Transcript Tool on Depression Assessment 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
Promouvoir la santé mentale des personnes agées en reliant les personnes, les idées et les ressource
Reality: Defining Seniors’ Mental Health
• • • • • • •
Mood Disorders Anxiety Disorders Dementia – Alzheimer’s Disease Personality Disorders Concurrent Disorders Schizophrenia; Autism Suicidal Behaviour
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
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%)
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
Recommended Screening Tools for Depression
Health care providers should have knowledge and skills in the application of age-appropriate screening and assessment tools for depression in older adults.
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
Are my older patients at higher risk of depression? (laminate)
• • • • • • • • • •
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
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
Tool development on
Depression Assessment
For Older Adults
Developed by NICE Mental Health Team
Part 1: RISK, SCREENING
Part 1: Risk Screening 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
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 )
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
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)
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
Part 2: WHEN TO TREAT, REFER, & MONITORING & LONG TERM TREATMENT
Commonly-used Antidepressant Medications Generic Name National Guidelines for Seniors Mental Health: Part 5 Trade Name Starting dose mg/day Average Dose Maximum recommended dose (CPS) Comments/Caution SSRI
Citalopram Celexa 10 20-40 40 mg Escitalopram Cipralex 5 Sertraline Zoloft 25
Other Agents
Buproprion Wellbutrin 100 Mirtazapine Remeron Moclobemide Manerix 15 150 Venlafaxine Effexor 37.5
10-20 50-150 20 mg 200 mg 100 mg BID 150 mg BID 30-45 45 mg 150-300 BID 300 mg BID 75-225 *375 mg May cause seizures Do not combine with MAO-B inhibitors or Tricyclics * For severe depression; May increase blood pressure
Tricyclic Antidepressants
Desipramine Norpramin 10-25 Nortriptyline Aventyl 10-25 50-150 40-100 300 mg 200 mg Anticholinergic properties cardiovascular side-effects; Monitor blood levels Anticholinergic properties; cardiovascular side-effects; Monitor blood levels
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
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
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
NICE – Mental Health Team Depression Assessment Tool, Evaluation
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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
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