Depression among Community Living Stroke Survivors Using Home Care Services

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Depression among Community Living Stroke
Survivors Using Home Care Services

• Maureen Markle-Reid, Gina Browne, Camille
  Orridge, Stacey Daub, Mary Lewis, Robin Weir,
  Jacqueline Roberts, Lehana Thabane, Amiram Gafni

11th Annual Stroke Collaborative October 20th,
2008 Toronto, Ontario
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THE PROBLEM OF DEPRESSION AFTER STROKE

• Depression is common among stroke survivors and
  is associated with poor health outcomes and
  increased cost
• Despite the potential benefit associated with the
  identification and treatment of post-stroke
  depression, it often remains unrecognized and
  untreated
• Untreated depression is associated with slower
  recovery, lower quality of life, increased
  mortality, increased use of health services and
  early institutionalization
• Recognition, prevention and treatment of
  post-stroke depression are critical to achieving
  optimal patient outcomes after stroke.

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OUTLINE

• Background
• Research Questions
• Methods
• Design, setting and participants
• Study variables
• Results
• Recruitment/participants
• Characteristics of community living stroke
  survivors using home care services
• Prevalence of depression
• Risk factors and costs of depression
• Summary
• Implications
• Conclusions

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THE PROBLEM OF STROKE THE FACTS

• Stroke is the third leading cause of mortality in
  Canada and is the most common disabling chronic
  condition
• 40,000 to 50,000 people in Canada experience a
  stroke each year, and 80 of these people
  survive
• 60 of stroke survivors are left with permanent
  disability, and 12 to 25 will have another
  stroke within the first year
• 50 of people with strokes have other chronic
  conditions.

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THE PROBLEM OF DEPRESSION AFTER STROKE THE FACTS

• Post-stroke depression occurs in 30-50 of all
  stroke survivors in the year following stroke
• Period of greatest risk is within the first few
  months of onset
• Depression can be caused by biochemical changes
  in the brain caused by the stroke or a normal
  psychological reaction to the losses from stroke
• High incidence of relapse.

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ONSET AND DURATION OF POST-STROKE DEPRESSION

• Post-stroke depression is long-lasting 50-60 of
  those depressed in first month post-stroke are
  still depressed at 1 year
• Average duration is 9-12 months may last up to 3
  years
• Delayed onset between 3 months and 2 years
  about 30 who were not initially depressed become
  depressed.

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THE PROBLEM OF DEPRESSION AMONG STROKE SURVIVORS
USING HOME CARE SERVICES

• Increasing demand for home care services
• Only 20 of stroke survivors require
  institutionalization and most (up to 80)
  eventually return to their homes
• Average of 20 of stroke survivors are referred
  to CCAC services following acute hospitalization
  or inpatient rehabilitation
• Stroke is one of the top three reasons for
  admission to the Toronto Central Community Care
  Access Centre (CCAC)
• Of seniors with a stroke, 35 received home care,
  as opposed to 9 of non-stroke survivors.

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THE PROBLEM OF DEPRESSION AMONG STROKE SURVIVORS
RECEIVING HOME CARE SERVICES

• Stroke survivors receiving home care services are
  at high risk for depression compared to general
  community living stroke survivors
• Multiple risk factors
• Lower functional ability and related quality of
  life
• gt 65 years of age
• Reduced life satisfaction
• Poor social support
• Higher prevalence of cognitive impairment

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WHY IS THIS RELEVANT?

• Depression is an important complication of stroke
  that may impede rehabilitation, recovery, quality
  of life, and caregiver health
• Stroke-associated depression may reduce survival
  and increase the risk of recurrent stroke
• Depression among older people, in general, is
  associated with poor functional outcomes and
  dependency, diminished quality of life,
  mortality, higher use of drugs and alcohol,
  increased use of healthcare resources, and poor
  compliance with treatment of co-morbid health
  conditions.

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WHY IS THIS RELEVANT?

