Download Depression - Alzheimers Is Not Waiting

Depression
Clinical Practice Guideline
1
Disclosures
2
Learning Objectives
3
Depression
 Depression
is a spectrum of mood
disorders characterized by a sustained
disturbance in emotional, cognitive,
behavioral, or somatic regulation and
associated with significant functional
impairment and a reduction in the capacity
for pleasure and enjoyment.
4
Introduction

Maintain a high index of suspicion for the
presence of depression or depressive symptoms
in long term care (LTC) patients

Late-life depression may be overlooked or
inadequately treated
5
Introduction

The relationship between medical conditions
and depression is complex

Depression may exacerbate coexisting medical
illness

Some medications may cause or contribute to
depression
6
Federal Regulations and Depression

F157-§483.10(b)(11) -- Notification of changes

(i) A facility must immediately inform the resident;
consult with the resident’s physician; and if known,
notify the resident’s legal representative or an
interested family member when there is:
• (B) A significant change in the resident’s physical, mental, or
psychosocial status (i.e., a deterioration in health, mental, or
psychosocial status in either life-threatening conditions or
clinical complications)

For purposes of §483.10(b)(11)(i)(B), Clinical complications are
such things as … or onset of depression
7
Federal Regulations and Depression

F250-§483.15(g)(1) The facility must provide
medically-related social services to attain or
maintain the highest practicable physical,
mental, and psychosocial well-being of each
resident

“Medically-related social services” means services
provided by the facility’s staff to assist residents in
maintaining or improving their ability to manage their
everyday physical, mental, and psychosocial needs
• Types of conditions to which the facility should respond with
social services by staff or referral include:

Depression
8
Federal Regulations and Depression
 EATING-§483.25(a)(1)(iv)

If the resident’s eating abilities have declined,
is there any evidence that the decline was
unavoidable?
1. What risk factors for decline of eating skills did the
facility identify?

d. Depression or confused mental state is responsible for
50% or eating problems or weight loss in Seniors
9
Federal Regulations and Depression

42 CFR 483.25(f)(1)&(2), F319, F320, Mental
and Psychosocial Functioning

Surveyors are instructed to review whether the facility had
identified, evaluated, and responded to a change in behavior
and/or psychosocial changes, including depression
10
Recognition

Recognition is the first stage of the care process
 Recognition” means identifying the presence of a
risk or condition

How: PHQ-2 shows that only 14-25% of
residents in LTC have depression


Caregivers identify depression poorly
The PHQ-2 identifies 85% of patients with depression
Reference: Practical Depression Screening in Residential Care. Am. J. Geriatrics Psychiatry. 17:7. July 2009. 556-564
11
Recognition

Does the patient have a history of depression or
a positive depression screening test?



Review available transfer information, referral data and
patient and family history
Look for history of depression, psychiatric disorder(s),
treatment of hospitalization
Document the presence of these conditions in the medical
record
12
Recognition




Depression is common among patients in the LTC
setting
Treatment is effective
Adopt a policy encouraging formal screening of all
patients for depression
Appropriate screening tools include:





Geriatric Depression Scale
Cornell Scale for Depression in Dementia
Center for Epidemiologic Studies of Depression Scale
Patient Health Questionnaire 9
Clinical Interview


Do you feel life is worth living?
What makes you happy?
13
Recognition

Does the patient have signs or symptoms of
depression?


Nursing staff are in a good position to recognize signs
and symptoms (S&S) of depression (Behavior – not
subjective)
Look for S&S in RAI. MDS, RAPs, progress notes,
family interaction notes
14
Symptoms Of Depression 3
Most
important
Depressed
Important
Difficulty
Sometimes
helpful
Appetite
mood most of the day, almost every day (by either subjective
report or observation made by others , Diminished interest or pleasure in
most activities, most of the time, Thoughts of death or suicide.
making decisions, Feelings of helplessness, Feelings of
worthlessness or hopelessness, Inappropriate feelings of guilt,
Psychomotor agitation or retardation not attributable to other causes, Social
withdrawal, avoidance of social interactions, going out, activities and/or
participation
change, Change in ability to think or concentrate, Change in
activities of daily living (ADLs), Family history of mood disorders, Fatigue or
loss of energy, worse than baseline, Insomnia or hypersomnia nearly every
day. Increased complaints of pain, Preoccupation with poor health or
physical limitations, Weight loss or gain.
 Sleep problems occur in 40%-68% of all patients, with only 19%
documented
Reference: Sleep: A Marker of Physical and Mental Health in the Elderly. Am. J. Geriatric Psychiatry. 14:16. 860-866. Oct. 2006
15
Recognition

