Role of Medications, Therapy and Education in the Treatment

of Mood Disorders of Nursing Homes

Jules Rosen M.D.

Professor, Psychiatry and Katz Graduate School of Business

University of Pittsburgh

Disclosure

Financial interest in Fox Learning Systems, Inc.

Goals

Understand the characteristics of late-life depression

Understand role of medications and therapy in treatment

Understand that depression in LTC may look different than in community

Role of environment critical in both causing depression and treating depression in LTC

New “f-tag” – Unnecessary Medications

Specific “milieu-oriented” therapy can be powerful

Understand the importance of staff education in depression recognition and treatment

Mood Disorders of Late-life in Longterm Care

Phenomenology

Evidence for Continuum

Mood Disorder

Major Depressive Episode

Minor Depression

Dysthymia

Clinical Course Treatment Response

Major Vs. Minor Depression Vs. Dysthymia

Major Depression

2 weeks duration

Depressed mood or loss of interest

5 of 9 symptoms

Significant distress or impaired functioning

Minor Depression

2 weeks duration

Depressed mood or loss of interest

2–4 of 9 symptoms

Significant distress or impaired functioning

Dysthymic Disorder

2 years duration

Depressed mood

2 of 6 symptoms

Significant distress or impaired functioning

Prevalence of Depression

Community elders: 3-5% with major depression 8-15% with minor depression

Primary Care 5-10% with major depression 10-20% with minor depression

Nursing Homes 10-15% with major depression 25 – 40% with minor depression

Biological Nonpsychiatric physical

illness Gene polymorphisms

ClinicalSymptom severityLifetime age of onsetComorbid anxiety Cognitive impairment

Psychosocial –Intrapersonal

Demographics Personality disorder Traits and dispositions

Psychosociall Environmental –

Social supports

Perceived chronic stress

Life events/acute stress

Physical environment

Nested Potential Predictors of Treatment Response in Late Life Depression

The

DepressedOlderAdult

Biological

ClinicalPsychosocial – Intrapersonal

Psychosocial – Environmental

Courtesy, Mary Amanda Dew, Ph.D.

Presentations Depression

Somatic Presentation

Anxiety Symptoms

Associated with Medical Illness

Associated with Social Stressors of Nursing Home Placement

Why to they complain “I’m Sick”

Infection Loss of interest Loss of pleasure Low energy, fatigue Negative mood

(irritable) Excessive sleep Loss of appetite

Depression Loss of interest Loss of pleasure Low energy, fatigue Negative mood

(irritable) Excessive or too little

sleep Loss of appetite

3 Yr. incidence of most common complaints in primary care settings (Kromke et al. Am J Med 1989)

Chest pain

fatigue

dizziness

headache

edema

back pain

dyspnea

insomnia

abd. pain

numbness

0

1

2

3

4

5

6

7

8

9

10

3 yr

. in

cid

ence

%

cause unknowncause known

Predictors of Somatic Worry (Lyness et al, 1993

Variable (N=91) P <Age 0.0005Education 0.0003Hamilton Depression Score 0.0002Gender NSCumulative illness Rating NSKarnofsky Perfomance NS

Treatment of Depression

Pharmacological Approach Essential in community and primary care settings Minimal data of effectiveness in nursing homes Will discuss UNIQUE aspects of nursing home

depression Non-pharmacological Approach

Few standardized randomized trials Psychotherapy may be extremely helpful Staff approach depends on understanding UNIQUE

characteristics of nursing home depression “Control-relevant” intervention Staff Education is Key

Late-life Depression in Community

Prognosis poor if untreated 20-40% of older depressed patients are well

at one to five years of follow-up

Acute treatment: all classes of meds effective

Rates of remission: 27 to 78% with longer studies resulting in higher rates (8-12 weeks)

Maintenance and continuation tx: dose that gets them well, keeps them well

Treating to complete remission is best protection from recurrence or chronicity

Proportion of partial and non-responders at weeks 4 to 10 classified as full responders after additional weeks of treatment

Mulsant et al., J Clin Psychopharmacology, 26(2):113-120, 2006

195

N=78 nonresponders N=28 responders who relapsed

N=89 responders with no relapse

Received Augmentation

Received Augmentation

Recovered n=24

Did not n=24

Did not/ Terminated

n=11

Recovered n=78

Did not n=7

Recovered n=14

n=48 n=21

Does Pharmacotherapy Augmentation Work

in Late-Life Depression?

