xiii update in psychogeriatrics, may 8th 2008 1 recognition & treatment of depression in elderly...

XIII Update in Psychogeriatrics, May 8th 2008

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Recognition & treatment of depression in elderly

What is the power

of nurses and

nursing assistants?

Karel G. Brühl, MD


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Depression in elderly & the role of nurses and nursing assistants ...

Nurses and all health care professionals can make a big difference for depressed elderly

Update to help you use knowledge of 2008 for your patients & family


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Depression in elderly & the role of nurses and nursing assistants ...

I. In psycho geriatric care, NL

II. In recognition

III. In treatment

IV. ‘things to do’


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Role of nurses in Psycho geriatric carefrom a dutch perspective

Psycho geriatric care = Long Term Care and Dementia Care

Outside Nursing Homes: Assisted Living Facilities or at Home

In Nursing Homes

I.


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Dementia patients: most live at Home, 1 of 6 in Nursing Home

0

10

20

30

40

50

60

70

%

Nursing HomeAssisted LivingHome

I.Dutch perspective


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IN NURSING HOMES

Multidisciplinary team: Several therapists/paramedical nursing assistants coordinate care nursing home physician

= Medical Doctor + 3 years geriatric education = staff member, not consultant

1 doctor: 100 patients in nursing home

I.Dutch

perspective


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IN Nursing HomesNetherlands

Few registered nurses, many nursing assistants

Quantity of nursing assistants:

40 nursing assistants: 1 doctor

I.Dutch

perspective


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Dementia care at Home

Netherlands Family Home care nurses and nursing

assistants general practitioner &

- Clinical geriatrician in hospital

- Social geriatrician at home: case-management

I.


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Dementia care at home: Casemanagement

New: Geriant Foundation 100 professionals, 1500 patients

Aim: improve functioning and Quality of

Life in people living with dementia

2001: 300 new patients 2007: 1000 new patients

I.Dutch

perspective


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.52.595.29495.29

4.

In the Netherlands yet some areas offer casemanagement at home

The Netherlands


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Casemanager = specialized nurse Registered Nurse + 2 years

psycho geriatric education 50 - 70 patients Central role: first assessment till

death or nursing home Most face to face contacts with

patients: 15.000 in 2007

I.Dutch

perspective


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Patient contacts 2007

nurse and NA'sgeriatricianpsychologist

I.

Geriant Foundation


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Casemanagers had over 15.000 contacts in 2007

I.


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400.000 nurses in NL8 Nurses: 1 doctor

I.


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Nurses’ power

All times, all over the world:

Number of nurses and nursing assistants high

Amount of contacts with patients high

We rely on nurses’ observations, also for symptoms of depression in Long Term Care

I.


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How well do nurses recognize depression?

3 questions come first:

1. What is depression in elderly?

2. What is depression in dementia?

3. What is its prevalence?

II.


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Prevalence depression

elderly living in the community: 15 %

no depression85%

depression15%

II.

Beekman et al, Br J Psychiat. 1999


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prevalence

in elderly depending on long term care: 30%

no depression70%

depression30%

II.

recognition

Alexopoulos, Lancet 2005


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What is depression in Elderly?

Minor depression and Major depression = depressive

episode DSM-IV: international ‘standard’ in high quality research

seems simple, is not simple

II.

recognition


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About 50% of depressions, in elderly who seek help, are recognized

patient doesnot seek helpdepression isnot recognizedtreatment (nosucces)treatment:succes 12,5%

II.

recognition

Hoogendijk, VUmc 2006


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Symptoms of depressive episode: Not simple

II.

recognition


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Depressive episodeDSM-IV

At least 5 symptomsMost of the day2 weeks or longer

The 2 most important or ‘gateway symptoms’:

Depressed mood or appears depressed Decreased Interest or pleasure

II.

recognition


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DSM-IV gateway symptoms:

1. Depressed mood 2. Loss of interest or pleasure

3. Weight and appetite 4. Sleep disturbance

5. Motor activity: agitated or slowed

6. Loss of energy

7. Feeling worthless or guilty

8. Indecisive, loss concentration

9. Thoughts of death or suicide or suicide attempt

Other symptoms:


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Depressive episode in elderly 5 symptoms often too many minor depression: 2 - 4 symptoms Impact on work, social or personal

functioning Not caused by medication or other

general medical condition (like dementia...)

II.

recognition


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In dementia: even harder to recognize Less verbal abilities Some symptoms due to dementia

itself: e.g. loss of interest in cooking or biking because it is not possible anymore

Mood symptoms change fast from situation to situation & from moment to moment

II.

recognition


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Irritability also symptom of depression in dementia?

not in DSM-IV depressive episode

II.

recognition


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Depression in Alzheimer's disease

New criteria, by Olin et al, 2002 differences with DSM-IV:

reduced pleasure in response to usually pleasant activities can be noticed by others (nurses) !

‘New’: Irritability & Social withdrawal 3 instead of 5 symptoms

Should be easier to recognize

II.

recognition


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Back to what is the power of nurses and nursing assistants

In mental health care for elderly

who are depending on long term care

number of studies is rising ....

II.

recognition


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2007 pub med: over 400 studies on elderly depression and nurses

0

5

10

15

20

25

30

35

PubMed

19721977198219871992199720022007

II.

recognition


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Review : Recognition of depression by nurses

The Question: how well do nurses and nursing assistants recognize

depression?

