Depression in Connecticut Nursing Homes: How We Can Help Our Depressed Elders

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Depression in Connecticut Nursing Homes How We
Can Help Our Depressed Elders

• Qualidigm
• October 2006

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Our Speakers

• Ann Spenard, MSN, RN C
• Clinical Advisor to the NHQI Project
• Manager of Long Term Care, DAVE2 Project
• Alice Bonner, APRN - BC, GNP
• Director of Clinical Quality, Massachusetts
  Extended Care Federation
• Clinical Instructor, UMASS Graduate School of
  Nursing, Worchester, MA
• Laurie Herndon, MSN, APRN-BC
• Gerontologic Nurse Practitioner
• Fallon Clinic, Worchester, MA

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Nursing Home Compare, MedQIC STAR

• www.medicare.gov/nhcompare
• www.medqic.org
• www.nhqi-star.org

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Follow-Up Conference Call

• Thursday, October 12th, 1030 1115 am
• Call in 1-800-914-3396
• Access Code 6133699

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Depression in CT Coding the MDS

• Ann Spenard, MSN, RN C

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2.1 Residents Who Have Become More Depressed or
Anxious

• Numerator Residents whose Mood Scale scores are
  greater on target assessmentt relative to prior
  assessmentt-1.
• Denominator All residents with a valid target
  assessment and valid prior assessment.

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2.1 Residents Who Have Become More Depressed or
Anxious

• Exclusions Resident satisfying and of the
  following conditions
• The Mood Scale score is missing on the target
  assessment .
• The Mood Scale score is missing on the prior
  assessment and the Mood Scale score indicates
  symptoms present on the target assessment.
• The Mood Scale score is at a maximum (value8) on
  the prior assessment.
• The resident is comatose or comatose status is
  unknown.

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Mood Scale Definition

• Mood Scale score is defined as the count of the
  number of the following eight conditions that are
  satisfied (range 0 through 8) on the target
  assessment.
• Any verbal expression of distress (E1a,c,e,f,g,h)
  Negative statements, repetitive calling out,
  self deprecation, expression of unrealistic
  fears, recurrent statements that something
  terrible is about to happen, repetitive health
  complaints

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Mood Scale Definition (continued)

• Shows signs of crying, tearfulness (E1mgt0)
• Motor agitation (E1ngt0)
• Leaves food uneaten (k4c is checked) on target or
  last full assessment.
• Repetitive health complaints (E1hgt0)
• Repetitive/recurrent verbalization (E1a,c,ggt0)
• Negative statements (E1a,e,fgt0)
• Mood symptoms not easily altered (E22)

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Coding Section E

• Remember that Section E (Indicators of
  Depression, Anxiety, Sad Mood) has a 30 day look
  back.
• The intent in coding these items is to record the
  frequency of indicators observed in the last 30
  days, irrespective of the assumed cause of the
  indicator (behavior).

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Coding Section E (Continued)

• Definition Feelings of distress may be expressed
  directly by the resident who is depressed,
  anxious or sad. However, statements such as Im
  so depressed are rare in the older nursing
  facility population. Rather, distress is more
  commonly expressed in the following ways
• Verbal expressions of distress, sleep cycle
  issues, sad, apathetic, anxious appearance, loss
  of interest.

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Coding Section E (Continued)

• Process When completing this section of the
  MDS
• converse with the resident if they are able
• observe the resident encourage all staff that
  come in contact with the resident to share
  observation of any of these indicators
• consult with direct care staff across all shifts
• speak to family who have direct knowledge of the
  residents behavior
• review the medical record including nursing
  notes, behavior logs, activities notes and
  therapy notes

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Coding Section E (Continued)

• Coding Remember, code regardless of what you
  believe the cause to be.
• Code a 0 if the indicator was not exhibited in
  the last 30 days.
• Code a 1 if the indicator of this type exhibited
  up to five days a week (i.e., exhibited at least
  once during the last 30 days but less than 6 days
  a week.
• Code a 2 if the indicator of this type exhibited
  daily or almost daily (6,7 days a week)

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Common Coding Issues

• The person coding this item does not read the
  chart for the indicators.
• Not capturing behaviors that are so common the
  they become baseline or normal for a resident.
• Not coding a item that happens at least once
  during the look back period.

