Download Role of Medications, Therapy and Education in the Treatment of

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
Disclosure
 Financial interest in Fox Learning Systems, Inc.
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
Mood Disorders of Late-life in Longterm
Care
Evidence for Continuum
Mood Disorder
Major Depressive
Episode
Phenomenology
Minor
Depression
Clinical Course
Dysthymia
Treatment Response
Major Vs. Minor Depression Vs. Dysthymia
Major Depression
Minor Depression
Dysthymic Disorder
 2 weeks
 2 weeks
 2 years duration
duration
duration
 Depressed
 Depressed
mood or loss
of interest
 5 of 9
mood or loss of
interest
 2–4 of 9
symptoms
symptoms
 Significant
 Significant
distress or
impaired
functioning
distress or
impaired
functioning
 Depressed mood
 2 of 6 symptoms
 Significant
distress or
impaired
functioning
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
Nested Potential Predictors of Treatment Response
in Late Life Depression
Clinical
Biological


Nonpsychiatric physical
illness
Gene polymorphisms




Symptom severity
Lifetime age of onset
Comorbid anxiety
Cognitive impairment
The
Depressed
Older
Adult
Biological



Psychosocial –
Intrapersonal
Demographics
Personality disorder
Traits and dispositions
Clinical
Psychosocial –
Intrapersonal
Psychosocial –
Environmental
Courtesy, Mary Amanda Dew, Ph.D.
Environmental –
Psychosociall

Social supports

Perceived chronic stress
Life events/acute stress

Physical environment
Presentations Depression
 Somatic Presentation
 Anxiety Symptoms
 Associated with Medical Illness
 Associated with Social Stressors of Nursing
Home Placement
Why to they complain “I’m Sick”
 Infection
 Depression
 Loss of interest
 Loss of interest
 Loss of pleasure
 Loss of pleasure
 Low energy, fatigue
 Low energy, fatigue
 Negative mood
 Negative mood
(irritable)
 Excessive sleep
 Loss of appetite
(irritable)
 Excessive or too little
sleep
 Loss of appetite
3 Yr. incidence of most common complaints in primary care settings
(Kromke et al.
Am J Med 1989)
cause unknown
cause known
10
3 yr. incidence %
numbness
0
abd. pain
1
insomnia
2
dyspnea
3
back pain
4
edema
5
headache
6
dizziness
7
fatigue
8
Chest pain
9
Predictors
of Somatic Worry
(Lyness et al, 1993
Variable (N=91)
P<
Age
Education
Hamilton Depression Score
Gender
Cumulative illness Rating
Karnofsky Perfomance
0.0005
0.0003
0.0002
NS
NS
NS
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
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
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
Does Pharmacotherapy Augmentation Work
in Late-Life Depression?
195
N=78 nonresponders
N=89 responders
with no relapse
Received
Augmentation
Received
Augmentation
n=48
n=21
Recovered Did not
n=24
n=24
50.0%
N=28 responders
who relapsed
Recovered Did not
n=14
n=7
vs.
66.7%
Recovered
n=78
vs.
Did not/
Terminated
n=11
87.6%
chi squared (df = 1) = 23.20, p < .001
Dew MA, Reynolds CF et al., Am J of Psychiatry, 2007
Even “Old Old” with Depression Respond
to Treatment
24
22
59-69 (N=163)
70-75 (N=80)
76-95 (N=80)
20
18
HRS-17 Total
16
14
12
10
8
6
4
2
0
0
2
4
6
8
10
12
14
Week from treatment start
Gildengers et al. J Affect Disord, 69(1-3):177-184, 2002
16
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%
Time to Recurrence from Randomization:
MTLD-II
Log rank X2=9.77, df=3, p=.0206
1.0
% free from recurrence
0.8
0.6
0.4
Paroxetine + IPT (n=28)
Paroxetine + Clinical Management (n=35)
IPT + Placebo (n=35)
Clinical Management + Placebo (n=18)
0.2
0.0
0
10
20
30
40
50
60
70
80
90
100
110
120
Weeks since randomization
Reynolds, Dew, Pollock, et al. N Engl J Med, 354(11):1130-1138, 2006
Factors Contributing to Relapsing, Chronic Illness Course in LateLife 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
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
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
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!!!
“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.
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.
“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
Control-Relevant Intervention:
Goals of Nursing Home Therapy
 Reduce stressors
 Loss of control
 Temporal variability
 Hopelessness
 Develop relationships
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
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
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
Methods
 Pre-intervention rating
 2-month intervention
 Post-intervention rating
 Follow-up rating
 2 months after termination
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.
Responders vs. Non-Responders
Responders
Non - Responders
 More compliant with
 Less compliant with
treatment – refusal
rate of 11.2%
 Perceived
environment as less
“cohesive” prior to
intervention
 Improved perception
of “cohesiveness”
treatment – refusal
rate of 28% (P <0.01)
 No change in
perception of cohesion
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
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)
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
Examples of Research on Staff Education
Cohn; 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
Examples of Research on Staff Education
Brooks; 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
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
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
Clinical Curriculum
 Normal Aging
 Medications
 Understanding Depression
 Residents’ Rights and
 Behavioral Treatment of
Depression
 Understanding Dementia
and Alzheimer’s Disease
 Working with Dementia
 Agitation and Aggression
 Communication / The MDS
Abuse
 Restraints / Falls
 Skin care / Pressure Ulcers
 Fire / Disaster preparedness
 Pain Assessment and
Management
 Universal Precautions and
Infection Prevention
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
Short form Series for CNAs (57 topics):
Mental Health Topics
THE AGING PROCESS
DEMENTIA

Physical Changes of Aging

Understanding Dementia

Emotional and Cognitive Changes
of Aging

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
DEPRESSION

Caring for the Elderly with
Depression

Depression: Recognizing the Signs
and Symptoms


Assessing and Preventing Suicide
in the Elderly
MEDICATIONS

Depression and Failure to Thrive


Depression and Resistance to care
Introduction to Medications for the
Elderly

Psychiatric Medications

OBRA Medication Guidelines
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
Compliance with training at computer and
lecture sites (CNA and Others)
70
Computer
CNA
Computer
other
60
50
% 40
of Staff 30
Lecture
CNA
Lecture
Other
20
10
0
Computer Site
Lecture Site
Satisfaction with Training
100
90
Percentage of Responders
80
Computer Site
%
Lecture Site
70
60
50
40
30
20
10
0
Very Much
Some
What
Response
Not At All
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
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
“It is not enough to add
years to one’s life…one
must also add life to
those years”