Role of Medications, Therapy and Education in the Treatment of Mood Disorders of Nursing Homes

1. Role of Medications, Therapy and Education in theTreatment of Mood Disorders of Nursing Homes Jules Rosen M.D. Professor, Psychiatry and Katz Graduate School of Business University of Pittsburgh

2. Disclosure • Financial interest in Fox Learning Systems, Inc.

3. 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

4. Mood Disorders of Late-life in Longterm Care Evidence for Continuum Mood Disorder Major Depressive Episode Minor Depression Dysthymia Treatment Response Clinical Course Phenomenology

5. 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 Major Vs. Minor Depression Vs. Dysthymia Dysthymic Disorder • 2 years duration • Depressed mood • 2 of 6 symptoms • Significant distress or impaired functioning

6. 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

7. Nested Potential Predictors of Treatment Response in Late Life Depression Clinical Biological Nonpsychiatric physical illness Symptom severity l l Lifetime age of onset l Genepolymorphisms l Comorbidanxiety l Cognitive impairment l The Depressed Older Adult Biological Psychosocial – Intrapersonal Environmental– Clinical Psychosociall Psychosocial – Demographics Social supports l Intrapersonal Personality disorder Perceived chronic stress l l Psychosocial– Traits and dispositions Life events/acute stress l l Environmental Physical environment l Courtesy, Mary Amanda Dew, Ph.D.

8. Presentations Depression • Somatic Presentation • Anxiety Symptoms • Associated with Medical Illness • Associated with Social Stressors of Nursing Home Placement

9. 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 Why to they complain “I’m Sick”

10. 3 Yr. incidence of most common complaints in primary care settings (Kromke et al. Am J Med 1989)

11. Predictors of Somatic Worry (Lyness et al, 1993

12. 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

13. 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

14. 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

15. Does Pharmacotherapy Augmentation Work in Late-Life Depression? 195 N=78 nonresponders N=28 responders who relapsed N=89 responders with no relapse Received Augmentation Received Augmentation n=48 n=21 Recovered n=24 Did not n=24 Recovered n=78 Did not/ Terminated n=11 Recovered n=14 Did not n=7 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

16. 24 59-69 (N=163) 22 70-75 (N=80) 20 76-95 (N=80) 18 16 14 12 HRS-17 Total 10 8 6 4 2 0 0 2 4 6 8 10 12 14 16 Week from treatment start Gildengers et al. J Affect Disord, 69(1-3):177-184, 2002 Even “Old Old” with Depression Respond to Treatment

17. Preventing Recurrence of DepressionReynolds 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%

18. Time to Recurrence from Randomization: MTLD-II Reynolds, Dew, Pollock, et al. N Engl J Med, 354(11):1130-1138, 2006

19. 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

20. Nortriptyline: Standard vs. low dose in nursing home residentsStreim 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

21. 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

22. 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!!!

23. “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.

24. 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.

25. “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

26. Control-Relevant Intervention:Goals of Nursing Home Therapy • Reduce stressors • Loss of control • Temporal variability • Hopelessness • Develop relationships

27. 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

28. 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

29. 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

30. Methods • Pre-intervention rating • 2-month intervention • Post-intervention rating • Follow-up rating • 2 months after termination

31. 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.

32. 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 Responders vs. Non-Responders

33. 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

34. 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)

35. 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

36. 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

37. 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

38. Annual Costs (& hidden costs) of Education(estimates based on market surveys)

39. 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

40. 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 Clinical Curriculum

41. 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

42. 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 Short form Series for CNAs (57 topics): Mental Health Topics 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

43. 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

44. Compliance with training at computer and lecture sites (CNA and Others)

46. 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

47. Contact Information Jules Rosen MD, Professor of Psychiatry University of Pittsburgh rosenji@upmc.edu; (412) 246 5900 Fox Learning Systems, Inc. www.foxlearningsystems.com (412) 531 1889

48. “It is not enough to add years to one’s life…one must also add life to those years”