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Questions and Answers
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Contact Us

• Qualidigm - 860-632-2008
• www.qualidigm.org
• Ann Spenard 860-613-4183 aspenard_at_qualidigm.org
• Michelle Pandolfi 860-632-3735 mpandolfi_at_qualidigm
  .org

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Transforming the Lives of Nursing Home
ResidentsEvaluating Managing Depression

• Laurie Herndon, APRN-BC, GNP
• Consultant
• Alice Bonner, APRN-BC, GNP
• Director of Clinical Quality
• Massachusetts Extended Care Federation
• October 5, 2006

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Goal for Today

• Have you identify at least ONE area that you
  would like to improve/implement in your facility
  when you go back
• Decide to BE or FIND a champion for depression
  recognition and treatment at your facility

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What Makes Someone a Champion?

• They articulate a vision that others have, but
  cannot always convey
• They are committed to hard work and personal
  sacrifice to achieve their goal
• They believe in the importance of the goal for
  the benefit of others

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Who can be a Champion?
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Consider this successful model

• Have your champions form a mental health team
• Gain expert knowledge and skills, but must be
  more than one person
• Support each other and commit to setting and
  achieving goals specific to depression
• Give the team the ability to focus on one area

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What is Depression?

• It is not just feeling sad it is not a transient
  response to losses or disappointments or to
  loneliness or boredom
• Depression is a spectrum of mood disorders
  characterized by a sustained disturbance in
  emotional, cognitive, behavioral, or somatic
  regulation and associated with significant
  functional impairment and a reduction in the
  capacity for pleasure and enjoyment
• AMDA Depression Clinical Practice Guideline,
  2003

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Why Should We Be Especially Concerned About
Depression?

• In the general population over age 65, about 15
  of people experience symptoms of depression that
  make it difficult to function or cause distress
  (minor depression)
• About 1-2 of people over age 65 have major
  depression
• But in the nursing home population

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Depression in the Nursing Home

• 70 at one time experience depressed, sad or blue
  mood
• 50 have minor depression
• 12-16 of older adults in nursing homes have
  major depression (Mulsant, 1999)
• Depression is typically under-reported in nursing
  home residents
• Severe depression carries a significant mortality
  risk (Beekman, 1997 Pennix, 1999)

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Depression in the Nursing Home

• 300,000 or 20 of the 1.5 million nursing home
  residents have symptoms of depression
• 13 develop new episodes of major depression and
  18 develop new symptoms of depression over a one
  year period

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Depression Is Most Strongly Correlated With Which
Medical Conditions?

• Cerebrovascular disease
• 25
• 30-60 of post-stroke residents will experience
  depression within 24 months
• Parkinsons disease
• 40
• Dementia
• 50
• 33 have major depressive disorder (MDD)

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Barriers to Detecting Depression in Older Adults

• What do you think they are?

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Barriers to Detecting Depression in Older Adults

• Limited time in medical/nursing encounter
• Providers may have varying expertise with
  geriatric depression
• Lack of mental health providers in nursing homes
  in some regions
• Limited reimbursement for mental health services
• Formulary restrictions

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Barriers to Detecting Depression in Older Adults

• Many competing demands and co-morbidities
• Belief that depression is a natural consequence
  of old age
• Ageism
• By medical providers
• By the resident or society
• Facility Characteristics (possibly)

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Barriers to Detecting Depression in Older
Adults

• More often report somatic (physical) symptoms
• Less often report depressed mood
• Have difficulty admitting to a mental health
  diagnosis (stigma of MH) or feel they should just
  be able to get over it
• May present with masked or atypical
  depression (hidden by preoccupation with physical
  concerns and complicated by overlap of physical
  and emotional symptoms)
• Elders will often rally when with health care
  providers

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Factors Associated with Lower Recognition Rates
of Depression

• More advanced age
• Language or cultural barriers
• Significant sensory impairments
• Confounding medical conditions
• Significant cognitive impairment
• Family stating resident has always been like
  this
• Failure to recognize signs and symptoms of
  depression in older adults as being different
  from younger population

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AMDA Depression Clinical Practice Guideline
(2003)Depression Algorithm
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Recognition of Depression

• Step 1. Does the resident have a history of
  depression or a positive depression screening
  test?
• Step 2. Does the resident have signs and
  symptoms of depression?
• Step 3. Does the resident have risk factors for
  depression?

