Home care for depression in dementia


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Home care for depression in dementia

  1. 1. Recognition & treatment of depression in elderly What is the power of nurses and nursing assistants? Karel G. Brühl, MD
  2. 2. Depression in elderly & the role of nurses and nursing assistants ... <ul><li>Nurses and all health care professionals can make a big difference for depressed elderly </li></ul><ul><li>Update to help you use knowledge of 2008 for your patients & family </li></ul>
  3. 3. Depression in elderly & the role of nurses and nursing assistants ... <ul><li>I. In psycho geriatric care, NL </li></ul><ul><li>II. In recognition </li></ul><ul><li>III. In treatment </li></ul><ul><li>IV. ‘things to do’ </li></ul>
  4. 4. Role of nurses in Psycho geriatric care from a dutch perspective <ul><li>Psycho geriatric care = Long Term Care and Dementia Care </li></ul><ul><li>Outside Nursing Homes : </li></ul><ul><li> Assisted Living Facilities </li></ul><ul><li> or at Home </li></ul><ul><li>In Nursing Homes </li></ul>I.
  5. 5. Dementia patients: most live at Home, 1 of 6 in Nursing Home I. Dutch perspective
  6. 6. IN NURSING HOMES <ul><li>Multidisciplinary team: </li></ul><ul><li>Several therapists/paramedical </li></ul><ul><li>nursing assistants  coordinate care </li></ul><ul><li>nursing home physician </li></ul><ul><li>= Medical Doctor + 3 years geriatric education </li></ul><ul><li>= staff member, not consultant </li></ul><ul><li>1 doctor: 100 patients in nursing home </li></ul>I. Dutch perspective
  7. 7. IN Nursing Homes Netherlands <ul><li>Few registered nurses, many nursing assistants </li></ul><ul><li>Quantity of nursing assistants: </li></ul><ul><li>40 nursing assistants: 1 doctor </li></ul>I. Dutch perspective
  8. 8. Dementia care at Home Netherlands <ul><li>Family </li></ul><ul><li>Home care nurses and nursing assistants </li></ul><ul><li>general practitioner & </li></ul><ul><li>- Clinical geriatrician in hospital </li></ul><ul><li>- Social geriatrician at home: case-management </li></ul>I.
  9. 9. Dementia care at home: Casemanagement <ul><li>New: Geriant Foundation </li></ul><ul><li>100 professionals, 1500 patients </li></ul><ul><li>Aim: </li></ul><ul><li>improve functioning and Quality of Life in people living with dementia </li></ul><ul><li>2001: 300 new patients </li></ul><ul><li>2007: 1000 new patients </li></ul>I. Dutch perspective
  10. 10. <ul><li>.52.595.29495.29 </li></ul><ul><li>4. </li></ul>In the Netherlands yet some areas offer casemanagement at home The Netherlands
  11. 11. Casemanager = specialized nurse <ul><li>Registered Nurse + 2 years psycho geriatric education </li></ul><ul><li>50 - 70 patients </li></ul><ul><li>Central role: first assessment till death or nursing home </li></ul><ul><li>Most face to face contacts with patients: 15.000 in 2007 </li></ul>I. Dutch perspective
  12. 12. Patient contacts 2007 I. Geriant Foundation
  13. 13. Casemanagers had over 15.000 contacts in 2007 I.
  14. 14. 400.000 nurses in NL 8 Nurses: 1 doctor I.
  15. 15. Nurses’ power <ul><li>All times, all over the world: </li></ul><ul><li>Number of nurses and nursing assistants high </li></ul><ul><li>Amount of contacts with patients high </li></ul><ul><li>We rely on nurses’ observations, also for symptoms of depression in Long Term Care </li></ul>I.
  16. 16. How well do nurses recognize depression? <ul><li>3 questions come first: </li></ul><ul><li>What is depression in elderly? </li></ul><ul><li>What is depression in dementia? </li></ul><ul><li>What is its prevalence? </li></ul>II.