Does the patient have risk factors for
depression?

Evaluate for risk factors
• If risk factors are present, develop an interdisciplinary (IDT)
care plan
• If no risk factors are found, monitor periodically (every 3
months)
16
Some Risk Factors for Depression










Alcohol or substance abuse
Current use of a medication associated with a high risk of
depression
Hearing or vision impairment severe enough to affect function – 30%
increase rate of depression
History of attempted suicide
History of psychiatric hospitalization
Medical diagnosis or diagnoses associated with a high risk of
depression
New admission or change in environment
New stressful losses, including loss of autonomy, loss of privacy,
loss of functional status, loss of body part, or loss of family member,
friend or pet
Personal or family history of depression or mood disorder
Personality Anxiety Disorder – Sleep problem (day time)
17
Assessment
 Assessment
is the second stage of the
care process

“Assessment” means clarifying the nature
and causes of a condition or situation and
identifying its impact on the individual
18
Assessment

Has the patient had a persistently depressed
mood or loss of interest or pleasure for at least 2
weeks?




Has depressed mood (dysphoria) or loss of interest or pleasure
(anhedonia) been present for at least 2 weeks; and
has dysphoria or anhedonia contributed to the patient’s
functional or social impairment or decline
Is substance abuse or bereavement not present
Personality Disorder
• Personality traits influence clinical outcomes in a day hospital
Reference: Treatment of Elderly Depressed Patients. Am. J. Geriatric Psychiatry. 17. 335-344. April 2009.
19
Assessment

Is it appropriate to perform a medical work-up for
factors contributing to signs and symptoms of
possible depression?

Will depend upon:
•
•
•
•
patient’s condition
prognosis
advance care directives
expressed preferences of the patient or family
20
Laboratory Tests For Evaluating
Possible Depression3
Preferred Tests
Other Tests That May Be
Considered
Chemistry profile (electrolytes,
 Electrocardiogram
blood urea nitrogen, creatinine,
 Folate level
glucose)
 Serum calcium level
 Complete blood count
 Serum level of digoxin or
 Serum levels of anticonvulsant
theophylline, if taking either
or tricyclic antidepressant, if taking medication
either type of medication
 Urinalysis
 Thyroid function (T3, T4, TSH)
 Vitamin B12 level

21
Assessment

Is the patient taking medications that might
cause or contribute to depression?
• Many medications can affect:



mood
affect
level of consciousness
22
Medications That May Cause
Symptoms of Depression

Alpha-methyl dopa
 Anabolic steroids
 Anti-arrhythmic
medications
 Anticonvulsant
medications
 Antidementia
 Barbiturates
 Benzodiazepines (i.e.,
long acting)

Carbidopa or levodopa
 Certain beta-adrenergic
antagonists (propranolol)
 Clonidine
 Cytokines (specifically IL2)
 Digitalis preparations
 Glucocorticoids
 H2 blockers
 Metoclopramide
 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.
23
Assessment

Does the patient have one or more conditions
that may increase the likelihood of depression or
that may cause depressive symptoms
24
Important Comorbid Conditions*

Most important






Alcohol dependency
Cerebrovascular
diseases
Medications that can
cause mood disorders
Neurodegenerative
disorders (e.g.,
Alzheimer’s disease,
Parkinson’s disease,
multiple sclerosis)
Substance abuse
Sleep apnea (40%-60%
of patients with
dementia)

Important















Cancer
Chronic obstructive pulmonary disorder
Chronic pain
Congestive heart failure
Coronary artery disease
Diabetes
Electrolyte imbalance
Endocrine disorders (thyroid)
Head trauma
Metabolic problems
Myocardial infarction
Orthostatic hypotension
Physical, verbal, emotional abuse
Schizophrenia
Anxiety
*Reference: Is a Medical Illness Causing your Patients Depression. Current Psychiatry. 8. 2009. 43-54.
25
Assessment
 Do
the patient’s signs and symptoms
resolve with treatment of comorbid
condition(s)?