50.0% vs. 66.7% vs. 87.6%

chi squared (df = 1) = 23.20, p < .001

Dew MA, Reynolds CF et al., Am J of Psychiatry, 2007

Even “Old Old” with Depression Respond to Treatment

Week from treatment start

0 2 4 6 8 10 12 14 16

HR

S-1

7 T

otal

0

2

4

6

8

10

12

14

16

18

20

22

24

59-69 (N=163)70-75 (N=80)76-95 (N=80)

Gildengers et al. J Affect Disord, 69(1-3):177-184, 2002

Preventing Recurrence of Depression Reynolds et al 2006

Randomized, controlled trial of elderly patients with major depression who had had a response to initial treatment with paroxetine and interpersonal psychotherapy

Mean age: 77; 60% were first episode; 65% female

Relapse Rates Medication plus therapy: 35% Medication plus supportive visits:37% Placebo meds plus therapy: 68% Placebo meds plus supportive visits: 58%

Time to Recurrence from Randomization: MTLD-II

Reynolds, Dew, Pollock, et al. N Engl J Med, 354(11):1130-1138, 2006

Weeks since randomization

0 10 20 30 40 50 60 70 80 90 100 110 120

% f

ree

fro

m r

ecu

rre

nce

0.0

0.2

0.4

0.6

0.8

1.0

Paroxetine + IPT (n=28)Paroxetine + Clinical Management (n=35)IPT + Placebo (n=35)Clinical Management + Placebo (n=18)

Log rank X2=9.77, df=3, p=.0206

Factors Contributing to Relapsing, Chronic Illness Course in Late-Life Depression

Psychosocial factors: Role transitions, bereavement, increasing

dependency, interpersonal conflicts Progressive depletion of psychosocial and economic

resources

Chronic sleep disturbances

Cerebrovascular disease

Neurodegenerative disorders

Limited access to adequate treatment

Nortriptyline: Standard vs. low dose in nursing home residents

Streim et al: Am J Geriatr Psychiatry 8:2, 2000

>12 on HDRS

Significant dysphoria

Blessed Information- Memory-Concen. < 18

Randomized (2:1) to standard or low dose, stratified by cognitive status

10 weeks of treatment

Low dose: 10 - 13 mg./day

Standard: 60 - 80 mg. / day

Results N = 69, Completers: Standard: 25, low: 16

Drop-out rate: similar

Both groups responded (p<0.001), no difference between groups

Interaction between dose and cognitive status Cog. Intact: better on standard dose Cog. Impaired: better on low dose

plasma levels similar for both cognitive groups, suggesting pharmaco-dynamic effect

Treatment of Minor Depression in Long-Term Care with Paroxetine

(Burrows, et al; 2002)

8-week placebo controlled trial

24 patients randomized with no dementia or mild dementia

No difference between placebo and medication!!!

“Politics” of Medication Treatment

The Quality Indicators required documentation of “Depression without antidepressants” until recently

NOW: CMS’ State Operating Manual (SOM) identify anti-depressants as medications requiring GDR (gradual dose reduction)!

Although data does not support all nursing home residents benefit from medications, residents with history of depression should not be subjected to GDR.

Why do pharmacological studies fail in Nursing Homes?

Depression in nursing homes differ than in community Psychosocial losses Medical burden Loss of control

Measurement of depression in NH may be different than depression in the community HDRS and GDS focus on mood and health NH should focus on QoL.

“Therapy” in Long-Term Care

Therapy “Treatment of illness or disability”

Nursing home residents have the lack of ability to create their own socialization program or seek pleasurable activities.

Goal is to create “therapy” that addresses this disability

Control-Relevant Intervention:Goals of Nursing Home Therapy

Reduce stressors Loss of control Temporal variability Hopelessness

Develop relationships

Control-Relevant Intervention

Socialization Designed by residents, based on prior

interests Participation, duration and frequency

determined by resident

Structured rating instruments

Global assessment of nursing staff

Raters and clinical staff blind to level of participation

Methods

Cognitive ability (MMSE > 18)

3 months residency

SCID DX: MDE (mild-to-moderate severity) Subsyndromal depression: sad mood or

marked apathy and two symptoms Dysthymia or other mild depressive states

Intervention

Coordinated by recreation therapist

1 to 2 hours 4 or 5 days/week

Initial week: small groups, lead by therapist

Week 2–7: increasing autonomy of group Lunch, cards, outside trips, board games

Final week: review progress and discuss strategy for continuation

Methods

Pre-intervention rating

2-month intervention

Post-intervention rating

Follow-up rating 2 months after termination

Results

“responders” identified at end of active study period

Two primary caregivers had to concur that patient was significantly improved (vs. some improvement, no improvement, or worse).

45% were significantly improved

After intervention stopped, all responders relapsed.

