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Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
Home care for depression in dementia
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Home care for depression in dementia

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  • 1. Recognition & treatment of depression in elderly What is the power of nurses and nursing assistants? Karel G. Brühl, MD
  • 2. 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
  • 3. 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’
  • 4. Role of nurses in Psycho geriatric care from 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.
  • 5. Dementia patients: most live at Home, 1 of 6 in Nursing Home I. Dutch perspective
  • 6. 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
  • 7. IN Nursing Homes Netherlands
    • Few registered nurses, many nursing assistants
    • Quantity of nursing assistants:
    • 40 nursing assistants: 1 doctor
    I. Dutch perspective
  • 8. 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.
  • 9. 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
  • 10.
    • .52.595.29495.29
    • 4.
    In the Netherlands yet some areas offer casemanagement at home The Netherlands
  • 11. 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
  • 12. Patient contacts 2007 I. Geriant Foundation
  • 13. Casemanagers had over 15.000 contacts in 2007 I.
  • 14. 400.000 nurses in NL 8 Nurses: 1 doctor I.
  • 15. 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.
  • 16. How well do nurses recognize depression?
    • 3 questions come first:
    • What is depression in elderly?
    • What is depression in dementia?
    • What is its prevalence?
    II.
  • 17. Prevalence depression elderly living in the community: 15 % II. Beekman et al, Br J Psychiat. 1999
  • 18. prevalence in elderly depending on long term care: 30% II . recognition Alexopoulos, Lancet 2005
  • 19. 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
  • 20. About 50% of depressions, in elderly who seek help, are recognized II . recognition Hoogendijk, VUmc 2006
  • 21. Symptoms of depressive episode: Not simple II . recognition
  • 22. Depressive episode DSM-IV
    • At least 5 symptoms
    • Most of the day
    • 2 weeks or longer
    • The 2 most important or ‘gateway symptoms’:
    • Depressed mood or appears depressed
    • Decreased Interest or pleasure
    II . recognition
  • 23. 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:
  • 24. 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
  • 25. 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
  • 26. Irritability also symptom of depression in dementia? not in DSM-IV depressive episode II . recognition
  • 27. 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
  • 28. 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
  • 29. 2007 pub med: over 400 studies on elderly depression and nurses II . recognition
  • 30. Review : Recognition of depression by nurses
    • The Question:
    • how well do nurses and nursing assistants recognize depression?
    II . recognition
  • 31. 4 high quality studies
    • 2 in USA nursing homes
    • 1 in USA home health care
    • 1 in the Netherlands: nursing home
    II. review
  • 32. Study in nursing homes Baltimore USA Rovner, 1991
    • Recognition:
    • Nursing assistants: 65%
    • Nursing home physicians: 14%
    • Family members: 70% !
    •  Doctors not part of staff: consultants
    • and specificity of doctors was high: 95 % (nurses 68%)
    •  advise doctors: ask nurse assistant first
    • 4 x better recognition!
    II. review
  • 33. Study in Nursing Homes New York Teresi, 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
  • 34. = about 50% of depressions in elderly who seek help are recognized II. review
  • 35. 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
  • 36. 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
  • 37. 4 High Quality studies: How well do Nurses and NAs recognize depression? II. review 65% Rovner 78% Falck 44% Teresi 45% Brown recognition study
  • 38. 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
  • 39. 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
  • 40. Small talk improves quality of life nursing home residents NIVEL, Beek et al, 2008 III. Treatment
  • 41. 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
  • 42. 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
  • 43. Exercise helps against depression enough studies show evidence for that  “ Appropriate Exercise” III. treatment
  • 44. Help with exercise works too III. Treatment
  • 45. Other help?
    • Pimp my ride...
    III. Treatment
  • 46. Duo bike: a combination of interventions
  • 47. 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
  • 48. Staff training positive effect on depression evidence 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
  • 49. ‘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.
  • 50. 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.
  • 51. 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.
  • 52. Things to do (4)
    • Include exercise, emotion oriented care, daily activity programs, medication options in your care planning
  • 53. 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
  • 54.
    • Thank you!
    • [email_address]

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