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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
Agenda
• Welcome & Purpose of Presentation
• Birth and Formation of the CCSMH
• Overview National Guideline Project
• Dissemination and Implementation
• Conclusion and Questions
Year
25
20
15
10
5
01921 1931 1941 1951 1961 1971 1981 1991 2001 2011 2021 2031 2041
Pe
rce
nta
ge
65-74 75-84 85+
Reality: Seniors (by age sub-groups) as % of the Total Pop.
Canada, 1921-2041
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
• 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
Mental Illness is NOT a normal consequence of aging!
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%)
CCSMH
Responding to the Needs of the Seniors’ Mental Health Community
Birth and Formation of the CCSMH2002
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”
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
The CCSMH is committed to ….
CCSMH Steering Committee MembersAlzheimer Society of Canada
Canadian Academy of Geriatric Psychiatry CARP Canada’s Association for the 50 Plus
Canadian Association of Social WorkersCanadian Caregiver CoalitionCanadian Geriatrics Society
Canadian Health Care AssociationCanadian Mental Health Association
Canadian Nurses AssociationCanadian Psychological Association
Canadian Society of Consulting PharmacistsCollege of Family Physicians of Canada
Public Health Agency of Canada (Advisory)
Collaboration is a necessity for success!
CCSMH: Strategic Goals
1. To ensure that SMH is recognized as a key Canadian health and wellness issue
2. To facilitate initiatives related to enhancing & promoting seniors’ mental health resources
3. To ensure growth and sustainability of the CCSMH
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
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
Seniors’ Mental Health Research: Falling Between the Cracks
CCSMH
Responding to the Needs of the Seniors’ Mental Health Community
CCSMH National Guideline Project
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
Role Individual
Chair Dr. David Conn
Project Director Ms. Faith Malach
Project Manager Ms. Jennifer Mokry (completed March 06)
Project Assistant Ms. Kimberley Wilson
Co-Leads - LTC Dr. David Conn; Dr. Maggie Gibson
Co-Leads – Delirium Dr. David Hogan; Dr. Laura McCabe
Co-Leads – DepressionDr. Marie-France Tourigny-Rivard; Dr. Diane
Buchanan
Co-Leads – SuicideDr. Adrian Grek; Dr. Marnin Heisel; Dr. Sharon
Moore
Advisory Ms. Simone Powell / Dr. Louise Plouffe
Guideline Development Project Steering Committee
Members of LTC Guideline Development Group
Name Role Discipline
Dr. David Conn Co-Chair Psychiatry
Dr. Maggie Gibson Co-Chair Psychology
Dr. Sid Feldman Group Member Family Medicine
Dr. Sandi Hirst Group Member Nursing / CGNA
Dr. Ken LeClair Consultant Psychiatry
Sandra Leung Group Member Pharmacy
Dr. Penny MacCourt Group Member Social Work
Dr. Kathy McGilton Group Member Nursing
Ljiljana Mihic Group Member Psychology
Karen Cory Consultant Medical Librarian
Dr. Lynn McCleary Consultant Nursing/Social Work
• 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
Creation of Canada’s FIRST National Evidence Based Guidelines
for Seniors’ Mental Health
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
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.
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.
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
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
Review of Process: The Beginning
Guideline Topics
Formalized
Determine & Formalize Co-Leads for each group
Formalize Guideline Development Groups
CCSMH – overall facilitationCo-chairs – primarily responsible for all aspects of guidelinesGroup Members – 4-8 per guidelineConsultants – called on as appropriate
Determine & Formalize Group Members and
Consultants for each group
Determined criteria for selectionGathered Names and Contacted individualsFormalized membership
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
Guidelines: Categories of Evidence:
Ia Evidence from meta-analysis of randomized controlled trialsIb Evidence from at least one randomized controlled trialIIa Evidence from at least one controlled study without randomizationIIb Evidence from at least one other type of quasi-experimental studyIII Evidence from non-experimental descriptive studies, such as comparative studies, correlation studies and case-control studiesIV Evidence from expert committees reports or opinions and/or clinical experience of respected authorities
Shekelle et al 1999
Guidelines: Strength of Recommendation
A Directly based on category I evidenceB Directly based on category II evidence or extrapolated recommendation from category I evidenceC Directly based on category III evidence or extrapolated recommendation from category I or II evidenceD Directly based on category IV evidence or extrapolated recommendation from category I, II, or III evidence
Shekelle et al 1999
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
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
Dissemination and Implementation
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)
What do we do next?
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
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.
The Assessment and Treatment of Mental Health Issues in Long Term Care Homes
Focus on Mood and Behaviour Symptoms
David Conn, MD, FRCPCMaggie Gibson, Ph.D., C.Psych
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.
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.
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.
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.
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.
Treatment of Depressive Symptoms & Disorders
• Consider the type and severity of depression in developing a treatment plans [B].
• Psychological and social interventions.
• Pharmacologic interventions.
Treatment of Behavioural Symptoms
• Psychological and social interventions.– Social contact– Sensory/ relaxation– Structured recreational activities– Individualized behaviour therapy
• Pharmacologic interventions.– Weigh potential benefit & harm
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
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.
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.
Mr. M
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?
Depression
Psychological and social therapies, Antidepressants, ECT
Apathy Pain
Depression
Dementia
Analgesics,adjuvants, education, physical activity, self -help strategies
Cognitive enhancers, modulated stimulation, emotion-oriented support
Psycho-stimulants, increased structure, heightened stimulation
Psychological and social therapies, Antidepressants, ECT
Mr. M’s care plan was revised to include:
• Structured social contact (volunteer)
• Music therapy
• Spousal support (planning and problem-solving)
• Inclusion of a prn analgesic to be used prior to major care activities (e.g., bathing)
Epilogue:
Increased pain control and changes to Mr. M’s socialenvironment led to a reduction in resistive behaviours,improved sleep and increased participation in recreational activities (with assistance; spontaneousparticipation did not resume). Screening at regular (3month) intervals triggered adjustments to Mr. M’s careplan as needed in response to escalation in behaviouraland depressive symptoms. The palliative focus in Mr. M’scare plan was increased as his dementia progressed. Helived in the long term care home for three years beforedying peacefully.