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Recognition Step 1.History of Depression
/Positive Depression Screening

• Appropriate screening tests include
• Geriatric Depression Scale (GDS)
• Cornell Scale for Depression in Dementia (CSDD)
• Center for Epidemiologic Studies of Depression
  Scale (CES-D)
• Patient Health Questionnaire 9 (PHQ9)
• in QIO toolkit or at www.nhcqf.org
• available through www.MedQIC.org

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Recognition Step 2.Signs or Symptoms of
Depression

• Use the RAI (MDS and RAP triggers)
• Use other parts of the medical record
• Obtain family input
• Obtain staff input
• Practitioners
• Nursing staff on all three shifts
• Social workers
• Dieticians
• Activities staff
• Chaplains
• Therapists

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Recognition Step 2.Signs or Symptoms of
Depression

• May include
• Changes in socialization patterns or attendance
  at social or recreational activities
• Apathy, anger, irritability, combative or
  resistive behaviors
• Preoccupation with life review, somatization
• Increased use of health services and resources
• Delusions (in major depressive disorder with
  psychotic features)

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Recognition Step 2.Observations Suggestive of
Depression

• Cognitive patterns related to items in Section B
  of the MDS 2.0
• History of depression or other psychiatric
  disorder
• Mood and behavior patterns (MDS Section E)
• Nutritional problems (MDS Section K-4)
• Weight changes (MDS Section K-3)
• Future versions of the MDS may contain
  different section numbers and/or cross references

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Recognition Step 2. Most Important Signs and
Symptoms

• Depressed mood most of the day, almost every day,
  by either
• Subjective report (feels sad or empty)
• Observation made by others (appears tearful)
• Diminished interest or pleasure in most
  activities, most of the time
• Thoughts of death or suicide

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Recognition Step 2. Important Signs and Symptoms

• Difficulty making decisions
• Feelings of helplessness
• Feelings of worthlessness or hopelessness
• Inappropriate feelings of guilt
• Psychomotor agitation or retardation not
  attributable to other causes
• Social withdrawal, avoidance of social
  interactions or going out

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Recognition Step 2. Other Sometimes Helpful
Signs and Symptoms

• Appetite change
• Morning sluggishness and lack of energy that
  improves markedly later in the day
• Change in ability to think or concentrate
• Change in activities of daily living (ADLs)
• Family history of mood disorders
• Fatigue or loss of energy, worse than baseline
• Insomnia or hypersomnia nearly every day
• Increased complaints of pain
• Preoccupation with poor health or physical
  limitations
• Weight loss or gain
• Alexopoulos et al, 2001

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Need to Consider the 3 Ds

• Depression
• Dementia
• Delirium
• Not always easy to tell the difference
• Many overlapping symptoms

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Recognition Step 2. Differentiating depression,
dementia, delirium

• Time frame generally more acute with delirium
• Delirium linked to an underlying medical etiology
• Delirium has fluctuating level of consciousness
• Delirium may have marked psychomotor agitation or
  retardation
• Dementia usually includes cognitive impairment
  recognized over a period of time by family,
  friends or neighbors

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Recognition Step 2. What Questions Do You Ask
Your Resident?

• Maybe not what, but how
• What do you dream about?
• Are there things that you regret, or wish you
  had done differently in your life?
• What keeps you up at night?
• If we could do one thing differently for you
  here, what would that one thing be?
• Hows the food?
• Are you sleeping well at night?

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Recognition Step 2. Ask About

• Pain
• Comfort
• Contentment
• Anger
• Guilt
• Sleep
• Constipation
• Interactions with staff

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What are residents, family and staff seeking?