II.

recognition


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4 high quality studies

2 in USA nursing homes 1 in USA home health care 1 in the Netherlands: nursing home

II.review


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Study in nursing homes Baltimore USARovner, 1991

Recognition: Nursing assistants: 65% Nursing home physicians: 14% Family members: 70% !

Doctors not part of staff: consultantsand specificity of doctors was high: 95 % (nurses 68%)

advise doctors: ask nurse assistant first4 x better recognition!

II.review


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Study in Nursing Homes New YorkTeresi, 2001 42 % recognition by nurses 45 % recognition by nursing assistants 44 % recognition by psychiatrists

55-65% with screening scales for depressive symptoms (GDS or HAMD)

II.review


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= about 50% of depressions in elderly who seek help are recognized

patient doesnot seek helpdepression isnot recognizedtreatment (nosucces)succes

II.review


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USA study, New York in Home health care, Brown, 2002

Recognition nurses 45 %

new study with staff training (Bruce, Brown, JAGS 2007) in depression assessment and referral: recognition higher, appropriate referral rate, improvement of depressive symptoms and cure rate of depression higher

II.review


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Study in Nursing Home Amsterdam, Falck, 1999

Nursing assistants: 78% Nursing home physicians: 68%

If nursing home physician & NAs both answered YES depressed: recognition was almost 90%!

!! Nursing assistants talked in groups of 4 before answering yes or no depressed

Doctors here are staff members, not consultants

II.review


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4 High Quality studies:

How well do Nurses and NAsrecognize depression?

study recognition

Brown 45%

Teresi 44%

Falck 78%

Rovner 65%

II.review


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So: recognition of depression by nurses and nursing assistants

Few studies, compared to importance nurses and nursing assistants in mental health care of elderly

Screening scales higher recognition e.g Geriatric Depression Scale in Nursing homes, Jongenelis 2006: over 85% recognition!

Staff training helps to improve recognition as well

II.review


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Treatment of depression

What evidence is there for a positive effect of interventions or treatment by nurses?

Treatment = non-pharmaceutical and pharmaceutical treatment

Non-pharmaceutical treatment = psychological and psycho-social interventions

III. ‘the good part’Making elderly

Feel better


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Small talk improves quality of life nursing home residents NIVEL, Beek et al, 2008

III.Treatment


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International reviews*: effect of psychosocial interventions for depression in dementia

* Verkaik et al, 2005; Livingstone et al, 2005, Verhey 2006

Proved Effective :

Emotion oriented care Behavior therapy (25

studies) Snoezelen Exercise Music therapy

!! Combinations

Proved NOT effective:

Reality orientation Validation

Not yet enough high quality studies:

Activities without behavior therapy (5)

Reminiscence (5) Antidepressants *(4)

* Bains ea, cochrane 2006

III.Treatment


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Antidepressive medication

Currently debate about effectivity and side effects

30-35% placebo effect might be a psycho-social effect as well !

If nurses believe in it: even a better effect?

In practise medication helpful , especially for the more severe depressions

Yet not enough studies in elderly in general

III.Treatment


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Exercise helps against depression enough studies show evidence for that

“Appropriate Exercise”

III.treatment


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Help with exercise works too

III.Treatment


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Other help?

Pimp my ride...

III.Treatment


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Duo bike: a combination of interventions


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Another combined intervention? Admission to nursing home

Prevalence of depressive symptoms after 6 months in nursing home decreased from 41 % - 29 %

Smalbrugge, JAGS 2006

III.treatment


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Staff training positive effect on depressionevidence found in studies all over the world

Care intervention late life depression in residential care Australia, Llewellyn Jones, 1999

Staff training based on behavior therapy

combined with exercise program USA, Teri et al, 2003

Emotion oriented care training & pleasant events, care plan by nursing assistants: study in Dutch nursing homes preliminary data PhD study, Verkaik

III.treatment


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‘Things to do’ Admit it: we all miss a lot of depressions

in elderly

Communication is the key. Talk in your team about symptoms, doubts, failures and successes in recognition and treatment

Use screening scale for depression e.g. GDS: around 85% recognition in Nursing Homes

Ask for staff training in depression management

IV.


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Things to do (2)

Nurses and nursing assistants: speak out!

allway have the doctor or psychologist included your observation and opinion in a depression diagnose

Doctors, psychologists e.o: never just examine the patient, always examine other staff members opinion as well

Always ask family: they know best !

IV.


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Things to do (3)

Freely use DSM-IV criteria depressive episode, it will save many patients a lot of suffering

In Alzheimer’s: you might want to use the ‘provisional diagnostic criteria’ from Olin et al

IV.


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Things to do (4)

Include exercise, emotion oriented care, daily activity programs, medication options in your care planning


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Finally

Effective use of the power of nurses and nursing assistants in mental health care improves the quality of life of elderly

And will improve everybody’s work satisfaction as well


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Thank you!

[email protected]

xiii update in psychogeriatrics, may 8th 2008 1 recognition & treatment of depression in elderly...

Documents

mdxiii update

doxiii update

dutch perspectivexiii

geriant foundationxiii

homethe netherlandsxiii

nursing homei

nursing homesi

dementia care