Take appropriate action if medical diagnoses or conditions are
suspected of contributing to depressive symptoms
When depression and a medical condition coexist, both
conditions are likely to require treatment
To the extent possible, address underlying causes and evaluate
the impact of such measures
26
Assessment

Clarify the diagnosis

The DSM-IV defines the following types of depressive
disorders:
•
•
•
•
•
Mild episode of major depression
Moderate episode of major depression
Severe episode of major depression
Severe episode of major depression with psychotic features
Minor depression disorder – 80% convert to MDD (Major
Depression Disorder)
• Bipolar type II
• Dysthymic disorder
• Adjustment disorder with depressed mood or with mixed
anxiety and depressed mood
27
Major Depression
Depressed
Mood
+
4 symptoms
x
2 weeks
•Weight loss or gain
•Insomnia or hypersomnia
•Psychomotor retardation
•Agitation (irritability, anxiety, fatigue)
•Decreased energy
•Guilt feelings
•Inability to concentrate
•Thoughts of death or suicide (life
not worth living)
Loss of
interest or
pleasure
+
4 symptoms
x
2 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.
28
Rating Scales
 Use
at the beginning of treatment
 Only reliable way to obtain an objective
measure
 Essential to monitoring the effectiveness
of treatment




Geriatric Depression Scale (GDS)
Cornell Scale for Depression in Dementia (CSDD)
Center for Epidemiologic Studies of Depression Scale
(CES-D)
Patient Health Questionnaire 9 (PHQ-9)

Most reliable and efficient
29
Assessment

Does the situation warrant additional psychiatric
support?
• Depression is often managed readily by primary
care practitioners (80/20)
• Effective psychiatric support may not be readily
available in the LTC setting
• In some cases, however, psychiatric support is
helpful


25% improve with medication, while 58% improve with
counseling and medication
Post-stroke depression resolves in 6 months regardless
of treatment (20-40% have behavioral symptoms)
30
Assessment

Does the patient’s depression exhibit
complications that may pose a risk to the patient
or to others?


Determine if the patient is psychotic, severely
agitated, aggressive, neurovegetative, or suicidal
Suicide risk increases with the severity of depression
31
Treatment

Treatment is the third stage of the care process

“Treatment” means selecting and providing
appropriate interventions for that individual
32
Treatment

Depression usually responds to treatment with
psychotherapy, medications, or a combination of the
two
An effective individualized care plan includes both
nonpharmacologic and pharmacologic interventions


Pharmacologic:
1.

Antianxiety, antipsychotic, antidepressive and antidementia
Non-Pharmacologic (other psychotherapies):
Emotion-oriented, interpersonal therapy, sensory stimulation
therapy
2. Cognitive Behavioral Therapy (CBT) – (art, music, massage)
only in early stage, Problem Solving Therapy, Environmental
Activity – (exercise)
3. Supportive Therapies
1.
33
Phases of Depression Treatment3
Phase
Duration
Goal
Acute
Approx. 3 months
To achieve complete
recovery from signs and
symptoms of acute
depressive episode (i.e.,
remission)
Continuation
4-6 months
To prevent relapse as
patient’s depressive
symptoms continue to
decline and his or her
functionality improves
Maintenance
•
•
3 months or longer,
depending on patient’s needs
• Over the age of 70, usually
12-24 months or lifetime if
more than 2 episodes
To prevent recurrence of
a new depressive
episode
• Relapse occurs in 4060%
34
Treatment