Responders vs. Non-Responders

Responders

More compliant with treatment – refusal rate of 11.2%

Perceived environment as less “cohesive” prior to intervention

Improved perception of “cohesiveness”

Non - Responders

Less compliant with treatment – refusal rate of 28% (P <0.01)

No change in perception of cohesion

Role of Education in LTC

12 hours required by OBRA guidelines

Some mandatories

Poor monitoring of compliance

Little monitoring of competency

No standardization of quality of education

Coordinators of education

DON or Education Director

Human Resources Director

Survey of DON’s in California Most feel unprepared for all aspects of job Psychosocial and behavioral are weakest

areas (Soecklin et al. Annals of LTC 1998; 6:122-129)

In Minnesota, 60% provide little or no education in depression / psychiatric problems (Grant LA et al. J Gerontol. Nurs. 2000; 1:9-16)

CNA perception of training (Mercer et al. J Gerontol. Social Work: 1993; 21:95-112)

(Cohn et al. J. of Long-Term Care Administration 1987; 20-25)

Boring

Repetitive

Punitive

Lacking in relevance to job

Little training in depression and dementia

Examples of Research on Staff EducationCohn; J. of Gerontological Nursing; 1990

Five mandatory 90-minute sessions over 5 months

Each session presented 4-5 times over 2 days

Advanced degree nurses with special skills

60% of CNAs attended 4 of the 5 sessions

Enhanced knowledge

Enhanced self-reported job performance

Examples of Research on Staff EducationBrooks; J of AMDA; 2000; 191-196

Comparison of lecture and videotape in-service for CNAs: 3 facilities

Compliance with single inservice: 27%

Both methods showed improved knowledge immediately

4 months later; knowledge was WORSE than earlier pre-test

Annual Costs (& hidden costs) of Education

(estimates based on market surveys)

Expenses Low end ($) High end ($)

Coordinator of Education 15,000 50,000

Educational materials 1500 4000

Outside consultants 500 3000

Overtime 2000 8000

Total 19,000 65,000

Computer-based interactive video

Solutions for Longterm Care by Fox Learning Systems Created with NIHM funding Uses television documentary approach with

interactive video REAL LIFE, REAL LEARNING

Available to all staff on all shifts individually or in groups

Brings experts to each facility

Administrative Software Schedules all staff for training Maintains record of training completed and

competency scores

Clinical Curriculum

Normal Aging

Understanding Depression

Behavioral Treatment of Depression

Understanding Dementia and Alzheimer’s Disease

Working with Dementia

Agitation and Aggression

Communication / The MDS

Medications

Residents’ Rights and Abuse

Restraints / Falls

Skin care / Pressure Ulcers

Fire / Disaster preparedness

Pain Assessment and Management

Universal Precautions and Infection Prevention

Safety Curriculum

Ergonomics & Proper Body Mechanics

Manual Resident Transfers

Mechanical Resident Transfers

Preventing Slips, Trips, and Falls

Safely Caring for Aggressive Residents

Transitional Return to Work

Short form Series for CNAs (57 topics): Mental Health Topics

THE AGING PROCESS Physical Changes of Aging Emotional and Cognitive Changes

of Aging

DEPRESSION Caring for the Elderly with

Depression Depression: Recognizing the Signs

and Symptoms Assessing and Preventing Suicide

in the Elderly Depression and Failure to Thrive Depression and Resistance to care

DEMENTIA

Understanding Dementia

The Effects of Dementia on the Brain

The Art of Dementia Caregiving

External Causes of Agitation

Internal Forces of Agitation

Dementia Care: Bathing and Showering

MEDICATIONS

Introduction to Medications for the Elderly

Psychiatric Medications

OBRA Medication Guidelines

Compliance with Training at Computer-site vs. Lecture-site

Each site received one training module / month

Participation required

Lecture: Live lecture + 2 video sessions

Computer: All personnel scheduled according to shift primary and secondary

Compliance with training at computer and lecture sites (CNA and Others)

0

10

20

30

40

50

60

70

% of Staff

Computer Site Lecture Site

ComputerCNAComputerother

LectureCNALectureOther

Satisfaction with Training

0

10

20

30

40

50

60

70

80

90

100

Very Much Some What Not At AllResponse

Per

cent

age

of R

espo

nder

s

Computer Site

Lecture Site

%

Conclusion

Depression comes in various forms in elders in longterm care

Treatment involves medications and therapy INTEGRATION OF FAMILY AND STAFF IN PSYCHOSOCIAL

INTERVENTIONS ACTIVITIES BASED THERAPIES

UNDERSTAND ROLE OF STAFF EDUCATION

Gradual Dose Reduction should NOT be attempted in residents with history of major depression unless medically indicated

Contact Information

Jules Rosen MD, Professor of Psychiatry

University of Pittsburgh

rosenji@upmc.edu; (412) 246 5900

Fox Learning Systems, Inc.

www.foxlearningsystems.com

(412) 531 1889

“It is not enough to add years to one’s life…one must also add life to those years”