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Canadian Coalition for Seniors’ Mental Health

Canadian Coalition for Seniors’ Mental Health. National Interdisciplinary Guidelines for Seniors’ Mental Health – Together We Can Improve the Assessment and Management of the Mental Health Concerns of Older Canadians Dr. David B. Hogan The Long Term Care Association of Manitoba

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Canadian Coalition for Seniors’ Mental Health

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  1. Canadian Coalition for Seniors’ Mental Health National Interdisciplinary Guidelines for Seniors’ Mental Health – Together We Can Improve the Assessment and Management of the Mental Health Concerns of Older Canadians Dr. David B. Hogan The Long Term Care Association of Manitoba May 29, 2007

  2. Agenda • Welcome & Purpose of Presentation • Birth and Formation of the CCSMH • Overview National Guideline Project • Dissemination and Implementation • Conclusion and Questions

  3. 65-74 75-84 85+ Reality: Seniors (by age sub-groups) as % of the Total Pop. Canada, 1921-2041 25 20 15 10 5 0 Percentage 1921 1931 1941 1951 1961 1971 1981 1991 2001 2011 2021 2031 2041 Year

  4. Reality: Defining Seniors’ Mental Health • Mood Disorders • Anxiety Disorders • Dementia – Alzheimer’s Disease and Other Dementias • Personality Disorders • Substance Use and Addiction / Concurrent Disorders • Schizophrenia; Autism • Suicidal Behaviour

  5. Mental Illness is NOT a normal consequence of aging! • Depression: 15% – 20% in the community • LTC: 80 - 90% of residents • Alzheimer’s: 1 in 3 of those over 85 • Delirium • up to 50% of older persons admitted to acute care / 70% incidence in ICU • Suicide: The 1997 suicide rate for older Canadian men was nearly 2x that of the nation as a whole

  6. 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%)

  7. CCSMH Responding to the Needs of the Seniors’ Mental Health Community Birth and Formation of the CCSMH 2002

  8. Birth and Formation of the CCSMH • CAGP created the Millennium Project-1999 “To improve the mental health of the elderly in LTC through education, advocacy and collaboration” • National Symposium 2002: Gaps in Mental Health Services for Seniors in LTC Facilities “To engage all relevant stakeholders in order to identify and implement action plans to improve mental health for seniors living in LTC facilities”

  9. The CCSMH is committed to …. To promote the mental health of seniors’ by connecting people, ideas & resources • Education • Advocacy / Public awareness • Research • Best Practices -Assessment & Treatment • Family Caregivers • Human Resources

  10. Collaboration is a necessity for success! CCSMH Steering Committee Members Alzheimer Society of Canada Canadian Academy of Geriatric Psychiatry CARP Canada’s Association for the 50 PlusCanadian Association of Social WorkersCanadian Caregiver CoalitionCanadian Geriatrics SocietyCanadian Health Care AssociationCanadian Mental Health AssociationCanadian Nurses AssociationCanadian Psychological AssociationCanadian Society of Consulting PharmacistsCollege of Family Physicians of CanadaPublic Health Agency of Canada (Advisory)

  11. CCSMH: Strategic Goals • To ensure that SMH is recognized as a key Canadian health and wellness issue • To facilitate initiatives related to enhancing & promoting seniors’ mental health resources • To ensure growth and sustainability of the CCSMH

  12. CCSMH: Supporters • Pop. Health Fund, Public Health Agency of Canada • Max Bell Foundation • CIHR Institutes- IA; INMHA • Baycrest – in kind • RBC Foundation; F.K. Morrow Foundation, • AstraZeneca, Eli Lilly, Janssen-Ortho, Pfizer, Organon, Lundbeck

  13. Maturity and Growth: Key Accomplishments • Invitation to Present at Senate Hearings on Mental Health x2 • National Guidelines Project • National Conferences • September 25th & 26th 2005 (Ottawa) • September 24th & 25th 2007 (Toronto) • CCSMH Research Initiative • Research Workshop with CIHR 2004 • Seniors’ Mental Health Research Network

  14. Seniors’ Mental Health Research: Falling Between the Cracks

  15. VISIT OUR WEBSITEWWW.CCSMH.CA

  16. CCSMH Responding to the Needs of the Seniors’ Mental Health Community CCSMH National Guideline Project

  17. CCSMH Guideline Project: Setting the Context • Funding awarded in Jan. 2005 by Public Health Agency of Canada, Population Health Fund • Goal:To lead and facilitate the development of evidence-based recommendations for best practice guidelines in areas of seniors’ mental health