Implement appropriate treatment for the patient’s
depression




Minimize institutional aspects of the environment
Facilitate interaction with family members and friends
Provide opportunities for spiritual activity (50% of LTC
residents have an interest)
Provide socialization interventions
35
Psychotherapy

Considerable advances have occurred

Both cognitive-behavioral therapy and learningbased therapy have a significant impact on
depression symptoms in older adults
36
Pharmacologic Treatment

All antidepressants approved by the U.S. Food
and Drug Administration have been shown to be
relatively safe in most populations

However, they are effective in some, but not all,
populations
37
Electroconvulsive Therapy (ECT)

(ECT) should be considered if:


The patient’s condition is rapidly deteriorating or,
If antidepressant medication is not tolerated or has
failed
•
•
•
Mild depression – failure of 4-6 antidepressants
Moderate depression – failure of 2-4 antidepressants
Sever depression – failure of 1-2 antidepressants or
suicidal risks
• 50% effective
• Transitional Stimulation (limited studies in seniors)
38
Assessing Treatment Response

Treatment response can vary widely among
depressed elderly patients

Patient response is generally not predictable
before the initiation of treatment

Beliefs that older patients in general respond
more slowly to antidepressant treatment are
unsubstantiated12-15
39
Most Common Psychosocial
Interventions for Depression
Intervention
Preferred Techniques
Cognitive-behavioral therapy
 Interpersonal therapy
 Problem-solving therapy
 Supportive therapy
Psychotherapy

Psychosocial
intervention

Activities and exercise
 Bereavement groups
 Family counseling
 Participation in social events
 Psychoeducation
 Celebrate 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.
40
Federal Regulations and Depression

F329 - §483.25(l) Unnecessary Drugs

1. General. Each resident’s drug regimen must be
free from unnecessary drugs.
•
•
•
•
•
•
An unnecessary drug is any drug when used:
(i) In excessive dose (including duplicate therapy); or
(ii) For excessive duration; or
(iii) Without adequate monitoring; or
(iv) Without adequate indications for its use; or
(v) In the presence of adverse consequences which indicate
the dose should be reduced or discontinued; or
• (vi) Any combinations of the reasons above.
41
Federal Regulations and Depression (F 329)

INTENT: §483.25(l) Unnecessary drugs

The intent of this requirement is that each resident’s entire
drug/medication regimen be managed and monitored to achieve
the following goals:
• The medication regimen helps promote or maintain the resident’s
highest practicable mental, physical, and psychosocial well-being,
as identified by the resident and/or representative(s) in collaboration
with the attending physician and facility staff

Risk/Benefit (Just document in progress note);
 Pharmacists must notify
 MD can ignore
• Non-pharmacological interventions (such as behavioral
interventions) are considered and used when indicated, instead of,
or in addition to, medication;
• Clinically significant adverse consequences are minimized; and
42
Federal Regulations and Depression (F 329)

Determining the frequency of monitoring. The frequency and
duration of monitoring needed to identify therapeutic
effectiveness and adverse consequences will depend on
factors such as clinical standards of practice, facility policies
and procedures, manufacturer’s specifications, and the
resident’s clinical condition

Monitoring involves three aspects:
• Periodic planned evaluation of progress toward the therapeutic
goals;
• Continued vigilance for adverse consequences; and
• Evaluation of identified adverse consequence
43
Federal Regulations and Depression (F 329)

Tapering of a Medication Dose/Gradual Dose
Reduction (GDR)

There are various opportunities during the care process to
evaluate the effects of medications on a resident’s function and
behavior, and to consider whether the medications should be
continued, reduced, discontinued, or otherwise modified
44
Federal Regulations and Depression (F 329)

For any individual who is receiving an antipsychotic
medication to treat a psychiatric disorder other than
behavioral symptoms related to dementia (for example,
depression with psychotic features), the GDR may be
considered contraindicated, if:


The continued use is in accordance with relevant current standards of
practice and the physician has documented the clinical rationale for why
any attempted dose reduction would be likely to impair the resident’s
function or cause psychiatric instability by exacerbating an underlying
psychiatric disorder; or
The resident’s target symptoms returned or worsened after the most
recent attempt at a GDR within the facility and the physician has
documented the clinical rationale for why any additional attempted dose
reduction at that time would be likely to impair the resident’s function or
cause psychiatric instability by exacerbating an underlying medical or
psychiatric disorder
45
F 329
Antidepressants






