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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 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”