  18. Guideline Development Project Steering Committee

  19. Members of LTC Guideline Development Group

  20. Creation of Canada’s FIRST National Evidence Based Guidelines for Seniors’ Mental Health • Assessment & Treatment of Delirium • Assessment & Treatment of Depression • Assessment & Treatment of Mental Health Issues in LTC Homes (with a focus on mood & behaviour) • Assessment of Suicide Risk and Prevention of Suicide

  21. Clinical Relevance of Delirium in Older Adults • Delirium is very common & potentially treatable • Higher rates of mortality • Increased risk of cognitive decline & dementia • Worse functional outcomes & higher rates of entry to LTC • Prolonged lengths of hospital stay • Poorer outcomes with rehab • Under-recognized or misdiagnosed as dementia or depression • Often ignored even though window on brain integrity & quality of care • Often ignored by psychologists even though neuropsychological disorder

  22. The Epidemiology of Late-Life Suicide • Seniors have high suicide rates worldwide, including in Canada and the U.S. • 430 people 65+ died by suicide in Canada in 2002; 5198 died by suicide in the U.S. in 2004 • As of 2001, there were 1.6 million adults 65+ in Ontario or 12.8% of the population. • The number of seniors in Ontario may rise to 3.6 million (22.2%) by 2031. • “Baby boomers” have high rates of suicide.

  23. Long Term Care Homes (LTC) in Canada • 7% of the Canadian population resides in LTC at any one time. • 40% resides in LTC at some time. • Institutionalization increases with age (38% of women and 24% of men over 85 live in LTC). • Institutionalization correlates with decline in ability to perform ADLs & IADLs. • “Baby Boomers” will start utilizing LTC in significant numbers around 2020.

  24. CCSMH Guideline Project: Setting the Context - Scope of Guidelines • Multidisciplinary • Older adults (65+) • Continuum of Healthcare Settings • Should address variations across Canada • Cross referencing between guidelines • Consumer input and involvement necessary • Gaps in knowledge to be identified

  25. What’s in the Guideline? • Background • Screening and Assessment • Treatment Options • Psychotherapies & Psychosocial Interventions • Pharmacological Treatment • Monitoring and Ongoing treatment • Education & Prevention • Special populations • Systems of Care

  26. Review of Process: The Beginning Guideline Topics Formalized Determine & Formalize Co-Leads for each group • Determine & Formalize Group Members and Consultants for each group • Determined criteria for selection • Gathered Names and Contacted individuals • Formalized membership • Formalize Guideline Development Groups • CCSMH – overall facilitation • Co-chairs – primarily responsible for all aspects of guidelines • Group Members – 4-8 per guideline • Consultants – called on as appropriate

  27. Review of Process: Phase I & II • Phase I: Group Admin.& Preparation for Draft Documents (Apr. –June 2005) • Meetings with Co-leads & Workgroups • Creation of • -Terms of Reference • -Guiding Principles & Scope • -Guideline Framework Template • Comprehensive Literature and • Guideline Review • Identification of review tools and • grading of evidence tools • Phase II: Creation of Draft Documents (May-Sept. 2005) • Meetings with Co-leads & • Workgroups • Shortlist, Review & Rate • Literature and Guidelines • Summarize evidence, gaps and • recommendations • Create draft documents • Review and revise draft • documents and recommendations

  28. Guidelines: Categories of Evidence: Ia Evidence from meta-analysis of randomized controlled trials Ib Evidence from at least one randomized controlled trial IIa Evidence from at least one controlled study without randomization IIb Evidence from at least one other type of quasi-experimental study III Evidence from non-experimental descriptive studies, such as comparative studies, correlation studies and case-control studies IV Evidence from expert committees reports or opinions and/or clinical experience of respected authorities Shekelle et al 1999

  29. Guidelines: Strength of Recommendation A Directly based on category I evidence B Directly based on category II evidence or extrapolated recommendation from category I evidence C Directly based on category III evidence or extrapolated recommendation from category I or II evidence D Directly based on category IV evidence or extrapolated recommendation from category I, II, or III evidence Shekelle et al 1999

  30. Review of Process: Phase III & Phase IV Phase III: Dissemination & Consultation Stage 1: To guideline group members (May – Dec. 2005) Stage 2: CCSMH Best Practices Conference Participants (Sept 2005) Stage 3: Consultants & Additional Stakeholders (Oct 2005 – Feb. 2006) • Phase IV: Revised Draft of Guideline Documents (Oct. 2005 – Jan. 2006) • Feedback from external stakeholders reviewed & discussed • Achieving consensus within guideline groups on recommendations & content • Final revisions