• Quality of life, not just quality of care
• Staff who are respectful and well trained
• Most of all staff who care
• they want to help
• they are kind and good to me
• there are enough of them
• they are friendly and cheerful
• they are patient and have time for me
• NCCNHR 1985
• Tellis-Nayak and Tellis-Nayak 2005

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Recognition Step 2. Recognizing Suicidal Ideation

• May be subtle
• Easier to recognize active
  behaviors
• Active suicidal behaviors
• Hoarding pills or plastic wastebasket liners
• Passive suicidal behaviors
• Refusing medications, nutrition and care

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Recognition Step 2. Recognizing Suicidal Ideation

• Older age has an ? risk of suicide, especially in
  males
• One fourth of all suicides occur in persons ?65
• Risk factors depression, physical illness,
  living alone, male sex, alcoholism, over age 80
• Dont make the mistake of thinking, Hes too
  frail and sick. He couldnt commit suicide.

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Recognition Step 3.Risk Factors for Depression
in Older Adults

• Alcohol or substance abuse
• Current use of a medication associated with a
  high risk of depression
• Hearing or vision impairment severe enough to
  affect function
• Personal or family history of depression or mood
  disorder
• History of attempted suicide
• History of psychiatric hospitalizations

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Recognition Step 3.Risk Factors for Depression
in Older Adults

• New admission
• Change in environment
• Deterioration in health status
• Loss of autonomy
• Loss of privacy
• Loss of functional status

• Loss of significant relationship (death, divorce)
• Loss of mobility
• Loss of a body part
• Loss of roles (retirement)
• Financial stress
• Poor social supports

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Recognition of Depression

• Step 1. Does the resident have a history of
  depression or a positive depression screening
  test?
• Step 2. Does the resident have signs and
  symptoms of depression?
• Step 3. Does the resident have risk factors for
  depression?
• Yes to Any ? Go to Assessment
• No to All ? Routinely screen/check all residents
  for depression (at a minimum quarterly)

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Assessment

• Step 4. Has the resident had a persistently
  depressed mood or loss of interest or pleasure
  for at least two weeks?
• Step 5. Is it appropriate to perform a medical
  work-up for factors contributing to signs and
  symptoms of possible depression?

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Assessment Step 4. Persistent Depressed
Mood/Loss of Interest

• If the resident has depressed mood (dysphoria),
  loss of interest or pleasure (anhedonia) for gt2
  weeks, and if either has contributed to
  functional or social impairment, depressive
  disorder is likely (assuming bereavement or
  substance abuse not present)
• Contact health care practitioner for more input
  on differential diagnosis

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Assessment Step 5. Consider Medical Work-Up

• Consult practitioner on condition, prognosis,
  advance care directives
• Consult resident and/or family on expressed
  wishes
• Usual work-up includes
• History and physical
• Interdisciplinary RAI process
• Laboratory testing

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Assessment Step 5. Lab Tests for Evaluating
Possible Depression

• Electrocardiogram
• Folate, B12 levels
• Serum levels of digoxin or theophylline if taking
  either of those
• Urinalysis

• Chem profile (BUN, electrolytes, creatinine,
  glucose, Ca)
• CBC
• Serum levels if taking anticonvulsants, TCAs
• Thyroid Function Tests (TSH)

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Assessment

• Step 6. Is the resident taking medications that
  might cause or contribute to depression?
• Side effects of drugs, or the effects of multiple
  medications (polypharmacy) for other illnesses,
  may be confused with depressive symptoms
• If Yes ?
• Contact provider to adjust/change medications as
  appropriate

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Assessment Step 6.Medications That May Cause
Symptoms of Depression

• Anabolic steroids
• Anti-arrhythmic medications (e.g., amiodarone,
  mexiletine)
• Anticonvulsant medications
• Barbiturates
• Benzodiazepines
• Carbidopa or levodopa

• Certain beta-blockers (e.g., propanolol)
• Clonidine
• Cytokines (specifically IL-2)
• Digitalis preparations
• Glucocorticoids
• H2 blockers
• Metoclopramide
• Metronidazole (flagyl)
• Opioids

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Assessment

• Step 7. Does the resident have one or more
  conditions that may increase the likelihood of
  depression or that may cause depressive symptoms?
• If Yes ? Identify and manage possible underlying
  causes before adding medications for depression
  (or while adding medications, if depression is
  severe)
• Consider using a standardized tool to guide your
  resident assessment

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Assessment Step 7.Is It Depression or Something
Else?