  17. 17. Prevalence depression elderly living in the community: 15 % II. Beekman et al, Br J Psychiat. 1999
  18. 18. prevalence in elderly depending on long term care: 30% II . recognition Alexopoulos, Lancet 2005
  19. 19. What is depression in Elderly? <ul><li>Minor depression and </li></ul><ul><li>Major depression = depressive episode </li></ul><ul><li>DSM-IV: international ‘standard’ in high quality research </li></ul><ul><li>seems simple, is not simple </li></ul>II . recognition
  20. 20. About 50% of depressions, in elderly who seek help, are recognized II . recognition Hoogendijk, VUmc 2006
  21. 21. Symptoms of depressive episode: Not simple II . recognition
  22. 22. Depressive episode DSM-IV <ul><li>At least 5 symptoms </li></ul><ul><li>Most of the day </li></ul><ul><li>2 weeks or longer </li></ul><ul><li>The 2 most important or ‘gateway symptoms’: </li></ul><ul><li>Depressed mood or appears depressed </li></ul><ul><li>Decreased Interest or pleasure </li></ul>II . recognition
  23. 23. DSM-IV gateway symptoms: 1. Depressed mood 2. Loss of interest or pleasure <ul><li>3. Weight and appetite  </li></ul><ul><li>4. Sleep disturbance </li></ul><ul><li>5. Motor activity: agitated or slowed </li></ul><ul><li>6. Loss of energy </li></ul><ul><li>7. Feeling worthless or guilty </li></ul><ul><li>8. Indecisive, loss concentration </li></ul><ul><li>9. Thoughts of death or suicide or suicide attempt </li></ul>Other symptoms:
  24. 24. Depressive episode in elderly <ul><li>5 symptoms often too many </li></ul><ul><li>minor depression: 2 - 4 symptoms </li></ul><ul><li>Impact on work, social or personal functioning </li></ul><ul><li>Not caused by medication or other general medical condition (like dementia...) </li></ul>II . recognition
  25. 25. In dementia: even harder to recognize <ul><li>Less verbal abilities </li></ul><ul><li>Some symptoms due to dementia itself: e.g. loss of interest in cooking or biking because it is not possible anymore </li></ul><ul><li>Mood symptoms change fast from situation to situation & from moment to moment </li></ul>II . recognition
  26. 26. Irritability also symptom of depression in dementia? not in DSM-IV depressive episode II . recognition
  27. 27. Depression in Alzheimer's disease <ul><li>New criteria, by Olin et al, 2002 differences with DSM-IV: </li></ul><ul><li>reduced pleasure in response to usually pleasant activities </li></ul><ul><li> can be noticed by others (nurses) ! </li></ul><ul><li>‘ New’: Irritability & Social withdrawal </li></ul><ul><li>3 instead of 5 symptoms </li></ul><ul><li>Should be easier to recognize </li></ul>II . recognition
  28. 28. Back to what is the power of nurses and nursing assistants <ul><li>In mental health care for elderly </li></ul><ul><li>who are depending on long term care </li></ul><ul><li>number of studies is rising .... </li></ul>II . recognition
  29. 29. 2007 pub med: over 400 studies on elderly depression and nurses II . recognition
  30. 30. Review : Recognition of depression by nurses <ul><li>The Question: </li></ul><ul><li>how well do nurses and nursing assistants recognize depression? </li></ul>II . recognition
  31. 31. 4 high quality studies <ul><li>2 in USA nursing homes </li></ul><ul><li>1 in USA home health care </li></ul><ul><li>1 in the Netherlands: nursing home </li></ul>II. review
  32. 32. Study in nursing homes Baltimore USA Rovner, 1991 <ul><li>Recognition: </li></ul><ul><li>Nursing assistants: 65% </li></ul><ul><li>Nursing home physicians: 14% </li></ul><ul><li>Family members: 70% ! </li></ul><ul><li> Doctors not part of staff: consultants </li></ul><ul><li>and specificity of doctors was high: 95 % (nurses 68%) </li></ul><ul><li> advise doctors: ask nurse assistant first </li></ul><ul><li>4 x better recognition! </li></ul>II. review
  33. 33. Study in Nursing Homes New York Teresi, 2001 <ul><li>42 % recognition by nurses </li></ul><ul><li>45 % recognition by nursing assistants </li></ul><ul><li>44 % recognition by psychiatrists </li></ul><ul><li>55-65% with screening scales for depressive symptoms (GDS or HAMD) </li></ul>II. review
  34. 34. = about 50% of depressions in elderly who seek help are recognized II. review
  35. 35. USA study, New York in Home health care, Brown, 2002 <ul><li>Recognition nurses 45 % </li></ul><ul><li>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 </li></ul>II. review
  36. 36. Study in Nursing Home Amsterdam, Falck, 1999 <ul><li>Nursing assistants: 78% </li></ul><ul><li>Nursing home physicians: 68% </li></ul><ul><li>If nursing home physician & NAs both answered YES depressed: recognition was almost 90%! </li></ul><ul><li>!! Nursing assistants talked in groups of 4 before answering yes or no depressed </li></ul><ul><li>Doctors here are staff members, not consultants </li></ul>II. review
