1) Depression is common in patients with chronic kidney disease (CKD) and can influence how patients make decisions about their treatment, including dialysis.
2) Assessing depression in CKD patients can be challenging due to overlapping symptoms from their kidney disease and other medical conditions.
3) An interdisciplinary team approach is needed to properly evaluate, diagnose, and manage depression in CKD patients. This includes screening for depression, supporting patients and families, and referring to mental health and palliative care services when needed.
Carter Sherman Annotated Bib. Bipolar DisorderCarter Sherman
This annotated bibliography summarizes research on the bio-psycho-social aspects of bipolar disorder. Key findings include:
1. Bipolar disorder is often associated with co-occurring mental illnesses and lower quality of life, even during stable phases.
2. Social factors like interpersonal problems, occupational issues, and early onset may predict higher suicide risk. Mortality is also elevated compared to the general population.
3. Physical health problems and sleep disturbances are more common for those with bipolar disorder. Severe mental illness increases risks of chronic health issues.
4. Men and women experience different symptoms, though rates are consistent between genders. Diagnosis and treatment can also differ based
The document provides background information on a 60-year-old patient named D.P. who was admitted to the hospital with acute kidney injury. Key details include that he has a history of chronic kidney disease, type 2 diabetes, and hypertension. He lacks formal education and has a history of unhealthy behaviors like poor diet, smoking, and substance abuse. He is currently undergoing further evaluation and treatment in preparation for fistula placement and management of his acute medical issues.
1) End-stage renal disease (ESRD) is a chronic condition requiring artificial means of excretion for survival, impacting patients' sense of control and leading to high rates of anxiety and depression compared to other chronic illnesses.
2) Depression is common in ESRD patients and can complicate treatment compliance. Additional stressors like biochemical changes and cognitive impairment may also contribute to depression.
3) The physical and time demands of dialysis treatment restrict patients' diets, activities, and social interactions, further impacting their quality of life and psychological well-being. Faith and religion help some patients cope.
Depression is common in patients with several neurologic disorders such as Alzheimer's disease, stroke, Parkinson's disease, and multiple sclerosis. Diagnosing depression in patients with neurologic disorders is challenging due to overlapping symptoms. Few controlled trials have evaluated treatment of depression in neurologic disorders. Existing studies suggest antidepressants may help treat depression in some neurologic conditions, though more research is still needed.
The document discusses various psychiatric and psychosocial emergencies including anxiety and panic reactions, bipolar disorder, depression, eating disorders, grief, homicidal or violent behavior, ineffective coping, psychotic behavior, and suicide. For each topic, it covers causes, assessments involving subjective and objective data collection, potential nursing diagnoses, and planning interventions and monitoring. Physical examinations, diagnostic tests, education, and pharmacological treatments are addressed.
Developmental Disabilities and Community LifeRoss Finesmith
This document discusses community-based treatment of epilepsy in developmentally disabled individuals. It notes higher incidence of difficult-to-control seizures and limited ability for testing in this population. It reviews factors like legal guardians, family involvement, group home staff, and challenges of medication administration and testing. It provides guidance on antiepileptic drug selection considering efficacy, side effects, and treating co-morbid conditions.
This document discusses community-based treatment of epilepsy in developmentally disabled individuals. It notes higher incidence of difficult-to-control seizures and potential for adverse effects from medications in this population. It reviews factors like legal guardians, family involvement, group home staff, and challenges with diagnostic testing. It provides guidance on antiepileptic drug selection considering efficacy, side effects, and treatment of any co-morbid conditions.
This document discusses community-based treatment of epilepsy in developmentally disabled individuals. It notes that many principles of antiepileptic drug therapy for non-disabled individuals also apply to those with developmental disabilities, but that treating physicians face additional challenges. These include a higher rate of difficult-to-control seizures, limited ability to do diagnostic testing due to cognitive impairments, and greater risk of adverse drug effects. It also discusses the trend toward deinstitutionalization and relocation of developmentally disabled individuals to community settings, increasing the need for community physicians to treat their medical issues like epilepsy. The role of legal guardians, family members, and group home staff in providing care and information is also covered.
Carter Sherman Annotated Bib. Bipolar DisorderCarter Sherman
This annotated bibliography summarizes research on the bio-psycho-social aspects of bipolar disorder. Key findings include:
1. Bipolar disorder is often associated with co-occurring mental illnesses and lower quality of life, even during stable phases.
2. Social factors like interpersonal problems, occupational issues, and early onset may predict higher suicide risk. Mortality is also elevated compared to the general population.
