings (Kromke et al. Am J Med 1989)
Chest pain
fatigue
dizziness
headache
edema
back pain
dyspnea
insomnia
abd. pain
numbness
0
1
2
3
4
5
6
7
8
9
10
3 yr
. in
cid
ence
%
cause unknowncause known
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Predictors of Somatic Worry (Lyness et al, 1993
Variable (N=91) P <Age 0.0005Education 0.0003Hamilton Depression Score 0.0002Gender NSCumulative illness Rating NSKarnofsky Perfomance NS
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Treatment of Depression
Pharmacological Approach Essential in community and primary care settings Minimal data of effectiveness in nursing homes Will discuss UNIQUE aspects of nursing home
depression Non-pharmacological Approach
Few standardized randomized trials Psychotherapy may be extremely helpful Staff approach depends on understanding UNIQUE
characteristics of nursing home depression “Control-relevant” intervention Staff Education is Key
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Late-life Depression in Community
Prognosis poor if untreated 20-40% of older depressed patients are well
at one to five years of follow-up
Acute treatment: all classes of meds effective
Rates of remission: 27 to 78% with longer studies resulting in higher rates (8-12 weeks)
Maintenance and continuation tx: dose that gets them well, keeps them well
Treating to complete remission is best protection from recurrence or chronicity
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Proportion of partial and non-responders at weeks 4 to 10 classified as full responders after additional weeks of treatment
Mulsant et al., J Clin Psychopharmacology, 26(2):113-120, 2006
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195
N=78 nonresponders N=28 responders who relapsed
N=89 responders with no relapse
Received Augmentation
Received Augmentation
Recovered n=24
Did not n=24
Did not/ Terminated
n=11
Recovered n=78
Did not n=7
Recovered n=14
n=48 n=21
Does Pharmacotherapy Augmentation Work
in Late-Life Depression?
50.0% vs. 66.7% vs. 87.6%
chi squared (df = 1) = 23.20, p < .001
Dew MA, Reynolds CF et al., Am J of Psychiatry, 2007
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Even “Old Old” with Depression Respond to Treatment
Week from treatment start
0 2 4 6 8 10 12 14 16
HR
S-1
7 T
otal
0
2
4
6
8
10
12
14
16
18
20
22
24
59-69 (N=163)70-75 (N=80)76-95 (N=80)
Gildengers et al. J Affect Disord, 69(1-3):177-184, 2002
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Preventing Recurrence of Depression Reynolds et al 2006
Randomized, controlled trial of elderly patients with major depression who had had a response to initial treatment with paroxetine and interpersonal psychotherapy
Mean age: 77; 60% were first episode; 65% female
Relapse Rates Medication plus therapy: 35% Medication plus supportive visits:37% Placebo meds plus therapy: 68% Placebo meds plus supportive visits: 58%
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Time to Recurrence from Randomization: MTLD-II
Reynolds, Dew, Pollock, et al. N Engl J Med, 354(11):1130-1138, 2006
Weeks since randomization
0 10 20 30 40 50 60 70 80 90 100 110 120
% f
ree
fro
m r
ecu
rre
nce
0.0
0.2
0.4
0.6
0.8
1.0
Paroxetine + IPT (n=28)Paroxetine + Clinical Management (n=35)IPT + Placebo (n=35)Clinical Management + Placebo (n=18)
Log rank X2=9.77, df=3, p=.0206
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Factors Contributing to Relapsing, Chronic Illness Course in Late-Life Depression
Psychosocial factors: Role transitions, bereavement, increasing
dependency, interpersonal conflicts Progressive depletion of psychosocial and economic
resources
Chronic sleep disturbances
Cerebrovascular disease
Neurodegenerative disorders
Limited access to adequate treatment
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Nortriptyline: Standard vs. low dose in nursing home residents
Streim et al: Am J Geriatr Psychiatry 8:2, 2000
>12 on HDRS
Significant dysphoria
Blessed Information- Memory-Concen. < 18
Randomized (2:1) to standard or low dose, stratified by cognitive status
10 weeks of treatment
Low dose: 10 - 13 mg./day
Standard: 60 - 80 mg. / day
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Results N = 69, Completers: Standard: 25, low: 16
Drop-out rate: similar
Both groups responded (p<0.001), no difference between groups
Interaction between dose and cognitive status Cog. Intact: better on standard dose Cog. Impaired: better on low dose
plasma levels similar for both cognitive groups, suggesting pharmaco-dynamic effect
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Treatment of Minor Depression in Long-Term Care with Paroxetine
(Burrows, et al; 2002)
8-week placebo controlled trial
24 patients randomized with no dementia or mild dementia
No difference between placebo and medication!!!