  37. 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. 38. So: recognition of depression by nurses and nursing assistants <ul><li>Few studies, compared to importance nurses and nursing assistants in mental health care of elderly </li></ul><ul><li>Screening scales higher recognition </li></ul><ul><li>e.g Geriatric Depression Scale in Nursing homes, Jongenelis 2006: over 85% recognition ! </li></ul><ul><li>Staff training helps to improve recognition as well </li></ul>II. review
  39. 39. Treatment of depression <ul><li>What evidence is there for a positive effect of interventions or treatment by nurses? </li></ul><ul><li>Treatment = non-pharmaceutical and pharmaceutical treatment </li></ul><ul><li>Non-pharmaceutical treatment = psychological and psycho-social interventions </li></ul>III. ‘ the good part’ Making elderly Feel better
  40. 40. Small talk improves quality of life nursing home residents NIVEL, Beek et al, 2008 III. Treatment
  41. 41. International reviews*: effect of psychosocial interventions for depression in dementia * Verkaik et al, 2005; Livingstone et al, 2005, Verhey 2006 <ul><li>Proved Effective : </li></ul><ul><li>Emotion oriented care </li></ul><ul><li>Behavior therapy (25 studies) </li></ul><ul><li>Snoezelen </li></ul><ul><li>Exercise </li></ul><ul><li>Music therapy </li></ul><ul><li>!! Combinations </li></ul><ul><li>Proved NOT effective : </li></ul><ul><li>Reality orientation </li></ul><ul><li>Validation </li></ul><ul><li>Not yet enough high quality studies : </li></ul><ul><li>Activities without behavior therapy (5) </li></ul><ul><li>Reminiscence (5) </li></ul><ul><li>Antidepressants *(4) </li></ul><ul><li>* Bains ea, cochrane 2006 </li></ul>III. Treatment
  42. 42. Antidepressive medication <ul><li>Currently debate about effectivity and side effects </li></ul><ul><li>30-35% placebo effect might be a psycho-social effect as well ! </li></ul><ul><li>If nurses believe in it: even a better effect? </li></ul><ul><li>In practise medication helpful , especially for the more severe depressions </li></ul><ul><li>Yet not enough studies in elderly in general </li></ul>III. Treatment
  43. 43. Exercise helps against depression enough studies show evidence for that  “ Appropriate Exercise” III. treatment
  44. 44. Help with exercise works too III. Treatment
  45. 45. Other help? <ul><li>Pimp my ride... </li></ul>III. Treatment
  46. 46. Duo bike: a combination of interventions
  47. 47. Another combined intervention? Admission to nursing home <ul><li>Prevalence of depressive symptoms after 6 months in nursing home decreased from 41 % - 29 % </li></ul><ul><li>Smalbrugge, JAGS 2006 </li></ul>III. treatment
  48. 48. Staff training positive effect on depression evidence found in studies all over the world <ul><li>Care intervention late life depression in residential care </li></ul><ul><li>Australia, Llewellyn Jones, 1999 </li></ul><ul><li>Staff training based on behavior therapy combined with exercise program </li></ul><ul><li>USA, Teri et al, 2003 </li></ul><ul><li>Emotion oriented care training & pleasant events, care plan by nursing assistants: study in Dutch nursing homes preliminary data PhD study, Verkaik </li></ul>III. treatment
  49. 49. ‘Things to do’ <ul><li>Admit it: we all miss a lot of depressions in elderly </li></ul><ul><li>Communication is the key. Talk in your team about symptoms, doubts, failures and successes in recognition and treatment </li></ul><ul><li>Use screening scale for depression </li></ul><ul><li>e.g. GDS: around 85% recognition in Nursing Homes </li></ul><ul><li>Ask for staff training in depression management </li></ul>IV.
  50. 50. Things to do (2) <ul><li>Nurses and nursing assistants: speak out! </li></ul><ul><li>allway have the doctor or psychologist included your observation and opinion in a depression diagnose </li></ul><ul><li>Doctors, psychologists e.o: never just examine the patient, always examine other staff members opinion as well </li></ul><ul><li>Always ask family: they know best ! </li></ul>IV.
  51. 51. Things to do (3) <ul><li>Freely use DSM-IV criteria depressive episode, it will save many patients a lot of suffering </li></ul><ul><li>In Alzheimer’s: you might want to use the ‘provisional diagnostic criteria’ from Olin et al </li></ul>IV.
  52. 52. Things to do (4) <ul><li>Include exercise, emotion oriented care, daily activity programs, medication options in your care planning </li></ul>
  53. 53. Finally <ul><li>Effective use of the power of nurses and nursing assistants in mental health care improves the quality of life of elderly </li></ul><ul><li>And will improve everybody’s work satisfaction as well </li></ul>
  54. 54. <ul><li>Thank you! </li></ul><ul><li>[email_address] </li></ul>