3. Physical health problems and sleep disturbances are more common for those with bipolar disorder. Severe mental illness increases risks of chronic health issues.
4. Men and women experience different symptoms, though rates are consistent between genders. Diagnosis and treatment can also differ based
The document provides background information on a 60-year-old patient named D.P. who was admitted to the hospital with acute kidney injury. Key details include that he has a history of chronic kidney disease, type 2 diabetes, and hypertension. He lacks formal education and has a history of unhealthy behaviors like poor diet, smoking, and substance abuse. He is currently undergoing further evaluation and treatment in preparation for fistula placement and management of his acute medical issues.
1) End-stage renal disease (ESRD) is a chronic condition requiring artificial means of excretion for survival, impacting patients' sense of control and leading to high rates of anxiety and depression compared to other chronic illnesses.
2) Depression is common in ESRD patients and can complicate treatment compliance. Additional stressors like biochemical changes and cognitive impairment may also contribute to depression.
3) The physical and time demands of dialysis treatment restrict patients' diets, activities, and social interactions, further impacting their quality of life and psychological well-being. Faith and religion help some patients cope.
Depression is common in patients with several neurologic disorders such as Alzheimer's disease, stroke, Parkinson's disease, and multiple sclerosis. Diagnosing depression in patients with neurologic disorders is challenging due to overlapping symptoms. Few controlled trials have evaluated treatment of depression in neurologic disorders. Existing studies suggest antidepressants may help treat depression in some neurologic conditions, though more research is still needed.
The document discusses various psychiatric and psychosocial emergencies including anxiety and panic reactions, bipolar disorder, depression, eating disorders, grief, homicidal or violent behavior, ineffective coping, psychotic behavior, and suicide. For each topic, it covers causes, assessments involving subjective and objective data collection, potential nursing diagnoses, and planning interventions and monitoring. Physical examinations, diagnostic tests, education, and pharmacological treatments are addressed.
Developmental Disabilities and Community LifeRoss Finesmith
This document discusses community-based treatment of epilepsy in developmentally disabled individuals. It notes higher incidence of difficult-to-control seizures and limited ability for testing in this population. It reviews factors like legal guardians, family involvement, group home staff, and challenges of medication administration and testing. It provides guidance on antiepileptic drug selection considering efficacy, side effects, and treating co-morbid conditions.
This document discusses community-based treatment of epilepsy in developmentally disabled individuals. It notes higher incidence of difficult-to-control seizures and potential for adverse effects from medications in this population. It reviews factors like legal guardians, family involvement, group home staff, and challenges with diagnostic testing. It provides guidance on antiepileptic drug selection considering efficacy, side effects, and treatment of any co-morbid conditions.
This document discusses community-based treatment of epilepsy in developmentally disabled individuals. It notes that many principles of antiepileptic drug therapy for non-disabled individuals also apply to those with developmental disabilities, but that treating physicians face additional challenges. These include a higher rate of difficult-to-control seizures, limited ability to do diagnostic testing due to cognitive impairments, and greater risk of adverse drug effects. It also discusses the trend toward deinstitutionalization and relocation of developmentally disabled individuals to community settings, increasing the need for community physicians to treat their medical issues like epilepsy. The role of legal guardians, family members, and group home staff in providing care and information is also covered.
Sat 0810-gallagher-end-of-life-care- -parkIhsaan Peer
This document discusses end of life care options in British Columbia from the perspective of Dr. Romayne Gallagher, a physician director of palliative care. It provides an overview of palliative care and its benefits compared to physician assisted dying. While palliative care aims to relieve suffering, physician assisted dying is not considered a part of palliative care by definitions from the WHO. The document outlines concerns about assessing mental competence for physician assisted dying and potential risks of legalizing the practice.
This document discusses community-based treatment of epilepsy in developmentally disabled individuals. It notes higher incidence of difficult-to-control seizures and potential for adverse effects from medications. Care is now provided in community settings like group homes rather than institutions. Physicians must work with legal guardians, family members, and caregivers to effectively manage patients' epilepsy and understand historical factors. Choosing antiepileptic drugs requires considering seizure type, psychiatric comorbidities, previous medication responses, and ability to administer medications properly in community settings. Neurodiagnostic testing can be challenging but helps identify seizure type and guide treatment.
