Geriatric Mental Health Evidence-based care: What works?

1. Geriatric Mental Health Evidence-based care: What works? Mary Lynn Piven, PhD, PMHCNS,BC UNC-Chapel Hill School of Nursing Focusing attention, building capacity, supporting action

2. Report: U.S. Health in International Perspective • Higher per capita on health care, but die sooner & experience more illness than residents in many other countries • “US health disadvantage”: higher rates of chronic disease & mortality among adults & higher rates of untimely death & injury among adolescents & small children. Focusing attention, building capacity, supporting action

3. IOM Report 2012 The Mental Health & Substance Use Workforce for Older Adults: In Whose Hands? • NC has a shortage of psychiatric mental health specialists • Increase the capacity of existing resources & agencies Focusing attention, building capacity, supporting action

4. Objectives 1. Define evidence-based practice 2. Discuss geriatric mental health evidence- based practices/programs for depression, dementia and alcohol use 3. Review evidence-based models of therapy 4. Consider your own agency and practices in geriatric mental health & how to increase capacity and quality of care Focusing attention, building capacity, supporting action

5. Definition of Evidence-based practice Integration of the best research evidence with clinical expertise & patient values (IOM, 2001) Strong scientific evidence (proof) that they produce positive outcomes “Promising practices” Values of individual as basis for informed choice & individual preferences (SAMSHA, 2011) Focusing attention, building capacity, supporting action

6. Practices vs. programs Focusing attention, building capacity, supporting action

7. Mr. Smith, 72 years old Cancer of larynx (voice box); hypertension; sleep disorder; chronic obstructive pulmonary disease; alcoholic & long-time smoker Continues to smoke & consume beer Frail; underweight Frequent infections/pneumonia; increasingly home-bound Innuendos about harming self Focusing attention, building capacity, supporting action

8. Screening Practices • Depression: Present Health Questionnaire (PHQ-9) Geriatric Depression Scare (GDS) • Cognitive Impairment: Mini-Cog; Folstein MMSE; Montreal Cognitive Assessment (MoCA) • Alcohol: CAGE; AUDIT Focusing attention, building capacity, supporting action

9. SO, WHAT WORKS? Focusing attention, building capacity, supporting action

10. Universal Prevention • Physical Activity • Mental Activity • Education & activity • Social engagement • Optimal physical health Focusing attention, building capacity, supporting action

11. New Practice Models Integration of screening, basic management and basic mental health services into primary care & social/human service agencies More expert consultation to private or public mental health system sectors Co-management of behavioral care/substance care Focusing attention, building capacity, supporting action

12. Depression & Evidence-base Combined use of antidepressants & psychotherapy in treatment of late life depression, esp. those with a clear psychosocial stressor (Bartels et al., 2002) Cognitive-behavioral, interpersonal therapy & problem solving therapy for mild to moderate depression (Mackin & Arean, 2005) Focusing attention, building capacity, supporting action

13. Antidepressants in older adults General agreement of the effectiveness of antidepressants Selective Serotonin Reuptake Inhibitors first line in geriatric depression Avoid tricyclics like amitriptyline, imipramine and doxepin due to serious cardiovascular & anticholinergic effects Focusing attention, building capacity, supporting action

14. Collaborative Care for depression Under-diagnosis in primary care where most older adults prefer MH care (52% vs. 14%) Collaboration among PCPs, case managers, and mental health specialists Role of “case manager” & chronic care model Cost offset hypothesis Good economic value (Jacob, et al. 2012) Focusing attention, building capacity, supporting action

15. Depression Management Programs • Program to Encourage Active Rewarding Lives for Seniors (PEARLS) - www.pearlsprogram.org • Improving Mood: Promoting Access to Collaborative Treatment (IMPACT) - www.impact.org • Healthy IDEAS - Identifying Depression, Empowering Activities for Seniors (HI) www.careforelders.org/healthyideas Focusing attention, building capacity, supporting action

16. Program Comparison Focusing attention, building capacity, supporting action

17. Healthy IDEAS: Program Goals Detect & reduce the severity of depressive symptoms in older adults Reach underserved populations Enable agency staff to deliver an evidence-based intervention for depression to older adults & caregivers. Improve linkage between community aging service providers & health/mental health professionals Focusing attention, building capacity, supporting action

18. Program Design Uses a manual which outlines steps & includes worksheets, client handouts, & forms to support & document process & client outcomes. Conducted in the client’s home on a one-to-one basis by case managers over a 3-6 month period. Entails partnerships with primary care & mental health care providers to facilitate referral & training, & ensure program fidelity & sustainability. Focusing attention, building capacity, supporting action

19. Core Intervention Components • Step 1: Screening • Step 2: Education • Step 3: Referral & Linkage • Step 4: Behavioral Activation • Empowering older adults to manage their depressive symptoms by engaging in meaningful, positive activities. • Step 5: Follow-up Reassessment Focusing attention, building capacity, supporting action