• In 1998, depression cost Canadians approximately
  14.4 billion dollars per year
• These costs are compounded by indirect costs to
  unpaid caregivers and society related to
  providing informal care

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RELATED WORK

• Most studies are based on surveys of the general
  population of community living seniors or general
  home care population
• Studies exclude people with cognitive impairment
  or other co-morbid health conditions
• Little is known about the prevalence of
  depression among community living stroke
  survivors using home care services or the risk
  factors for depression
• Little information on the characteristics of
  stroke survivors using home care services.

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MOOD DISTURBANCES
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What is DEPRESSION???
DEPRESSION IS A SERIOUS ILLNESS
--A Bio-Chemical Imbalance
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BEHAVIOURS ASSOCIATED WITH DEPRESSION

• Sadness
• Frequent crying
• Withdrawal
• Difficulty concentrating
• Difficulty making decisions
• Difficulty sleeping
• Lack of energy

• Feelings of worthlessness
• Negative outlook
• Over sensitive
• Feelings of hopelessness
• Recurrent thoughts of death or suicide
• Weight loss or weight gain (10lbs either way)

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DSM IV SYMPTOMS OF DEPRESSION
Depressed, Irritable, Volatile Mood, Worry
and/ or Anxiety
most of the day more days than not greater
than 2 weeks 5 symptoms Major
Depression greater than 2 years 2 symptoms
Dysthymia

• Over/under eating
• Over/under sleeping
• Fatigue, tiredness
• Low self-esteem

• Poor concentration/decision-making
• Hopelessness/pessimism
• Guilt, brooding and worry

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DISTINGUISHING FEATURESWEIGHING THE EVIDENCE
Emotional Response
Mood disturbance
Versus

• Feeling is Specific to Situation
• Focused Object of ? Feelings (one person/event)
• Appropriate/Timely
• Short Duration (days/weeks)
• Definite Onset

• Generalized
• Everyone (thing) (variety of people/events)
• Excessive/Unwarranted
• Long Duration (months/years)
• Insidious Onset (I dont know)

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TREATMENT FOR POST-STROKE DEPRESSION

• Depression in stroke survivors should not be
  regarded as inevitable or untreatable
• Prognosis is good with early identification and
  treatment
• 80-90 of depressive disorder can be treated
• Reducing just one depression-related risk factor
  can reduce the frequency and morbidity of
  depression.

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RESEARCH QUESTIONS

• What are the characteristics of stroke survivors
  referred to CCAC services?
• 2. What is the prevalence of depression in
  community living stroke survivors using home care
  services?
• 3. What are the risk factors for depression in
  community living stroke survivors using home care
  services?
• 4. What is the 6-month cost of use of health
  services for depressed community living stroke
  survivors using home care services?

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DEFINITIONS

• Prevalence of depression is the measure of the
  proportion of stroke survivors with depression at
  baseline
• Depressive symptoms CES-D gt 21
• Taking antidepressant medication
• Prevalence of recognized depression whether a
  stroke survivor identified as depressed is
  receiving any treatment (taking an antidepressant
  medication)
• Prevalence of adequately treated depression
  whether a stroke survivor identified as depressed
  is displaying depressive symptoms CES-D gt 21

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METHODS

• Design Cross-sectional survey using baseline
  data from a randomized controlled trial on the
  effects and costs of an interdisciplinary team
  approach to stroke rehabilitation for community
  living stroke survivors
• Setting Toronto Central CCAC
• Participants
• Confirmed diagnosis of stroke
• Up to 18 months post-stroke
• Eligible for home care services through the
  Toronto Central CCAC
• Able to speak and understand English or an
  appropriate translator is available
• Living at home in the community in the Toronto
  Central CCAC catchment area
• Study Period October 2005 September 2008

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STUDY VARIABLES

• Data Sources In-home interview, CCAC data,
  RAI-HC
• Dependent Variable Presence of depressive
  symptoms (CES-D gt 21)
• Independent Variables (known risk factors for
  depression)

6-Month Cost of Use of Health Services
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RESULTS
Assessed for Eligibility Referred to CCAC with a
Stroke Diagnosis (n 655)

• Excluded (n554)
• Did not meet inclusion criteria (n 308)
• Refused to participate (n 153)
• Deceased (n 3)
• Unable to contact (n 90)