Mrs. B, a 97-year-old woman living in a residential care home, was admitted to the hospital after a fall. Her daughter informed staff that Mrs. B had an advance health directive. Mrs. B was treated for aspiration pneumonia and other issues. Despite treatment, Mrs. B remained distressed and her condition deteriorated. She was found dead during an overnight medical team call. Opportunities to improve care included the residential home notifying the hospital of Mrs. B's advance directive and discussing her goals of care when she was confused upon admission.
This document discusses the effects of an ALS diagnosis on individuals and their caregivers over five phases: pre-diagnosis, acute diagnosis, chronic, recovery, and terminal. It outlines the physical, behavioral, spiritual, cognitive and emotional responses individuals may experience during diagnosis. It also examines what matters most to those with moderate to severe disability, such as relationships and everyday life, and how patient suffering impacts caregiver well-being. The document provides guidance on how healthcare professionals can help individuals and caregivers adjust and cope with change and loss, and introduces palliative and hospice care at appropriate times.
Depression and CV diseases: cardiologist perspectives Essam Mahfouz
The presentation discusses the epidemiology, mechanism, screening and diagnosis of depression and cardiovascular disease and how to mange this association
Assessing the Quality of End of-Life Care for Older Persons with Advanced Dem...mjbinstitute
Dementia is one of the most devastating illnesses affecting older persons. According to a survey from the Myers-JDC-Brookdale Institute, approximately 5% of Israeli elderly living in the community have advanced dementia.
This first study of the care of older people with advanced dementia in Israel reveals a wide range of unmet health and social service needs. It points to the need for a comprehensive policy for developing services to improve the quality of care and reduce the burden on the families.
The findings are contributing to the implementation of the national strategic plan for addressing the challenges of dementia, currently being implemented by the Ministry of Health, and to a new national program for palliative care for people with terminal illnesses, which is in the planning stages as a joint initiative of the Ministry of Health, JDC-ESHEL, and MJB.
The study was funded with the assistance of the Helen Daniels Bader Fund of Bader Philanthropies of Milwaukee, Wisconsin.
Orthogeriatrics delirium vs dementia and hip fracturesMarc Evans Abat
This document discusses dementia, delirium, and their connection to hip fractures in geriatric patients. It defines dementia and delirium according to DSM-IV criteria and differentiates between the two. Predisposing and precipitating factors for delirium are outlined. Prevention of delirium focuses on primary prevention through interventions targeting risk factors like cognitive impairment, immobilization, and medication use. Management of dementia includes both pharmacologic options like cholinesterase inhibitors and non-pharmacologic supportive care.
Depression is a common and dangerous complication of diabetes that affects about 15-20% of diabetic patients. Depression and diabetes can form a vicious cycle, as each condition increases the risk of the other developing or worsening. Having diabetes doubles the risk of depression compared to those without diabetes. Depression can also increase the risk of developing type 2 diabetes. Depression may prevent diabetics from properly managing their condition, worsening blood sugar control and increasing complications. Effective treatment of depression, such as antidepressants and cognitive psychotherapy, can significantly improve diabetes management and health outcomes for diabetic patients suffering from depression.
Carle Palliative Care Journal Club for 7/3/18Mike Aref
Journal club review of "Effect of Lorazepam With Haloperidol vs Haloperidol Alone on Agitated Delirium in Patients With Advanced Cancer Receiving Palliative Care: A Randomized Clinical Trial" by D. Hui et. al. in JAMA. 2017 Sep 19;318(11):1047-1056.
Depression in patients with medical conditionJunaid Saleem
Depression is commonly co-morbid with chronic medical disorders and worsens their outcomes. It decreases quality of life, functional ability, and adherence to medical treatment. It is also associated with worse health behaviors and increased medical costs. Depression independently increases mortality in conditions like diabetes, myocardial infarction, and stroke. Early identification and treatment of depression in medically ill patients can improve their quality of life and physical health outcomes. Selective serotonin reuptake inhibitors have shown benefits in reducing depressive symptoms and improving cardiac outcomes in patients with heart disease.
Depresi adalah masalah kejiwaan yang paling sering pada pasien dengan penyakit ginjal kronis dan dapat memprediksi hasil pasien dan kematian. Depresi terkait dengan kehidupan yang penuh stres yang ditandai dengan banyak kerugian dan oleh ketergantungan, yang bahkan dapat menyebabkan bunuh diri. Meskipun sejumlah besar pasien dengan penyakit ginjal kronis dan beban ekonomi mereka mewakili, hanya beberapa dari pasien ini menerima diagnosis dan terapi yang memadai. Pedoman Diagnostik dan Statistik Mental kriteria Gangguan-IV untuk depresi besar dapat membantu dalam membedakan gejala uremia dan depresi. Farmakoterapi tersedia dan antidepresan (trisiklik antidepresan dan selective serotonin re-uptake) telah berhasil digunakan dalam berbagai penelitian. Akhirnya, ada kebutuhan untuk welldesigned lanjut, membujur studi, kelangsungan hidup untuk memperjelas hubungan yang lebih baik antara depresi dan berbagai tahap disfungsi ginjal.
