Download Tool on Depression Assessment for Older Adults

Tool on
Depression:
Assessment
and Treatment
For Older Adults
CANADIAN COALITION FOR
SENIORS’ MENTAL HEALTH
To promote seniors’ mental health by connecting people, ideas and resources
COALITION CANADIENNE POUR LA SANTÉ
MENTALE DES PERSONNES ÂGÉES
Promouvoir la santé mentale des personnes agées en
reliant les personnes, les idées et les ressource
Reality: Defining Seniors’ Mental Health
•
•
•
•
•
•
•
Mood Disorders
Anxiety Disorders
Dementia – Alzheimer’s Disease
Personality Disorders
Concurrent Disorders
Schizophrenia; Autism
Suicidal Behaviour
Mental Illness is NOT a normal
consequence of aging!
•
•
•
•
Depression: 14.7% – 20% in the community
LTC: 80 - 90% of residents
Alzheimer’s: 1 in 3 over 85
Delirium
up to 50%
• Suicide:
Suicide rate for older Canadian men nearly 2x that of
the nation as a whole
Mental Illness is NOT a normal
consequence of aging!
•
•
•
•
•
•
•
Major Depression 2-4%
Depressive symptoms 14 – 20%
Schizophrenia 0.5%
Dementia 8% (rising to 34% in those >85)
Paranoid thoughts: 10%
Anxiety Disorders: 19%
Alcohol dependence 1-3%
(problem drinking 4-23%)
Who should be screened for depression?
•
•
•
•
•
•
•
•
•
•
•
Recently bereaved with symptoms 3-6 months after the loss
Socially isolated
Persistent complaints of memory difficulties
Chronic disabilities
Recent major illness (e.g., within 3 months)
Persistent sleep difficulties
Somatic concerns or anxiety
Refusal to eat or neglect of personal care
Recurrent or prolonged hospitalization
Diagnosis of dementia, Parkinson’s
Recent placement in a nursing/LTC home
Recommended Screening Tools
for Depression
Health care providers should have knowledge and
skills in the application of age-appropriate
screening and assessment tools for depression in
older adults.
Screening Tools for Depression
Without significant cognitive impairment in general
medical or geriatric settings include:
• Geriatric Depression Scale (GDS)
• SELFCARE
• Brief Assessment Schedule Depression Cards
(BASDEC) for hospitalized patients.
Moderate to severe cognitive impairment:
• Cornell Scale for Depression in Dementia
Are my older patients at higher
risk of depression? (laminate)
Risk factors:
• socially isolated
•
•
•
•
persistent complaints of memory difficulties
chronic disabling illness
major physical illness within the last 3 months
persistent sleep difficulties
• somatic concerns or recent-onset anxiety
• refusal to eat or neglect of personal care
• recurrent or prolonged hospitalization
• diagnosis of dementia, Parkinson’s disease, or stroke
• recent placement in a nursing/LTC home
Continued
If your patient is recently bereaved:
•
•
•
•
•
•
active suicidal ideation
guilt not related to the deceased
psychomotor retardation
mood congruent delusions
marked functional impairment (2 months after loss)
reaction that seems out of proportion to the loss
Tool development on
Depression
Assessment
For Older Adults
Developed by NICE Mental Health Team
Part 1:
RISK, SCREENING
Part 1: Risk Screening
1 IS MY PATIENT AT RISK FOR DEPRESSION?
National Guidelines for Seniors Mental Health: Part 2: 2.1.1
PREDISPOSING FACTORS
• Female
• Widowed or divorced
• Previous depression history
• Brain changes due to vascular problems
• Major physical and chronic disabling illnesses
• Medications or Polypharmacy
• Excessive alcohol use
• Social disadvantage & low social support
• Caregiver for person with a major disease (e.g.,dementia)
• Personality type (e.g., relationship or dependence problems)
PRECIPITATING FACTORS
• Recent bereavement
• Move from home to other places (e.g., nursing home)
• Adverse life events (e.g., losses, separation, financial crisis)
• Chronic stress with declining health, family or marital problems
• Social isolation
• Persistent sleep difficulties
2 RECOMMENDED ASSESSMENT OPTIONS
National Guidelines for Seniors Mental Health: Part 2: 2.1.2