20. Depression & at risk drinkingprogram components Integrating behavioral and substance use Systematic outreach & diagnosis Patient & family education & self-management support Provider accountability for outcomes Close monitoring & follow-up to prevent relapse Focusing attention, building capacity, supporting action

21. Screening, Brief Intervention, & Referral for Treatment (SBIRT) Early, brief intervention & treatment model Substance use screening as part of the standard agency intake process Referred to primary care, social, aging & other service providers Medicaid, Medicare, some commercial payers to certain professionals Focusing attention, building capacity, supporting action

22. Dementia & Evidence base • Anti-psychotics are NOT APPROVED for use with dementia; Non-pharmacologic interventions KEY • Clear, consistent benefits on cognitive function associated with Cognitive Stimulation Therapy (CST) over and above any medication effects, lasting 1-3 months after group • Language & Memory domains • Improved quality of life (Woods, Aguirre, Spector, & Orrell, 2012) Focusing attention, building capacity, supporting action

23. Dementia Cholinesterase inhibitors modestly reduce the rate if decline/enhance functioning over 6-12 months and may delay nursing home placement Cognitive stimulation can improve memory, problem solving, and mood and decrease behavioral disturbances. (Logsdon, McCurry & Teri, 2007) Focusing attention, building capacity, supporting action

24. Behavioral & Psychological Symptoms of Dementia (BPSD) Greater risk of delirium Agitation Delusions Hallucinations Vocalizations Wandering Depression (50%) Focusing attention, building capacity, supporting action

25. Quality of Life in Dementia Affected Adult Mood Engagement in pleasant activities Physical functioning Cognitive functioning (Logsdon, McCurry & Teri, 2007) Family caregivers • Mood • Engagement in pleasant activities • Ability to perform activities of daily living (ADLs)

26. Cognitive Stimulation Therapy • Improves cognition and quality of life for dementia even those on anticholinesterases (AChEIs) • Older age and being female associated with increased cognitive benefits from CST (Aguirre, Hoare, Streater, Spector, Woods & Orrell, 2013) • United Kingdom government NICE guidelines (2006) promotes a structured cognitive stimulation program Focusing attention, building capacity, supporting action

27. REACH I/II Focusing attention, building capacity, supporting action Multi-component psychosocial behavioral intervention to reduce caregiver burden & depression, support and improve caregiver to provide self-care and how to manage difficult behaviors in those with Alzheimer's disease or related disorders http://www.rosalynncarter.org/caregiver intervention_database/dementia/reach_ii_intervention/

28. Powerful Tools for Caregivers 6 weekly classes Develop self-care tools Communication; difficult situations; difficult decisions Participant evaluations indicate program improves: Self-Care behaviors, Management of emotions; Self-efficacy; Use of community resources Focusing attention, building capacity, supporting action

29. Types of therapy • Cognitive behavioral* • Behavioral • Problem-solving* • Interpersonal* • Reminiscence Practitioners: professional mental health practitioners, doctorally -& masters-level psychologists, as well as social workers, psychiatrically trained nurses & licensed marriages & family counselors Focusing attention, building capacity, supporting action

30. *Cognitive Therapy • The way we think and make sense of their experiences determines the way they feel and behave • Mental health, primary care, home-based care • Up to 20 individual or group sessions • CBT only & CBT plus anti-depressant are more effective than an antidepressant alone • Reduces depression symptoms & improves life satisfaction & coping strategies SAMSHA, Focusing attention, building capacity, supporting action

31. Behavior Therapy Depression results from a lack of pleasant events & excess of negative events Identifying & increasing participation in pleasant events 18 one-hour individual or group sessions in clinical setting Reduces depressive symptoms, improves life satisfaction & coping strategies Focusing attention, building capacity, supporting action

32. *Problem Solving Treatment Developed for primary care so a variety of health care professionals can learn and administer regardless of mental health background Part of IMPACT Model Most support for dissemination & implementation for the PST-PC (Primary Care Model) Focusing attention, building capacity, supporting action

33. Interpersonal Therapy Interpersonally relevant issues…” Manualized with 16 or fewer weekly sessions Unresolved grief, major life change, conflict with another person, initiating or sustaining relationships) Alternate coping strategies Includes psychoeduction about the biopsychosocial model of depression Focusing attention, building capacity, supporting action

34. Reminiscence Therapy Most consistently helpful when Major Depression present Meaning & life-story connects us to others Used widely with anxiety and health conditions that cause anxiety, behavioral problems due to dementia, or other physical health disorder—no evidence among racial & ethnic minority groups Focusing attention, building capacity, supporting action

35. Summary • Evidence-based practice is considered a minimum standard care for older adults • Evidence-based practices and programs are available to increase access and quality of geriatric mental health care in NC • What are your agency/community needs for these practices and programs? Focusing attention, building capacity, supporting action