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Tool on Depression: Assessment and Treatment 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

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Tool on Depression: Assessment and Treatment For Older Adults

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  1. Tool onDepression: Assessmentand TreatmentFor 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

  2. Reality: Defining Seniors’ Mental Health • Mood Disorders • Anxiety Disorders • Dementia – Alzheimer’s Disease • Personality Disorders • Concurrent Disorders • Schizophrenia; Autism • Suicidal Behaviour

  3. 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

  4. 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%)

  5. 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

  6. Recommended Screening Toolsfor Depression Health care providers should have knowledge and skills in the application of age-appropriate screening and assessment tools for depression in older adults.

  7. 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

  8. 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 Are my older patients at higher risk of depression? (laminate)

  9. 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

  10. Tool development onDepressionAssessmentFor Older AdultsDeveloped by NICE Mental Health Team

  11. Part 1: RISK, SCREENING

  12. 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 Part 1: Risk Screening

  13. 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 )

  14. 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

  15. 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)

  16. 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

  17. Part 2: WHEN TO TREAT, REFER, & MONITORING & LONG TERM TREATMENT

  18. 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

  19. 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

  20. 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

  21. NICE – Mental Health TeamDepression Assessment Tool, Evaluation

  22. Evaluation Outline • 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. • 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 • In-depth Qualitative Interviews • Conducted 3 months after workshop – focus group or individual interviews depending on scenario (tape recorded / transcribed) • Consent form • Evaluation of Workshop Sessions • To be distributed and collected at end of each session • Analysis – mid April – mid-May • Report- June 2008 NICE Conference

  23. 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

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