A structured interview using one of the following tools:
TOOLS DEVELOPED TO REFLECT DEPRESSION OLDER ADULTS WITH AVAILABLE
WEBSITES
In general medical practice, nursing/residential homes or inpatient settings
• SIG E CAPS(http://webmedia.unmc.edu/intmed/geriatics/reynolds/pearlcards/depression/depressionindex.htm)
• The Geriatric Depression Scale
(http://www.stanford.edu/~yesavage/GDS.html)
• Brief Assessment Schedule for the Elderly (BASDEC)
(http://www.medalreg.com/www/sheets/ch18/depression%20Koenig%20scale.xls)
In community surveys
• Center for Epidemiological Studies – Depression Scale
• The Geriatric Mental State Schedule (GMSS)
For depression in the presence of dementia or significant cognitive difficulties
• The Cornell Scale for Depression in Dementia
(http://www.emoryhealthcare.org/departments/fuqua/CornellScale.pdf )
3 DIAGNOSTIC CRITERIA
National Guidelines for Seniors Mental Health: Part 2: 2.2
DIAGNOSTIC CRITERIA FOR DEPRESSION - DSM 1+V )
A cluster of symptoms present on most days, most of the
time, for at least 2 weeks
• Depressed mood
• Loss of interest or pleasure in normal, previously enjoyed activities
• Decreased energy and increased fatigue
• Sleep disturbance
• Inappropriate feelings of guilt
• Diminished ability to think or concentrate
• Appetite change (i.e., usually loss of appetite in the elderly)
• Psychomotor agitation or retardation
• Suicidal ideation or recurrent thoughts of death
DSM IV-TR CLASSIFICATION (APA, 2000)
Make a clear DSM-IV diagnosis & document
Different types of depressive disorders
• Major depressive episodes
(i.e., part of unipolar, bipolar mood disorder or secondary to
a medical condition)
• Dysthymic disorder
• Depressive disorders not otherwise specified:
A group of disorders including minor depressive
disorder, post psychotic depressive disorder of
schizophrenia and depressive disorders of unclear
etiology (e.g., may be primary or secondary to a
medical condition or substance induced)
4 SUICIDE RISK
National Guidelines for Seniors Mental Health: Part 2: 2.1
Non-modifiable risk factors
• Old age
• Male gender
• Being widowed or divorced
• Previous attempt at self-harm
• Losses (e.g., health status, role, independence,
significant relations)
Potentially modifiable risk factors
• Social isolation
• Presence of chronic pain
• Abuse/misuse of alcohol or other medications
• Presence & severity of depression
• Presence of hopelessness and suicidal ideation
• Access to means, especially firearms
Behaviors to alert clinicians to potential suicide
• Agitation
• Giving personal possessions away
• Reviewing one’s will
• Increase in alcohol use
• Non-compliance with medical treatment
• Taking unnecessary risk
• Preoccupation with death
Part 2:
WHEN TO TREAT, REFER, &
MONITORING & LONG TERM
TREATMENT
Commonly-used Antidepressant MedicationsNational Guidelines for Seniors Mental Health: Part 5
Generic
Name
Trade
Name
Starting dose
mg/day
Average
Dose
Maximum
recommended
dose (CPS)
Comments/Caution
SSRI
Citalopram
Celexa
10
20-40
40 mg
Escitalopram Cipralex
5
10-20
20 mg
Sertraline
25
50-150
200 mg
Zoloft
Other Agents
Buproprion
Wellbutrin 100
100 mg BID 150 mg BID
Mirtazapine
Remeron
15
30-45
Moclobemide Manerix
150
150-300 BID 300 mg BID
Venlafaxine
37.5
75-225
Effexor
45 mg
*375 mg
Tricyclic Antidepressants
Desipramine
Norpramin 10-25
50-150
300 mg
Nortriptyline
Aventyl
40-100
200 mg
10-25
May cause seizures
Do not combine with MAO-B
inhibitors or Tricyclics
*For severe depression; May
increase blood pressure
Anticholinergic properties
cardiovascular side-effects;
Monitor blood levels
Anticholinergic properties;
cardiovascular side-effects;
Monitor blood levels
5 WHEN TO TREAT
National Guidelines for Seniors Mental Health: Part 2: 2.1.1
Following a positive screen for depression a complete bio-psycho-social
assessment should be conducted including:
• A review of diagnostic criteria in the DSM 1V-TR or ICD 10 manuals
