Canadian Coalition for Seniors

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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
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Agenda

• Welcome Purpose of Presentation
• Birth and Formation of the CCSMH
• Overview National Guideline Project
• Dissemination and Implementation
• Conclusion and Questions

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Reality Seniors (by age sub-groups) as of the
Total Pop.
Canada, 1921-2041
25 20 15 10 5 0
Percentage
1921 1931 1941 1951 1961 1971 1981 1991 2001
2011 2021 2031 2041
Year
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Reality Defining Seniors Mental Health

• Mood Disorders
• Anxiety Disorders
• Dementia Alzheimers Disease and Other
  Dementias
• Personality Disorders
• Substance Use and Addiction / Concurrent
  Disorders
• Schizophrenia Autism
• Suicidal Behaviour

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Mental Illness is NOT a normal consequence of
aging!

• Depression 15 20 in the community
• LTC 80 - 90 of residents
• Alzheimers 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

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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 gt85)
• Paranoid thoughts 10
• Anxiety Disorders 19
• Alcohol dependence 1-3 (problem drinking 4-23)

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CCSMH

• Responding to the Needs of the Seniors Mental
  Health Community
• Birth and Formation of the CCSMH
• 2002

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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

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The CCSMH is committed to .

• 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

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Collaboration is a necessity for success!
CCSMH Steering Committee Members Alzheimer
Society of Canada Canadian Academy of
Geriatric Psychiatry CARP Canadas Association
for the 50 PlusCanadian Association of Social
WorkersCanadian Caregiver CoalitionCanadian
Geriatrics SocietyCanadian Health Care
AssociationCanadian Mental Health
AssociationCanadian Nurses AssociationCanadian
Psychological AssociationCanadian Society of
Consulting PharmacistsCollege of Family
Physicians of CanadaPublic Health Agency of
Canada (Advisory)
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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

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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

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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

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Seniors Mental Health Research Falling Between
the Cracks
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VISIT OUR WEBSITEWWW.CCSMH.CA
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CCSMH

• Responding to the Needs of the Seniors Mental
  Health Community
• CCSMH National Guideline Project

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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

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Guideline Development Project Steering Committee
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 Depression Dr. Marie-France Tourigny-Rivard Dr. Diane Buchanan
Co-Leads Suicide Dr. Adrian Grek Dr. Marnin Heisel Dr. Sharon Moore
Advisory Ms. Simone Powell / Dr. Louise Plouffe
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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
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Creation of Canadas FIRST National Evidence
Based Guidelines for Seniors Mental Health

• 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

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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

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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.

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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.

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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

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Whats 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

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Review of Process The Beginning
Guideline Topics Formalized
Determine Formalize Co-Leads for each group

• Formalize Guideline Development Groups
• CCSMH overall facilitation
• Co-chairs primarily responsible for all aspects
  of guidelines
• Group Members 4-8 per guideline
• Consultants called on as appropriate

• Determine Formalize Group Members and
  Consultants for each group
• Determined criteria for selection
• Gathered Names and Contacted individuals
• Formalized membership

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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

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Guidelines Categories of Evidence

• Ia Evidence from meta-analysis of randomized
  controlled trials
• Ib Evidence from at least one randomized
  controlled trial
• IIa Evidence from at least one controlled study
  without
• randomization
• IIb Evidence from at least one other type of
  quasi-experimental study
• III Evidence from non-experimental descriptive
  studies, such as
• comparative studies, correlation studies
  and case-control studies
• IV Evidence from expert committees reports or
  opinions and/or
• clinical experience of respected
  authorities
• Shekelle et al 1999

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Guidelines Strength of Recommendation

• A Directly based on category I evidence
• B Directly based on category II evidence or
• extrapolated recommendation from category
  I
• evidence
• C Directly based on category III evidence or
• extrapolated recommendation from category
  I or
• II evidence
• D Directly based on category IV evidence or
  extrapolated
• recommendation from category I, II, or III
  evidence
• Shekelle et al 1999

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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

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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

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Dissemination and Implementation
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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)

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What do we do next?
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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

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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.

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• The Assessment and Treatment of Mental Health
  Issues in Long Term Care HomesFocus on Mood and
  Behaviour Symptoms
• David Conn, MD, FRCPC
• Maggie Gibson, Ph.D., C.Psych

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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.

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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.

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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.

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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.

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Assessment Recommendations

• The facilitys 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.

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Treatment of Depressive Symptoms Disorders

• Consider the type and severity of depression in
  developing a treatment plans B.
• Psychological and social interventions.
• Pharmacologic interventions.

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Treatment of Behavioural Symptoms

• Psychological and social interventions.
• Social contact
• Sensory/ relaxation
• Structured recreational activities
• Individualized behaviour therapy
• Pharmacologic interventions.
• Weigh potential benefit harm

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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

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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.

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Mr. M

• Mr. M , at 82 years of age, had adjusted well to
  his move to a long term care home. His diagnoses
  included dementia (probable Alzheimers 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 wifes visits, due to her own
  failing health.

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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?

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Mr. Ms 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)

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Epilogue

• Increased pain control and changes to Mr. Ms
  social
• environment led to a reduction in resistive
  behaviours,
• improved sleep and increased participation in
• recreational activities (with assistance
  spontaneous
• participation did not resume). Screening at
  regular (3
• month) intervals triggered adjustments to Mr. Ms
  care
• plan as needed in response to escalation in
  behavioural
• and depressive symptoms. The palliative focus in
  Mr. Ms
• care plan was increased as his dementia
  progressed. He
• lived in the long term care home for three years
  before
• dying peacefully.

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VISIT OUR WEBSITE TO DOWNLOAD THE
GUIDELINESWWW.CCSMH.CA