Baseline Measures
Randomized (n 101)
Allocated to Intervention Group (n 52)
Allocated to Control Group (n 49)
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CHARACTERISTICS OF COMMUNITY LIVING STROKE
SURVIVORS USING HOME CARE SERVICES (N 101)

• 75 had their first-ever stroke
• 70 were within their first six months
  post-stroke
• 73 with a hospital admission within the last 6
  months 47 in-patient rehabilitation 26 acute
  care hospital,
• 53 had one or more risk factors for stroke 44
  hypertension 19 hypercholesterolemia 15
  diabetes 5 smoking, obesity, alcohol
• Average age was 74 years
• 54 were male
• 35 had four or more chronic health problems

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CHARACTERISTICS OF COMMUNITY LIVING STROKE
SURVIVORS USING HOME CARE SERVICES (N 101)

• Taking an average of 6 prescription medications
  daily
• 70 had physical discomfort, limiting bathing and
  dressing
• 74 had physical or emotional problems limiting
  socialization
• 20 were cognitively impaired
• 77 reported unsteadiness on their feet
• 40 lived alone
• 18 had a family caregiver with depression

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PERCENTAGE OF STROKE SURVIVORS WITH DEPRESSION
(0-18 MONTHS POST-STROKE) (n101)
n58
n38
n20
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PREVALENCE OF DEPRESSION AMONG STROKE SURVIVORS
BY SUBGROUP
Population Rates 20-25 Primary
Care 25-30 Secondary Care
35 Hospital 50 Home Care 57
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PERCENTAGE OF STROKE SURVIVORS WITH DEPRESSIVE
SYMPTOMS (CES-D gt 21) BY NUMBER OF MONTHS
POST-STROKE (n101)
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PERCENTAGE OF DEPRESSION DETECTED AND TREATED
(n101)
100
Non-Depressed n43
Percent
57
Depression Not Detected and Not Treated
(n 20)
Depression Detected but Inadequately Treated
Depressed n58
(n 18)
Depression Detected and Adequately Treated
(n 20)
0
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PERCENTAGE OF DEPRESSION DETECTED AND TREATED IN
STROKE SURVIVORS WITH DEPRESSION (n58)
Percent
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PERCENTAGE OF STROKE SURVIVORS WITH DEPRESSIVE
SYMPTOMS (CES-D gt 21) USING ANTIDEPRESSANTS BY
NUMBER OF MONTHS POST-STROKE (n38)
N4
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DEPRESSION RISK FACTORS (n 101)
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6-MONTH PER PERSON COST OF USE OF HEALTH SERVICES
FOR STROKE SURVIVORS WITH AND WITHOUT DEPRESSION
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SUMMARY

• Depression is highly prevalent among community
  living stroke survivors using home care services
  in the first 1½ years following stroke
• Only 35 of depression was recognized and
  adequately treated
• Rate of depressive symptoms increases in the 18
  months after stroke
• Antidepressant use among those with depressive
  symptoms varies from 14-80 in the first 1½
  years following stroke
• Depression is associated with first-ever stroke
  poor health, low social support higher use of
  prescription medications having a family
  caregiver with depression and increased cost of
  use of health services.

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MYTHS

• Depression is a character flaw
• Depressed people can just snap out of it if
  they want to
• Asking a depressed person about suicidal
  thoughts is dangerous

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BARRIERS TO DETECTION AND TREATMENT

• Individual doesnt realize they are depressed
• Health care practioner doesnt recognize or
  diagnose depression
• Stigmas associated with having depression
• Concerns that medication or treatment will alter
  personality or cause other side effects

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ASSESSING POST-STROKE DEPRESSIONUNDERDIAGNOSIS

• Overlap with stroke symptoms
• Under-reporting of symptoms due to stigma
• Assumed to be a normal sign of aging
• Assumed to be a normal reaction to losses
• Difficult to assess in patients with severe
  language and memory impairments and those lacking
  insight
• Inadequate training of health professionals.