• An estimate of severity, including presence of psychotic or catatonic symptoms
• Risk of suicide, by directly asking patients about suicidal ideation, intent and plan
• Personal or family history of mood disorder
• Medication use and substance abuse
• Review of current stressors and life situation
• Level of functioning/disability
• Family situation, social integration/support
• Mental status exam, plus assessment of cognitive function
• Physical exam and lab tests to determine if medical issues contribute or mimic
depressive symptoms
Treatment can be divided into 3 main phases
• Acute treatment phase: to achieve remission of symptoms
• Continuation phase: to prevent recurrence or relapse of same episode of illness
• Maintenance or prophylaxis phase: to prevent future episodes or recurrence
6 GUIDELINES FOR TREATMENT
National Guidelines for Seniors Mental Health: Part 4 & 5
Psychotherapies & Psychosocial Interventions
• Supportive care should be offered to all patients who are depressed
• Psychotherapy is a first line of treatment or in combination with antidepressant medication
• Based on type of depression, coping style, level of cognitive functioning
• Psychotherapy – provided by trained mental health professionals
Pharmacological Treatment
• Medications are used in combination with psychosocial or psychotherapy treatments
• Part of overall treatment of depressed older adults
• See table for commonly used antidepressants
• See full guideline for details of prescribing and monitoring
7 WHEN TO REFER
National Guidelines for Seniors Mental Health: Part 3: 3.5
Recommendations for clinicians to refer for Psychiatric Care at Time of Diagnosis
• Psychotic depression
• Bipolar disorder
• Depression with suicidal ideation
8 MONITORING AND LONG TERM TREATEMENT
National Guidelines for Seniors Mental Health: Part 6: 3
Health care providers should monitor the older adult for
re-occurrence of depression for the first 2 years after treatment
• Ongoing monitoring should focus on depressive symptoms present
during initial episode
• Older adults in remission of their first episode should be treated for
a minimum of one year and up to 2 years from time of improvement
• Older adults with recurrent episodes should receive indefinite
maintenance therapy
• In LTC homes, response to therapy should be evaluated monthly
after initial improvement and then every three months, as well as
annual assessment after remission of symptoms
NICE – Mental Health Team
Depression Assessment Tool,
Evaluation
Evaluation Outline
1.
Case Description (stakeholder consultation and tool development process)






How many stakeholders were consulted?
What disciplines / health care sectors / organizations were represented?
What is the geographical representation of stakeholders?
How were stakeholders recruited?
Describe process of consultation (i.e., teleconference calls, material distribution, survey monkey etc.).
Describe limitations.
2.
Knowledge Transfer Survey




To be collected at 3 weeks and 3 months post workshop session
Offered in both paper and survey monkey form
Phone call reminders
Consent form
3.
In-depth Qualitative Interviews


Conducted 3 months after workshop – focus group or individual interviews depending on scenario
(tape recorded / transcribed)
Consent form
4.
Evaluation of Workshop Sessions

To be distributed and collected at end of each session
5.
Analysis – mid April – mid-May
6.
Report- June 2008 NICE Conference
www.nicenet.ca
Disclaimer: This tool is intended for information purposes only and is not intended
to be interpreted or used as a standard of medical/health practice.
CANADIAN COALITION FOR
SENIORS’ MENTAL HEALTH
To promote seniors’ mental health by connecting people, ideas and resources
COALITION CANADIENNE POUR LA SANTÉ
MENTALE DES PERSONNES ÂGÉES
Promouvoir la santé mentale des personnes agées en
reliant les personnes, les idées et les ressource
www.ccsmh.ca