All antidepressants classes,
e.g.,
Alpha - adrenoceptor
antagonist, e.g., mirtazapine
Dopamine-reuptake blocking
compounds, e.g., bupropion
Monoamine oxidase inhibitors
(MAOIs)
Serotonin (5-HT 2)
antagonists, e.g., nefazodone,
trazodone
Selective
serotoninnorepinephrine
reuptake inhibitors (SNRIs),
e.g., duloxetine, venlafaxine
Indications

Agents usually classified as
“antidepressants” are prescribed
for conditions other than
depression including anxiety
disorders, post-traumatic stress
disorder, obsessive compulsive
disorder, insomnia, neuropathic
pain (e.g., diabetic peripheral
neuropathy), migraine headaches,
urinary incontinence, and others
46
F 329
Antidepressants


Selective serotonin reuptake
inhibitors (SSRIs), e.g.,
citalopram, escitalopram,
fluoxetine, fluvoxamine,
paroxetine, sertraline
Tricyclic (TCA) and related
compounds
Dosage

Use of two or more
antidepressants
simultaneously may increase
risk of side effects; in such
cases, there should be
documentation of expected
benefits that outweigh the
associated risks and
monitoring for any increase in
side effects
47
F 329
Duration

Duration should be in accordance with pertinent literature, including clinical
practice guidelines
 Prior to discontinuation, many antidepressants may need a gradual dose
reduction or tapering to avoid a withdrawal syndrome (e.g., SSRIs, TCAs)
 If used to manage behavior, stabilize mood, or treat a psychiatric disorder,
refer to Section V –Tapering of a Medication Dose/Gradual Dose Reduction
(GDR) in the guidance
Monitoring

All residents being treated for depression with any antidepressant should be
monitored closely for worsening of depression and/or suicidal behavior or
thinking, especially during initiation of therapy and during any change in
dosage

Weekly for 1-3 months and quarterly thereafter (Do Not give 3 month
prescription if requested by PBM - Pharmacy Benefit Manager)
48
F 329
Interactions/Adverse Consequences/Positive Benefits




May cause dizziness, nausea, diarrhea, anxiety, nervousness,
insomnia, somnolence, weight gain, anorexia, or increased appetite.
Many of these effects can increase the risk for falls
Bupropion may increase seizure risk and be associated with
seizures in susceptible individuals
SSRIs in combination with other medications affecting serotonin
(e.g., tramadol, St. John’s Wort, linezolid, other SSRI’s) may
increase the risk for serotonin syndrome and seizures
Augmentation with Buspirone, Aripiprazole, or Lithium – limited
benefits in 4-6 weeks
49
F 329
Antidepressants

Monoamine oxidase inhibitors
(MAOIs), e.g., isocarboxazid,
phenelzine, tranylcypromine
Indications/Contraindications

Should not be administered to
anyone with a confirmed or
suspected cerebrovascular defect
or to anyone with confirmed
cardiovascular disease or
hypertension

Should not be used in the presence
of pheochromocytoma

MAO Inhibitors are rarely utilized
due to their potential interactions
with tyramine or
tryptophancontaining foods, other
medications, and their profound
effect on blood pressure
50
F 329
MAOIs (cont.)
Adverse Consequences

May cause hypertensive crisis if combined with certain foods,
cheese, wine

Exception: Monoamine oxidase inhibitors such as selegiline
(MAO-B inhibitors) utilized for Parkinson’s Disease, unless used
in doses greater than 10 mg per day
Interactions

Should not be administered together or in rapid succession with
other MAO inhibitors, tricyclic antidepressants, bupropion, SSRIs,
buspirone, sympathomimetics, meperidine, triptans, and other
medications that affect serotonin or norepinephrine
51
F 329
Antidepressants


