Title: Depression among Community Living Stroke Survivors Using Home Care Services
1Depression 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
2THE 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.
3OUTLINE
- 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
4THE 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.
5THE 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.
6ONSET 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.
7THE 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.
8THE 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
9WHY 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.
10WHY 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
11RELATED 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.
12MOOD DISTURBANCES
13What is DEPRESSION???
DEPRESSION IS A SERIOUS ILLNESS
--A Bio-Chemical Imbalance
14BEHAVIOURS 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)
15DSM 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
16DISTINGUISHING 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)
17TREATMENT 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.
18RESEARCH 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?
19DEFINITIONS
- 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
20METHODS
- 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
21STUDY 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
22RESULTS
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)
23CHARACTERISTICS 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
24CHARACTERISTICS 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
25PERCENTAGE OF STROKE SURVIVORS WITH DEPRESSION
(0-18 MONTHS POST-STROKE) (n101)
n58
n38
n20
26PREVALENCE OF DEPRESSION AMONG STROKE SURVIVORS
BY SUBGROUP
Population Rates 20-25 Primary
Care 25-30 Secondary Care
35 Hospital 50 Home Care 57
27PERCENTAGE OF STROKE SURVIVORS WITH DEPRESSIVE
SYMPTOMS (CES-D gt 21) BY NUMBER OF MONTHS
POST-STROKE (n101)
28PERCENTAGE 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
29PERCENTAGE OF DEPRESSION DETECTED AND TREATED IN
STROKE SURVIVORS WITH DEPRESSION (n58)
Percent
30PERCENTAGE OF STROKE SURVIVORS WITH DEPRESSIVE
SYMPTOMS (CES-D gt 21) USING ANTIDEPRESSANTS BY
NUMBER OF MONTHS POST-STROKE (n38)
N4
31DEPRESSION RISK FACTORS (n 101)
326-MONTH PER PERSON COST OF USE OF HEALTH SERVICES
FOR STROKE SURVIVORS WITH AND WITHOUT DEPRESSION
33SUMMARY
- 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.
34MYTHS
- 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
35BARRIERS 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
36ASSESSING 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.
37BARRIERS 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
38IMPLICATIONS 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
39Kessler-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.
40(No Transcript)
41TREATMENTS
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
42MOST EFFECTIVE INTERVENTIONS ARE
- PROACTIVE
- INTENSIVE
- TARGET HIGH RISK
- COMPREHENSIVE MULTIFACETED
- EVIDENCE-BASED
- COORDINATED INTERDISCIPLINARY COLLABORATION
43ONGOING 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
44POLICY IMPLICATIONS
- Allocation of resources for depression screening
and delivery of prevention strategies - Development of processes, protocols
- Training, monitoring and support
- Change attitudes and perceptions
45CONCLUSIONS
- 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.
46You can make a difference!
47ACKNOWLEDGEMENTS(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
48PARTNERS
- 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
49THANK 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 905-525-9140, ext. 22306
- Fax 905-521-8834
- E-mail mreid_at_mcmaster.ca