• Medical illness can look like depression
• Thyroid disease
• Conditions that may cause apathy, fatigue,
  disturbed sleep, diminished appetite
• Dementia has overlapping symptoms
• Impaired concentration
• Lack of motivation, loss of interest, apathy
• Psychomotor retardation
• Disrupted sleep
• Bereavement is different because
• Most disturbing symptoms resolve in 2 months
• Not associated with marked functional impairment

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Assessment Step 7.Most Important Comorbid
Conditions

• Alcohol dependency
• Cerebrovascular diseases
• Medications that can cause mood disorders
• Neurodegenerative disorders (e.g., Alzheimers
  disease, Parkinsons disease, multiple sclerosis)
• Substance abuse

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Assessment Step 7.Other Important Comorbid
Conditions

• Endocrine disorders (thyroid)
• Head trauma
• Metabolic problems (B12, folate deficiency)
• MI
• Orthostatic hypotension
• Physical, verbal emotional abuse
• Schizophrenia

• Cancer
• COPD
• Chronic pain
• Congestive heart failure
• Coronary artery disease
• Diabetes
• Electrolyte imbalance

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Mrs. Lemieux

• Mrs. Lemieux is admitted to the long term care
  unit with Parkinsons disease, HTN, mild CHF,
  arrhythmia. She is on sinemet, propanolol,
  furosemide, amiodarone. On her admission
  assessment, she is found to be incontinent, and
  the PA adds oxybutinin to the regimen. Her
  appetite declines, and megace is added. A week
  later, she is found to be withdrawn and has
  delusions.

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Mrs. Lemieux

• What is going on here?
• The geriatric prescribing cascade

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Preventing the Geriatric Prescribing Cascade

• Always do a careful analysis of
• Every diagnosis
• Every symptom (for possible etiologies)
• Every drug (for possible adverse effects or
  interactions)
• Use your consultant pharmacist
• Drug-drug interactions
• Drug-disease interactions
• Disease-disease interactions
• Drug-food interactions

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Assessment

• Step 8. Do the residents signs and symptoms
  resolve with any
• Changes in medications?
• Treatment of comorbid conditions?
• If Yes ? Consider whether additional treatment of
  depression is needed

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Assessment

• Step 9. Clarify the diagnosis
• Need the entire interdisciplinary team
• Key Symptoms
• Depressed mood (dysphoria)
• Loss of pleasure/interest (anhedonia)
• Thoughts of death or suicide
• Feeling sad
• Frequently feeling like crying
• Feeling like life is not worth living
• Should always be communicated when they are
  identified by any staff or family member

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DSM-IV Diagnostic Criteria For Depression

• Gateway Symptoms (must have 1)
• Depressed mood (dysphoria)
• Loss of interest or pleasure (anhedonia)
• Other Symptoms
• Appetite change or weight loss
• Insomnia or hypersomnia
• Psychomotor agitation or retardation
• Loss of energy
• Feelings of worthlessness or guilt
• Difficulty concentrating, making decisions
• Recurrent thoughts of suicide or death

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DSM-IV Types of Depression Disorders

• Major Depression
• 5 or more of the symptoms for at least 2 weeks
• Minor Depression (AKA mild or subclinical)
• 2-4 of the symptoms
• Dysthymia
• Persistent, chronic symptoms of mild depression
  for at least 2 years
• Bipolar Disorder
• Meets criteria for Major Depression with at least
  one hypomanic episode

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DIAGNOSING BIPOLAR DISORDER

• Elevated mood persisting for 1 weeks, plus
• Three of these symptoms
• inflated self-esteem, grandiosity
• hypersexuality
• ? activity
• ? need for sleep
• pressured speech
• racing thoughts, flight of ideas
• distractibility

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DIAGNOSING BIPOLAR DISORDER

• Grandiose or paranoid delusions may be present
• Older residents more like to have a type of
  bipolar depression that presents as irritability