Tricyclic antidepressants
(TCAs), e.g., amitriptyline,
amoxapine, doxepin,
arrhythmias (low doses are
appropriate for pain – Less
than 25mg)
Combination products, e.g.,
amitriptyline and
chlordiazepoxide, amitripytline
and perphenazine
Indications

TCAs and combination
products are rarely the
medication of choice in older
individuals
Adverse Consequences

Compared to other categories
of antidepressants, TCAs
cause significant
anticholinergic side effects and
sedation (nortriptyline and
desipramine are less
problematic)
52
Monitoring

Monitoring is the fourth phase of the care
process

“Monitoring” means reviewing the course of a
condition or situation as the basis for deciding to
continue, change, or stop interventions
53
Monitoring
 Monitor
the patient’s response to
treatment for depression

Goals of treatment may include, but need not be
limited to, the following:
• Resolution of signs and symptoms of depression
• Improvement of scores on the GDS, CSDD, or CES-D
• Improvement in attendance at and participation in usual
activities
• Improvement in sleep pattern
54
Pharmacotherapy Considerations

Pharmacokinetics and Drug Interactions




Pharmacokinetic differences among older patients produce
differing drug concentrations than in younger and healthier
groups
Patients taking multiple drugs are at risk for drug-drug
interactions and subsequent adverse events.
Most antidepressants are susceptible to drug interactions,
May be necessary to adjust doses of a patient’s other
medications
55
Pharmacotherapy Considerations

Treatment Strategies



No single class of antidepressant has been found to be more
effective than another in the acute treatment of late-life
depression, however side effects vary.
Therapeutic drug-level monitoring maybe useful initially
depending on the agent used (tricyclic)
Routine drug monitoring is not necessary except when:
• depressive symptoms do not respond to treatment or when
adverse side effects of treatment are apparent
56
Pharmacotherapy Considerations

Tricyclic tertiary amines at therapeutic doses frequently
are not tolerated in the LTC population

Monoamine oxidase inhibitors are not acceptable firstline drugs in the LTC setting
57
CHOICE OF ANTIDEPRESSANT 3
Drug
Class
Preferred Agents
Alternate
Agents
SSRIs


TCAs


Citalopram
 Escitalopram
 Mirtazapine
 Paroxetine
 Sertraline
 Venlafaxine XR/ Duloxatine
Desipramine
Nortriptyline
Not Recommended
Bupropion  Nefazodone
 Fluoxetine  Trazodone
 Amitriptyline
 Amoxapine
 Doxepin
 Imipramine
 Isocarboxazid
 Maprotiline
 Tranylcypromine
58
Doses of Antidepressants That Are Likely to be Adequate3
Average
Starting Dose
(mg/day)
Average Target
Dose After
6 Weeks
(mg/day)
Usual Final Acute
Dose (mg/day)
100
150 – 300
300 – 400
Citalopram
10 – 20
20 – 30
30 – 40
Desipramine
10 – 40
50 – 100
100 – 150
Escitalopram
10
10
10 – 20
Fluoxetine
10
20
20 – 40
Fluvoxamine
25 – 50
50 – 200
100 – 300
Mirtazapine
7.5 – 15
15 – 30
30 – 45
Nortriptyline
10 – 30
40 – 100
75 – 125
Paroxetine
10 – 20
20 – 30
30 – 40
Sertraline
25 – 50
50 – 100
100 – 200
Venlafaxine XR
25 – 75
75 – 200
150 – 300
Antidepressant
Bupropion SR
59
Treatment of Depression That Coexists with Mild to Moderate
Dementia
Preferred Treatment Option
Psychosocial
interventions

Pharmacologic
treatment

Other Options
That May Be
Considered
Caregiver-focused treatment
 Supportive psychotherapy
Medication alone (citalopram,
escitalopram, sertraline, venlafaxine
XR)
 Medication plus psychosocial
intervention
 Cholinesterase inhibitor

Bupropion SR
 Mirtazapine
 Paroxetine
60
Summary

Depressive symptoms are:


common among older adults
can have a major effect on their quality of life

Accurate diagnosis of depression is important

Depression usually responds to treatment with
psychotherapy, medications, or a combination of the two