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“Politics” of Medication Treatment
The Quality Indicators required documentation of “Depression without antidepressants” until recently
NOW: CMS’ State Operating Manual (SOM) identify anti-depressants as medications requiring GDR (gradual dose reduction)!
Although data does not support all nursing home residents benefit from medications, residents with history of depression should not be subjected to GDR.
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Why do pharmacological studies fail in Nursing Homes?
Depression in nursing homes differ than in community Psychosocial losses Medical burden Loss of control
Measurement of depression in NH may be different than depression in the community HDRS and GDS focus on mood and health NH should focus on QoL.
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“Therapy” in Long-Term Care
Therapy “Treatment of illness or disability”
Nursing home residents have the lack of ability to create their own socialization program or seek pleasurable activities.
Goal is to create “therapy” that addresses this disability
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Control-Relevant Intervention:Goals of Nursing Home Therapy
Reduce stressors Loss of control Temporal variability Hopelessness
Develop relationships
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Control-Relevant Intervention
Socialization Designed by residents, based on prior
interests Participation, duration and frequency
determined by resident
Structured rating instruments
Global assessment of nursing staff
Raters and clinical staff blind to level of participation
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Methods
Cognitive ability (MMSE > 18)
3 months residency
SCID DX: MDE (mild-to-moderate severity) Subsyndromal depression: sad mood or
marked apathy and two symptoms Dysthymia or other mild depressive states
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Intervention
Coordinated by recreation therapist
1 to 2 hours 4 or 5 days/week
Initial week: small groups, lead by therapist
Week 2–7: increasing autonomy of group Lunch, cards, outside trips, board games
Final week: review progress and discuss strategy for continuation
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Methods
Pre-intervention rating
2-month intervention
Post-intervention rating
Follow-up rating 2 months after termination
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Results
“responders” identified at end of active study period
Two primary caregivers had to concur that patient was significantly improved (vs. some improvement, no improvement, or worse).
45% were significantly improved
After intervention stopped, all responders relapsed.