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Assessment Step 9.Clarify the Diagnosis

• Does resident meet criteria for Major Depression?
• If resident comes close, but does not meet all
  criteria, may still require close monitoring and
  possibly treatment.
• People with minor depression are at high risk for
  developing major depression
• Studies show treatment for these conditions leads
  to improvement in many cases (Oxman, 2002)

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Assessment

• Step 10. Does the situation warrant additional
  psychiatric support?
• Consider for the following situations

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Assessment Step 10.Psychiatric Consultation May
Be Warranted

• Bipolar depression
• Depression with comorbid alcohol dependency or
  substance abuse
• Depression with comorbid dementia
• Depression with suicidal ideation
• Double depression (major depression and
  dysthymia)
• Dysthymic disorder
• Evaluation to determine if depression requires
  treatment
• Severe, uncomplicated, non-psychotic unipolar
  depression
• Psychotic depression
• Alexopoulos, 2001

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Assessment Step 10.Psychiatric Consultation May
Be Warranted

• Many regions of the country do not have adequate
  access to mental health teams in long term care
• However, data suggest that some regions with low
  rates of treatment for geriatric depression do
  not always correlate with a lack of geriatric
  mental health teams
• Nurses need to become champions for mental health
  and need to advocate for residents

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Assessment

• Step 11. Does the residents depression exhibit
  complications that may pose a risk to the
  resident or to others?
• Is the resident psychotic, severely agitated,
  aggressive, neurovegetative, or suicidal?

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Assessment Step 11.Suicide Risk

• Increases with the severity of depression
• Compounded by
• Bereavement
• Psychosis
• Recent physical disability
• Alcohol dependency or sedative/hypnotic abuse
• Risk is highest among white males 80 or older
• Next highest risk is among white males 65-80
  years old

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Step 12. Implement appropriate treatment for
the residents depression

• This is where virtually all nursing homes can
  improve!!

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Step 12. TreatmentFacility-Wide Approaches

• Minimize institutional aspects of environment
• Consistent staffing is most critical element!!!
• Facilitate interaction with family and friends,
  friendly visitor programs
• Provide opportunities for spiritual or religious
  activities
• Provide socialization interventions and
  structured, meaningful physical and intellectual
  activities
• Individualize plans for each resident with their
  input

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Meaningful Activity
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Definition of an Elder

• "An Elder is a person who is still growing,
  still a learner, still with potential, and whose
  life continues to have within it, promise for and
  connection to the future. An Elder is still in
  pursuit of happiness, joy and pleasure, and her
  or his birthright to these remains intact.
  Moreover, an Elder is a person who deserves
  respect and honor and whose work is to synthesize
  wisdom from long life experience and formulate
  this into a legacy for future generations."
• -Barry Barkan, Live Oak Institute

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Step 12. Treatment

• The combination of pharmacologic therapy
  (antidepressants) AND non-pharmacologic
  interventions has been shown to be more
  effective, in many cases, than either treatment
  alone
• Treatment must be individualized for every
  resident. However, strong consideration should be
  given to the combination of medication and
  psychosocial interventions in most residents.

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Step 12. TreatmentNon-Pharmacologic Interventions

• Types of psychotherapy
• Cognitive-behavioral therapy
• Interpersonal therapy
• Problem-solving therapy
• Supportive therapy
• Types of psychosocial interventions
• Bereavement groups
• Family counseling
• Participation in social events
• Psycho-education
• Exercise

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Step 12. TreatmentNon-Pharmacologic Interventions

• The new F tag 329 on medication management will
  look for the use of non-pharmacologic therapy for
  behaviors and other mental health disorders prior
  to or concomitant with a medication being used to
  treat the resident. (Recently released and
  available through your state health care
  association or CMS).