Treatment options should be consistent with the patient’s
and family’s wishes and advanced directives
61
Case Study:

In this example, a 65-year old woman spends most of
her day either asleep or awake and developed a habit of
leaving her room at night.
 Possible interventions:
 Dimming a light in her room rather than leaving it on (the light
was left on for safety reasons)
 Having a caregiver walk with her and then guiding her back
to bed
 Limiting naps to 30 minutes
 Offering her warm milk or soothing snacks prior to going to
bed
62
Case Study:
Wrong Psychotherapy and Right Psychotropics
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 recently
married for 4 years. Because of increasing anxiety, depression
and acrophobia she was disabled and admitted herself to a
nursing home. She was in psychotherapy for 6 months with
benefits but suddenly became increasingly critical of nursing staff
and uncooperative with treatment as discharge was planned.
MMSE confirmed that her cognitive function was intact. After
the therapist began to explore a history of sexual abuse, she
became uncooperative.
63
Outcomes of this Case Study:
Wrong Psychotherapy and Right Psychotropics

Talking about past abuse was too painful and she preferred to focus on the
present.

The therapist was encouraged to be more reality oriented and supportive, so
she was.

She suddenly left, after refusing medication for two weeks and was
readmitted 6 months later due to depression and impulsively divorcing her
husband.

Mrs. Jones said that she had life-long paranoia, which was hidden by
obsessive compulsive symptoms and acrophobia.

She was given depakote and her paranoia and anxiety reduced to levels that
were tolerable.
64
Case Study:
Depression, Dementia, and Psychosocial Issues
Carlos was a 72 year-old Mexican American who was admitted
for dementia 3 years after his wife passed away. He was friendly
and adjusted well. The family was extremely attentive and guilty
that they could not managed him at home, as was the custom in
their culture. Each family took turns initially on weekends
visiting or taking him home for a few hours. After several
months, the visits and outings gradually and unpredictably
decreased. Carlos was reported to have increasing isolation,
which escalated to disruptive behavior and sleep problems. I was
consulted after 3 months of increasing dysfunctional behavior
because of sexually inappropriate behavior with other patients
and staff that led to a state site visit.
65
Outcomes of this Case Study:
Depression, Dementia, and Psychosocial Issues

Carlos denied any knowledge of events and denied any symptoms, which
resulted in the initiation of Lexapro and Aricept.

A family conference was held with the weekend nursing staff and they
stopped their flirtatious behavior, separated Carlos from the females, and
now must confirm passes when they are scheduled.

The problems continued and after 3 months Carlos was transferred to
another nursing home.
66
Case Study:
Is there a Psychiatrist in the House?
I had been consulting with the Nursing Home, Happy Springs,
sporadically for several years. After several emergency
consultations and the patient eloping, I had a conference with the
new DON, Administrator, and Social Worker about the evaluation
of evolving psychiatric behavior problems. They said they did not
admit patients with mental health problems because most of the
problems were resolved, initially, after treatment with Xanax,
PRN, or Benadryl for sleep. Because the census was low, they
wanted help with patients who had psychiatric problems. The
DON believed that senior citizens had a right to be depressed and
would be overmedicated if seen by a psychiatrist and the Social
Worker discouraged psychotherapy consults because she thought
she would not be needed if outside therapists started seeing the
residents.
67
Nonpharmalogic Treatments for Depression
in Dementia

Emotion-Oriented Therapies

Brief Psychotherapies

Sensory 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.
68
Emotion-Oriented Therapies
 Validation
Therapy
 Simulated
Presence Therapy
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.
69
Brief Psychotherapies

Cognitive Behavioral Therapies

Earlier Stages of Cognitive Decline

Problem Solving Therapy
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.
70
Sensory Stimulation Therapy

Art/Music Therapy

Aromatherapy

Animal-Assisted/Pet Therapy

Activity Therapies

Massage/Touch Therapies

Multisensory Approaches
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.
71
Activity Therapies

Reports from these therapies have been very
positive

Include things such as:


Recreational activities
Physical activity programs (improve mood)
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.
72
Massage/Touch Therapies

Even though evidence is limited, it still supports the use
of massage and touch interventions for anxiety in
dementia.