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BARRIERS TO DETECTION AND TREATMENT IN HOME CARE
ARE MULTIFACTORIAL

• Eligibility for home care is determined primarily
  by physical needs
• Access to professional services is limited
• Use of standardized, evidence-based approach for
  screening, assessment and management
• Limited communication and collaboration between
  home care providers
• Short-term follow-up and support
• Little information on the best way to provide
  home care services for prevention and management
  of depression

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IMPLICATIONS WHAT CAN BE DONE?Home care
occupies a strategic position in the
identification and treatment of depression among
stroke survivors

• Key Components
• Assessment and screening
• Referral for treatment
• Ongoing monitoring and support

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Kessler-10 Screening Scale for Depressive
Symptoms and Anxiety
RECOGNIZING DEPRESSIVE SYMPTOMS

• During the past 30 days, about how often did you
  feel
• tired out for no good reason?
• nervous?
• so nervous that nothing could calm you down?
• hopeless?
• restless or fidgety?
• so restless that you could not sit still?
• depressed?
• that everything was an effort?
• so sad that nothing could cheer you up?
• worthless?

A score of 16-29/50 indicates medium risk for
anxiety and depression 30-50/50 indicates high
risk for anxiety and depression.
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TREATMENTS


MOST EFFECTIVE TREATMENT

• COUNSELING
• Interpersonal Therapy (IPT)
• Cognitive Behavioral
• Marital

• ANTIDEPRESSANTS
• SSRIs (Prozac, Zoloft, Paxil, Luvox)
• Tricyclics
• MAOs
• Herbal remedies i.e., St. Johns Wort

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MOST EFFECTIVE INTERVENTIONS ARE

• PROACTIVE
• INTENSIVE
• TARGET HIGH RISK
• COMPREHENSIVE MULTIFACETED
• EVIDENCE-BASED
• COORDINATED INTERDISCIPLINARY COLLABORATION

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ONGOING MONITORING AND SUPPORT

• Structured and planned contacts
• Regular follow-up to address risk factors, assess
  clinical outcomes and adherence to treatment
• Regular assessment of antidepressant and other
  medication therapy to assess response, side
  effects and compliance
• Increased attention to education and support for
  family caregivers of stroke survivors

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POLICY IMPLICATIONS

• Allocation of resources for depression screening
  and delivery of prevention strategies
• Development of processes, protocols
• Training, monitoring and support
• Change attitudes and perceptions

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CONCLUSIONS

• Depression is highly prevalent among stroke
  survivors receiving home care services in the
  first 1½ years post-stroke, and is associated
  with poor health outcomes and increased cost of
  use of health services
• Recognition and treatment of depression in stroke
  survivors using home care services is suboptimal
• Home care programs have the potential to play a
  major role
• Coordinated, multifaceted interventions to
  improve recognition and treatment of depression
  in home care need to be widely implemented.

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You can make a difference!
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ACKNOWLEDGEMENTS(2005 2008) Funded by

• CIHR Institute of Health Services and Policy
  Research
• CIHR Knowledge Translation Branch
• Ontario Ministry of Health and Long-Term Care
• Toronto Central Community Care Access Centre
• Bridgepoint Health
• McMaster University, System-Linked Research Unit
  on Health and Social Services Utilization
• Heart and Stroke Foundation of Ontario
• Greater Toronto Area Rehabilitation Network

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PARTNERS

• Toronto Central Community Care Access Centre
• Bridgepoint Health
• Saint Elizabeth Health Care
• VHA Home HealthCare
• VON
• COTA Health
• Ontario Ministry of Health and Long-Term Care
• McMaster University, System-Linked Research Unit
  on Health and Social Services Utilization

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THANK YOU!

• Maureen Markle-Reid, RN, MScN, PhD
• Principal Investigator
• Career Scientist, Ontario Ministry of Health and
  Long-Term Care
• Associate Professor, School of Nursing, McMaster
  University
• 1200 Main Street West, HSC 3N28H
• Hamilton, Ontario L8N 3Z5
• Tel [phone], ext. 22306
• Fax [phone]
• E-mail mreid_at_mcmaster.ca