  31. Review of Process: Phase V & VI Phase V: Completion of Final Recommendations & Guideline Document (Jan. 2006) • Phase VI: Dissemination & Evaluation • Translation, Formatting, Printing • Website, Hard Copy Mailout • Dissemination and Knowledge Exchange Team

  32. Dissemination and Implementation

  33. CCSMH Guideline Dissemination • 7500 Hard Copies • LTC guidelines: 2500 LTC facilities (CEO/Admin) • Delirium, Depression, Suicide guidelines: 1000 x3 Hospitals (Dir. Of Care Hosp.) • All four guidelines: 500 x4 (CAGP, Government, Administrators, Mental Health Teams, Academics, Libraries, Policy Planners etc.) • ~ 10,000 Downloads (as of May 9th 2007)

  34. What do we do next?

  35. CCSMH Guideline Implementation • Presentations/Education Sessions • Regional/Provincial Task Force Groups • Individual Organization/Team Commitment and Collaborative Review &Implementation • Research • Endorsements • Knowledge Exchange Committee • Personal Commitment from our Leaders

  36. CCSMH: Guideline Key Messages • These are the first ever National Guidelines that focus specifically on seniors’ mental health. • All four guidelines were created by and for interdisciplinary teams • Recommendations are based on the best current evidence available • Implementation of recommendations will ensure all Canadian seniors’ with mental health issues will consistently be treated with the best medical evidence and with a focus on dignity and well-being.

  37. The Assessment and Treatment of Mental Health Issues in Long Term Care HomesFocus on Mood and Behaviour Symptoms David Conn, MD, FRCPC Maggie Gibson, Ph.D., C.Psych

  38. Long Term Care (LTC) Homes • Facilities that provide LTC for seniors across Canada vary widely in size, appearance, resources and service models. • What LTC homes have in common is that they provide combined accommodation and health services for individuals who are unable to manage in a less supportive physical and social environment.

  39. Long Term Care (LTC) Homes in Canada • About 250,000 Canadian seniors live in a LTC home • 7% of the Canadian population 65+ reside in LTC at any one time. • 40% reside in LTC at some time. • Institutionalization increases with age (38% of women and 24% of men over 85 live in LTC). • Institutionalization correlates with decline in ability to perform ADLs & IADLs. • “Baby Boomers” will start utilizing LTC in significant numbers around 2020.

  40. Assumptions • There is a need to focus on both mental health and mental illness in LTC homes. • There is significant diversity in the LTC population. • Effective mental health management requires an interdisciplinary approach. • Relationships among residents, family members and staff are central in meeting mental health needs. • The milieu (social and physical environment) can promote or undermine mental health.

  41. General Care Recommendations • Encourage and support the involvement of the family in the institutional life of an older resident, including decision-making processes as appropriate [C] • Individualize care plans, with due consideration to best-practice guidelines and recommendations [D] • Other ones dealing with communication, dressing, bathing, activities and mealtime.

  42. Assessment Recommendations • The facility’s assessment protocol should specify that screening for depressive and behavioural symptoms will occur in the early post-admission phase and subsequently, at regular intervals, as well as in response to significant change [C]. • Positive screening with trigger detailed assessment • Ongoing evaluation.

  43. Treatment of Depressive Symptoms & Disorders • Consider the type and severity of depression in developing a treatment plans [B]. • Psychological and social interventions. • Pharmacologic interventions.

  44. Treatment of Behavioural Symptoms • Psychological and social interventions. • Social contact • Sensory/ relaxation • Structured recreational activities • Individualized behaviour therapy • Pharmacologic interventions. • Weigh potential benefit & harm

  45. Organizational and System Recommendations • LTC homes should develop the physical and social environment as a therapeutic milieu through the intentional use of design principles [D]. • Written protocol re staffing, medication administration and use of restraints; education & training program

  46. Organizational and System Recommendations • LTC homes should obtain mental health services from local practitioners, or multidisciplinary teams, with interest and expertise in geriatric mental health issues [D]. • Advocacy; ensure adherence to ethical & legislative rights; support implementation of best practices; and, monitor & evaluation.

  47. Mr. M Mr. M , at 82 years of age, had adjusted well to his move to a long term care home. His diagnoses included dementia (probable Alzheimer’s type) and osteoarthritis. Approximately a year into his residency, he rather abruptly stopped participating in recreational activities and developed insomnia. He began resisting care, and demanding to be to be left alone. Of note, these changes were concurrent with a reduction in his wife’s visits, due to her own failing health.

  48. Case Conceptualization Has his dementia progressed such that past routines are no longer appropriate? Has his pain changed such that current treatment no longer provides adequate control especially during care activities? Is he worried about or missing his wife? Has he become lonely? All of the above? Other?

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