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Responders vs. Non-Responders
Responders
More compliant with treatment – refusal rate of 11.2%
Perceived environment as less “cohesive” prior to intervention
Improved perception of “cohesiveness”
Non - Responders
Less compliant with treatment – refusal rate of 28% (P <0.01)
No change in perception of cohesion
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Role of Education in LTC
12 hours required by OBRA guidelines
Some mandatories
Poor monitoring of compliance
Little monitoring of competency
No standardization of quality of education
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Coordinators of education
DON or Education Director
Human Resources Director
Survey of DON’s in California Most feel unprepared for all aspects of job Psychosocial and behavioral are weakest
areas (Soecklin et al. Annals of LTC 1998; 6:122-129)
In Minnesota, 60% provide little or no education in depression / psychiatric problems (Grant LA et al. J Gerontol. Nurs. 2000; 1:9-16)
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CNA perception of training (Mercer et al. J Gerontol. Social Work: 1993; 21:95-112)
(Cohn et al. J. of Long-Term Care Administration 1987; 20-25)
Boring
Repetitive
Punitive
Lacking in relevance to job
Little training in depression and dementia
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Examples of Research on Staff EducationCohn; J. of Gerontological Nursing; 1990
Five mandatory 90-minute sessions over 5 months
Each session presented 4-5 times over 2 days
Advanced degree nurses with special skills
60% of CNAs attended 4 of the 5 sessions
Enhanced knowledge
Enhanced self-reported job performance
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Examples of Research on Staff EducationBrooks; J of AMDA; 2000; 191-196
Comparison of lecture and videotape in-service for CNAs: 3 facilities
Compliance with single inservice: 27%
Both methods showed improved knowledge immediately
4 months later; knowledge was WORSE than earlier pre-test
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Annual Costs (& hidden costs) of Education
(estimates based on market surveys)
Expenses Low end ($) High end ($)
Coordinator of Education 15,000 50,000
Educational materials 1500 4000
Outside consultants 500 3000
Overtime 2000 8000
Total 19,000 65,000
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Computer-based interactive video
Solutions for Longterm Care by Fox Learning Systems Created with NIHM funding Uses television documentary approach with
interactive video REAL LIFE, REAL LEARNING
Available to all staff on all shifts individually or in groups
Brings experts to each facility
Administrative Software Schedules all staff for training Maintains record of training completed and
competency scores
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Clinical Curriculum
Normal Aging
Understanding Depression
Behavioral Treatment of Depression
Understanding Dementia and Alzheimer’s Disease
Working with Dementia
Agitation and Aggression
Communication / The MDS
Medications
Residents’ Rights and Abuse
Restraints / Falls
Skin care / Pressure Ulcers
Fire / Disaster preparedness
Pain Assessment and Management
Universal Precautions and Infection Prevention
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Safety Curriculum
Ergonomics & Proper Body Mechanics
Manual Resident Transfers
Mechanical Resident Transfers
Preventing Slips, Trips, and Falls
Safely Caring for Aggressive Residents
Transitional Return to Work
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Short form Series for CNAs (57 topics): Mental Health Topics
THE AGING PROCESS Physical Changes of Aging Emotional and Cognitive Changes
of Aging
DEPRESSION Caring for the Elderly with
Depression Depression: Recognizing the Signs
and Symptoms Assessing and Preventing Suicide
in the Elderly Depression and Failure to Thrive Depression and Resistance to care
DEMENTIA
Understanding Dementia
The Effects of Dementia on the Brain
The Art of Dementia Caregiving
External Causes of Agitation
Internal Forces of Agitation
Dementia Care: Bathing and Showering
MEDICATIONS
Introduction to Medications for the Elderly
Psychiatric Medications
OBRA Medication Guidelines
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Compliance with Training at Computer-site vs. Lecture-site
Each site received one training module / month
Participation required
Lecture: Live lecture + 2 video sessions
Computer: All personnel scheduled according to shift primary and secondary
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Compliance with training at computer and lecture sites (CNA and Others)
0
10
20
30
40
50
60
70
% of Staff
Computer Site Lecture Site
ComputerCNAComputerother
LectureCNALectureOther
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Satisfaction with Training
0
10
20
30
40
50
60
70
80
90
100
Very Much Some What Not At AllResponse
Per
cent
age
of R
espo
nder
s
Computer Site
Lecture Site
%
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Conclusion
Depression comes in various forms in elders in longterm care
Treatment involves medications and therapy INTEGRATION OF FAMILY AND STAFF IN PSYCHOSOCIAL
INTERVENTIONS ACTIVITIES BASED THERAPIES
UNDERSTAND ROLE OF STAFF EDUCATION
Gradual Dose Reduction should NOT be attempted in residents with history of major depression unless medically indicated
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Contact Information
Jules Rosen MD, Professor of Psychiatry
University of Pittsburgh
[email protected]; (412) 246 5900
Fox Learning Systems, Inc.
www.foxlearningsystems.com
(412) 531 1889
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“It is not enough to add years to one’s life…one must also add life to those years”