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Step 12. TreatmentFactors in Determining Choice
of Pharmacologic Interventions

• Age
• Residents other medical or psychiatric illnesses
  (comorbidities)
• Other medications, potential interactions
• Medication costs, formulary constraints
• Prior response to or failure on a drug
• Side-effect profile and residents sensitivity to
  these effects
• Target signs and symptoms
• Training and experience of prescriber

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Step 12. TreatmentPharmacologic Interventions

• Categories of antidepressant agents
• Usual dosages
• Possible treatment strategies
• Antidepressants in frail, older adults should not
  be avoided. Evidence strongly suggests that these
  medications are safe and effective in this
  population, and are underutilized
• All psychoactive medications should be closely
  monitored, and discontinued if side effects occur
• Non-pharmacologic treatments should always be
  considered

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Step 12. TreatmentElectroconvulsive Therapy (ECT)

• Consider if resident is rapidly deteriorating,
  medications not tolerated or resident unable to
  take them
• Recent studies suggest ECT is well tolerated in
  elders and can lead to rapid response (Flint,
  2002)

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Step 12. TreatmentElectroconvulsive Therapy (ECT)

• Reasons to use ECT
• Effective for treatment of major depression
  mania response rates exceed 70 in older adults
• First-line treatment for residents at serious
  risk for suicide, life-threatening poor intake
• Standard for psychotic depression in older
  adults response rates 80
• Contraindications
• Increased intracranial pressure
• Recent MI or CVA
• Unstable CAD increase risk of complications
• May use maintenance ECT to prevent relapse
• May continue psychotherapy after completion of
  ECT treatment

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Definitions of Key Terms

• Response Positive effect from adequate
  treatment with at least a 50 reduction in signs
  and symptoms of acute depressive episode,
  provided that adequate medication, appropriate
  psychotherapy or both are provided
• Remission Complete resolution of all signs and
  symptoms of an acute depressive episode. Return
  to functional normality
• Recovery Sustained remission of signs and
  symptoms of depression
• Relapse Return of signs and symptoms of an
  acute depressive episode that was brought to
  remission but not full recovery
• Recurrence Development of a new episode of
  depression

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Phases of Depression Treatment

• Acute (About 3 months)
• Goal is to achieve complete resolution of signs
  and symptoms of acute depressive episode (ie,
  remission)
• Continuation (4-6 months)
• Goal is to prevent relapse as residents
  depressive symptoms continue to improve and his
  or her functionality improves (recovery phase)
• Maintenance (3 months or longer, depending)
• Goal is to prevent recurrence of a new depressive
  episode after complete recovery

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What Limits Achieving Remission in Geriatric
Residents?

• Misunderstanding of remission vs. response (dont
  stop at improvement if resident is not at
  functional baseline!)
• Remission rates improved with concomitant
  medication and psychotherapy in geriatric
  residents
• Ageism on part of health providers, residents,
  families
• Comorbidities
• Tolerability of individual antidepressants

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Step 13. Monitor Response to Treatment Clinical
Pearls

• Older residents do not take longer to respond on
  average compared with younger residents. However,
  some individual residents may take longer to
  respond.
• Start low, go slow was basically tested with
  TCAs. It has not been tested with SSRIs or other
  newer agents. SSRI dose escalation should be done
  gradually, but doses should be increased based on
  input from the team
• Practitioner should evaluate the resident at 2
  weeks, then consider changing or continuing
  treatment at 4 weeks and again at 6 weeks
• Suggestion put a tickler in the original order
  for the re-evaluation in 2 weeks

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Step 13. Monitor Response to Treatment

• Document approaches, timetables, goals of
  treatment in the ICP, progress notes.
• Goals may include
• Resolution of signs and symptoms of depression
• Improvement of scores on the GDS or CSDD
• Improvement in attendance at and participation in
  usual activities
• Improvement in sleep pattern

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Step 13. Monitor Response to Treatment

• Improvement is what is important to the resident
  or family, not only what we think is important
• We need to ask!!!