Touch massages have been found to temporarily relieve
agitated behavior for a short period of time
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.
73
Multisensory Approaches

Effective in reducing apathy in dementia according to the
Snoezelen/Multisensory Stimulation

Types:
 Light
 Texture
 Smell
 Sound
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.
74
Nonpharmacologic Interventions

Have potential for successful treatment of
depression in dementia

Types:




Emotion-Oriented Therapies
Behavioral Modification Programs
Cognitive-Behavioral Programs
Structured Activity Programs
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.
75
Clinical Investigation
Objectives:
Examine the prevalence, correlates, and medication
management of behavioral symptoms in elderly people living in residential
care/assisted living (RC/AL) facilities
Design:
Cross-Sectional Study
Settings:
Random sample of RC/AL facilities in four states (Florida,
Maryland, New Jersey, North Carolina)
Participants:
Total of 2078 RC/AL residents 65 and older
Measurement:
Behavioral symptoms were classified using modified
version 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,
76
Results

Approximately 34% exhibited one or more behavioral symptoms, once a
week

13% show aggressive behavioral symptoms

20% demonstrated physically nonaggressive behavioral symptoms

22% expressed verbal behavioral symptoms

13% resisted taking medications or activities of daily living care

More than 50% of RC/AL residents were on psychotropic medications

Two-thirds had some mental health problem indicator, such as dementia
depression, psychosis, or other psychiatric illnesses.
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,
77
Conclusions

Integrating mental health services within the
process of care in RC/AL is needed to manage
and accommodate the high prevalence of
behavioral symptoms in this evolving long-term
setting
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,
78
Clinical and Research News: Many Assisted-Living Residents
Not Getting Depression Help
Clinical Study: Duke University Medical Center – Lea Watson, MD

Cornell Scale for Depression and Dementia was the main test used
to measure physical and mental health


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.

13% of all subjects in this study had a score of greater than 7

At least a quarter of all subjects showed symptoms of depression,
such as sadness, tearfulness, worrying, or irritability

However, only 18% were diagnosed as being clinically depressed

Only 38% of patients with severe depression, a score of more than
12, were on antidepressants

Lea Watson commented that her next phase of work will directly
focus on depression in assisted-living facilities
79
Study: When Should a Patient Discontinue Treatment
for Elderly Depression?

Address the risks and benefits of treating a patient with
antidepressants when they have only experienced one episode of
major depression in their life.

The norm among experts has become treating a depressed elderly
person until they have fully recovered.

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
older patient with one incidence of depression would receive longterm treatment of up to 2 years.” Charles F. Reynolds III, MD

Most psychiatrists agree that the elderly with two or more episodes
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,
80
Contraindications to Tapering and GDR

GDR may be considered contraindicated for:
•
•
•

Antipsychotic medications for psychiatric disorders that do not include
behavioral symptoms related to dementia
Psychopharmacological medications
 Including antidementia agents and antidepressants
Sedative/hypnotics
GDR can be considered contraindicated (without and failing first) if
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
81
Recurrence and Residual Symptoms in
Geriatric Depression

Recurrence rates of 50% - 90% over 2-3 years

Lower remission rates in geriatric depression

After 6-month remission, 20%-30% retain residual symptoms
•

Greater distress and disability
Higher relapse rates in elderly patients compared to younger
patients
•
Maintenance therapy is important
82
Empirically Supported Psychotherapies
Cognitive Behavioral
Therapy (CBT)


Identify and modify negative
beliefs and negative
interpretations of the past,
present and future
Includes:
•
Education
•
Symptom and stress
management strategies
•
Desensitization to feared
stimuli
•
Cognitive challenges to
change beliefs
Interpersonal Therapy
(IPT)

Focuses on 4 types of
interpersonal problem
categories viewed as causes
of depression
•
Grief and morning
•
Interpersonal disputes
•
Role transitions
•
Social skill deficits
83