Rebecca Cowan, beh heallth in primary care Rebecca Cowan
The document discusses the integration of behavioral health services into primary care. It notes the current mental health system is inadequate to meet the high need, as mental illnesses are prevalent while psychiatric resources are limited. Integrating behavioral health into primary care can improve coordination of care for the many patients with mental and physical health comorbidities. Conditions like depression commonly co-occur with chronic diseases like diabetes and heart disease. The document advocates screening and treating behavioral health issues in primary care settings to better address patients' full range of needs.
Evaluation of the geriatric patients with behavioural dysfunctionDr Wasim
This document provides an overview of evaluating behavioral dysfunction in geriatric patients. It begins with definitions of key terms like geriatrics, gerontology, and behavioral and psychological symptoms of dementia (BPSD). It then discusses common types of behavioral dysfunction seen in older adults like agitation, irritability, delusions and hallucinations. The document outlines the approach to evaluation, including assessing for medical causes, psychiatric illnesses, and environmental stressors. Differential diagnoses like delirium, dementia, and mood disorders are explored. Assessment tools for conditions like BPSD are also mentioned. The "ABCs" model of antecedents, behavior, and consequences is described as a framework for understanding and intervening in problematic behaviors in older
This document provides guidance for healthcare professionals on determining a terminal prognosis and accessing hospice care. It discusses the challenges of prognosis, general clinical criteria like functional status and symptom burden, and disease-specific guidelines for predicting prognosis in cancers, end-stage cardiac or pulmonary disease, dementia, cerebrovascular disease, liver disease, HIV/AIDS, and end-stage renal disease without dialysis. Key points are that prognosis involves clinical judgment of multiple factors, physicians tend to overestimate survival, and guidelines provide population-level rather than individual predictions.
This document discusses two studies presented by Dr. Paresh Dandona on utilizing Certified Diabetes Educators (CDEs) to help manage diabetes patients in primary care settings under the guidance of an endocrinologist.
The first study found that 100 patients managed by CDEs had a mean A1C reduction of 1.6% after 6 months, significantly greater than the 0.26% reduction in a control group of 45 patients managed only by primary care physicians. Additional benefits included greater weight loss and improvements in blood pressure, LDL cholesterol, and triglycerides in the CDE-managed group.
The second study found that benefits on A1C, weight, blood pressure,
This document discusses end-of-life care considerations for patients with advanced dementia. It finds that feeding tubes do not prevent aspiration pneumonia or malnutrition in these patients and may in fact increase the risk of pressure ulcers and restraint use. Instead, oral assisted feeding is recommended to overcome eating difficulties. The benefits of discussing goals of care and treatment options are emphasized over defaulting to invasive interventions like feeding tubes that do not improve quality of life.
Geriatrics focuses on healthcare for the elderly aged 65 and over. It aims to promote health and prevent/treat diseases in older adults. Key competencies include managing cognitive/behavioral disorders, medications, mobility issues, atypical disease presentation, and palliative care. Geriatric medicine considers age-related decline of organs over a lifetime of habits. Common geriatric conditions include dementia, Alzheimer's, cancer, diabetes, heart disease, osteoporosis, Parkinson's, sleep disorders, and stroke. Most older adults take multiple daily medications which can impact hospital care if not reported. Specialties include rehabilitation, psychiatry, cardiology, and oncology tailored to senior needs. Treating geriatrics involves complex legal and medical
Neuro-Psychiatric aspect of Diabetes MellitusDr.Jeet Nadpara
- The document discusses the neuro-psychiatric aspects of diabetes mellitus, including the links between diabetes and conditions like depression. It notes that as early as the 17th century, diabetes was thought to be caused by sadness or emotional distress.
- Managing diabetes requires significant patient self-care and support systems, but psychiatric illnesses can interfere with self-management behaviors. Conditions like depression may also impact diabetes through neurohormonal changes.
- The document examines topics like cognitive effects of diabetes, links between diabetes and depression, eating disorders and diabetes, and the impacts on patients, families, and development.