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Step 13. Monitor Response to Treatment

• Monitor resident for side effects and
  interactions
• Document response to dosage adjustments and
  laboratory monitoring
• Along with warfarin, psychoactive medications are
  most commonly associated with adverse drug events
  in the nursing home
• The most frequent adverse drug events with
  psychoactive medications occur in the prescribing
  and monitoring phases of the medication use
  process

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Step 13. Monitor Response to TreatmentAdditional
Considerations

• Treat anxiety, chronic pain and insomnia
• Treat medical comorbidities
• Diabetes
• CAD and Stroke
• Dementia
• Parkinsons disease
• The resident with frequent falls
• Consider that depressive syndromes may also occur
  in caregivers, who may benefit from therapy

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Impact on Quality of Care and Quality of Life

• Effectively treating depression can have an
  impact on virtually all quality
  measures/indicators
• We must get residents to remission, not just
  response
• This requires more than recognition (screening
  and assessment) it requires effective treatment
  and monitoring as well

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Impact on Quality of Care and Quality of Life

• Residents may have good quality of care, as
  measured by health care experts, and still not
  have quality of life (decided by the residents
  themselves)
• What factors go into quality of life?
• Evidence shows strong correlation between staff
  and family satisfaction ratings and nursing home
  quality
• Its all about relationships
• Its having someone waiting for you
• (Carter Williams, one of the Pioneer Network
  Founders)

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Impact on Quality of Care and Quality of Life

• How do you reward a CNA who is spending time with
  a resident, having a conversation or giving them
  a manicure?
• How do we decide what is meaningful activity for
  a resident? Or what is important work for a staff
  member?
• How can we provide meaningful work for CNAs other
  long term care staff?

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Collaboration is Critical

• Use technology or systems that encourage
  collaboration (documentation, teams,
  neighborhoods)
• Keep work visible
• Build trust among workers, and between workers
  and the organization
• Encourage teams, discourage silos
• Acknowledge and give credit for creativity and
  hard work small contributions and ideas as well
  as successful outcomes

114
An Idea write out the 5 things that staff will
do to help with depression

• We will listen to your hopes and dreams, as well
  as your concerns and fears
• We will help you find activities that are
  meaningful to you
• We will help you have food you like to eat
• We will support you when youre sad
• We will keep working hard until you feel better

115
Small Things Add Up
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Summary

• Nursing Home Depression is
• Common
• Associated with morbidity
• Difficult to diagnose because of atypical
  presentations
• Undertreated!
• Best Practices are available
• Take them with you!!!
• Make detection and management of depression part
  of the fabric of the culture in your facility

117
Summary

• Suicide is a serious concern in depressed older
  residents, especially males
• Depression treatment (acute preventive) should
  be individualized and may include
• Psychosocial approaches
• psychotherapy
• pharmacotherapy
• ECT (for major or psychotic depression)
• Choice of antidepressant should be based on
  comorbidities, side-effect profiles, resident
  sensitivity, potential drug interactions,
  compliance. Generally SSRIs are first line (AAGP,
  2003)
• Consider combination therapy

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Best Practices

• Screen every resident on admission using a
  standardized, validated measurement tool
• Complete a more in depth assessment on anyone who
  screens positive
• Discuss treatment options with the entire
  interdisciplinary team, resident and family
• Treat depression either non-pharmacologically,
  pharmacologically, or both
• Monitor for improvement and continue to treat
  aggressively until improvement occurs

119
Best Practices

• Refer to mental health teams when appropriate
• Consider alternatives when mental health teams
  are not available (telemedicine)
• Follow up with all residents (depressed and
  non-depressed) to detect new episodes of
  depression
• Collect data and use the data to improve systems
  in your facility

120
Best Practices Person-directed care

• Promote principles of person-directed care
  throughout departments and throughout the
  facility
• Consistent staff assignment is a critical element
  of person-directed care
• Intimate knowledge of the residents unique needs
  is a major way to prevent and manage depression
• Engage the resident and family in the residents
  care
• Promote a home-like environment, not an
  institutional one
• Promote principles of quality of life, not just
  quality of care
• Let every staff member know how much you value
  them!

121
Core Values

• The biggest disease today is not leprosy or
  tuberculosis, but rather the feeling of being
  unwanted, uncared for, and deserted by everybody.
  We can cure physical diseases with medicine, but
  the only cure for loneliness, despair and
  hopelessness is love.-Mother Teresa

122
Thank You for Being a Leader in Depression
Detection and Management!
123
Thank You!

• Laurie Herndon, APRN-BC, GNP
• laurieherndon_at_yahoo.com
• Alice Bonner, APRN-BC, GNP
• abonner_at_mecf.org