C l i n i c a l r e s e a r c hAssessment and treatment o.docxhumphrieskalyn
The document discusses the high prevalence of comorbid mood disorders and substance use disorders. Some key points:
1) Epidemiological studies show over 40% of individuals with lifetime major depressive disorder had an alcohol use disorder, and over 19.7% of individuals with a past-year substance use disorder also had an independent mood disorder.
2) Fewer than 1% of individuals meeting criteria for a mood disorder had a substance-induced mood disorder, contradicting previous ideas that depression in substance abusers was caused by intoxication/withdrawal.
3) There are challenges in diagnosing mood disorders in individuals with active substance abuse, as intoxication/withdrawal can mimic mood disorder symptoms. However, delay
Sat 0810-gallagher-end-of-life-care- -parkIhsaan Peer
This document discusses end of life care options in British Columbia from the perspective of Dr. Romayne Gallagher, a physician director of palliative care. It provides an overview of palliative care and its benefits compared to physician assisted dying. While palliative care aims to relieve suffering, physician assisted dying is not considered a part of palliative care by definitions from the WHO. The document outlines concerns about assessing mental competence for physician assisted dying and potential risks of legalizing the practice.
This document discusses community-based treatment of epilepsy in developmentally disabled individuals. It notes higher incidence of difficult-to-control seizures and potential for adverse effects from medications. Care is now provided in community settings like group homes rather than institutions. Physicians must work with legal guardians, family members, and caregivers to effectively manage patients' epilepsy and understand historical factors. Choosing antiepileptic drugs requires considering seizure type, psychiatric comorbidities, previous medication responses, and ability to administer medications properly in community settings. Neurodiagnostic testing can be challenging but helps identify seizure type and guide treatment.
Mrs. B, a 97-year-old woman living in a residential care home, was admitted to the hospital after a fall. Her daughter informed staff that Mrs. B had an advance health directive. Mrs. B was treated for aspiration pneumonia and other issues. Despite treatment, Mrs. B remained distressed and her condition deteriorated. She was found dead during an overnight medical team call. Opportunities to improve care included the residential home notifying the hospital of Mrs. B's advance directive and discussing her goals of care when she was confused upon admission.
This document discusses the effects of an ALS diagnosis on individuals and their caregivers over five phases: pre-diagnosis, acute diagnosis, chronic, recovery, and terminal. It outlines the physical, behavioral, spiritual, cognitive and emotional responses individuals may experience during diagnosis. It also examines what matters most to those with moderate to severe disability, such as relationships and everyday life, and how patient suffering impacts caregiver well-being. The document provides guidance on how healthcare professionals can help individuals and caregivers adjust and cope with change and loss, and introduces palliative and hospice care at appropriate times.
Depression and CV diseases: cardiologist perspectives Essam Mahfouz
The presentation discusses the epidemiology, mechanism, screening and diagnosis of depression and cardiovascular disease and how to mange this association
Assessing the Quality of End of-Life Care for Older Persons with Advanced Dem...mjbinstitute
Dementia is one of the most devastating illnesses affecting older persons. According to a survey from the Myers-JDC-Brookdale Institute, approximately 5% of Israeli elderly living in the community have advanced dementia.
This first study of the care of older people with advanced dementia in Israel reveals a wide range of unmet health and social service needs. It points to the need for a comprehensive policy for developing services to improve the quality of care and reduce the burden on the families.
The findings are contributing to the implementation of the national strategic plan for addressing the challenges of dementia, currently being implemented by the Ministry of Health, and to a new national program for palliative care for people with terminal illnesses, which is in the planning stages as a joint initiative of the Ministry of Health, JDC-ESHEL, and MJB.
The study was funded with the assistance of the Helen Daniels Bader Fund of Bader Philanthropies of Milwaukee, Wisconsin.
Orthogeriatrics delirium vs dementia and hip fracturesMarc Evans Abat
This document discusses dementia, delirium, and their connection to hip fractures in geriatric patients. It defines dementia and delirium according to DSM-IV criteria and differentiates between the two. Predisposing and precipitating factors for delirium are outlined. Prevention of delirium focuses on primary prevention through interventions targeting risk factors like cognitive impairment, immobilization, and medication use. Management of dementia includes both pharmacologic options like cholinesterase inhibitors and non-pharmacologic supportive care.
Depression is a common and dangerous complication of diabetes that affects about 15-20% of diabetic patients. Depression and diabetes can form a vicious cycle, as each condition increases the risk of the other developing or worsening. Having diabetes doubles the risk of depression compared to those without diabetes. Depression can also increase the risk of developing type 2 diabetes. Depression may prevent diabetics from properly managing their condition, worsening blood sugar control and increasing complications. Effective treatment of depression, such as antidepressants and cognitive psychotherapy, can significantly improve diabetes management and health outcomes for diabetic patients suffering from depression.
Carle Palliative Care Journal Club for 7/3/18Mike Aref
Journal club review of "Effect of Lorazepam With Haloperidol vs Haloperidol Alone on Agitated Delirium in Patients With Advanced Cancer Receiving Palliative Care: A Randomized Clinical Trial" by D. Hui et. al. in JAMA. 2017 Sep 19;318(11):1047-1056.
Depression in patients with medical conditionJunaid Saleem
Depression is commonly co-morbid with chronic medical disorders and worsens their outcomes. It decreases quality of life, functional ability, and adherence to medical treatment. It is also associated with worse health behaviors and increased medical costs. Depression independently increases mortality in conditions like diabetes, myocardial infarction, and stroke. Early identification and treatment of depression in medically ill patients can improve their quality of life and physical health outcomes. Selective serotonin reuptake inhibitors have shown benefits in reducing depressive symptoms and improving cardiac outcomes in patients with heart disease.
Depresi adalah masalah kejiwaan yang paling sering pada pasien dengan penyakit ginjal kronis dan dapat memprediksi hasil pasien dan kematian. Depresi terkait dengan kehidupan yang penuh stres yang ditandai dengan banyak kerugian dan oleh ketergantungan, yang bahkan dapat menyebabkan bunuh diri. Meskipun sejumlah besar pasien dengan penyakit ginjal kronis dan beban ekonomi mereka mewakili, hanya beberapa dari pasien ini menerima diagnosis dan terapi yang memadai. Pedoman Diagnostik dan Statistik Mental kriteria Gangguan-IV untuk depresi besar dapat membantu dalam membedakan gejala uremia dan depresi. Farmakoterapi tersedia dan antidepresan (trisiklik antidepresan dan selective serotonin re-uptake) telah berhasil digunakan dalam berbagai penelitian. Akhirnya, ada kebutuhan untuk welldesigned lanjut, membujur studi, kelangsungan hidup untuk memperjelas hubungan yang lebih baik antara depresi dan berbagai tahap disfungsi ginjal.
Rebecca Cowan, beh heallth in primary care Rebecca Cowan
The document discusses the integration of behavioral health services into primary care. It notes the current mental health system is inadequate to meet the high need, as mental illnesses are prevalent while psychiatric resources are limited. Integrating behavioral health into primary care can improve coordination of care for the many patients with mental and physical health comorbidities. Conditions like depression commonly co-occur with chronic diseases like diabetes and heart disease. The document advocates screening and treating behavioral health issues in primary care settings to better address patients' full range of needs.
Evaluation of the geriatric patients with behavioural dysfunctionDr Wasim
This document provides an overview of evaluating behavioral dysfunction in geriatric patients. It begins with definitions of key terms like geriatrics, gerontology, and behavioral and psychological symptoms of dementia (BPSD). It then discusses common types of behavioral dysfunction seen in older adults like agitation, irritability, delusions and hallucinations. The document outlines the approach to evaluation, including assessing for medical causes, psychiatric illnesses, and environmental stressors. Differential diagnoses like delirium, dementia, and mood disorders are explored. Assessment tools for conditions like BPSD are also mentioned. The "ABCs" model of antecedents, behavior, and consequences is described as a framework for understanding and intervening in problematic behaviors in older
This document provides guidance for healthcare professionals on determining a terminal prognosis and accessing hospice care. It discusses the challenges of prognosis, general clinical criteria like functional status and symptom burden, and disease-specific guidelines for predicting prognosis in cancers, end-stage cardiac or pulmonary disease, dementia, cerebrovascular disease, liver disease, HIV/AIDS, and end-stage renal disease without dialysis. Key points are that prognosis involves clinical judgment of multiple factors, physicians tend to overestimate survival, and guidelines provide population-level rather than individual predictions.
This document discusses two studies presented by Dr. Paresh Dandona on utilizing Certified Diabetes Educators (CDEs) to help manage diabetes patients in primary care settings under the guidance of an endocrinologist.
The first study found that 100 patients managed by CDEs had a mean A1C reduction of 1.6% after 6 months, significantly greater than the 0.26% reduction in a control group of 45 patients managed only by primary care physicians. Additional benefits included greater weight loss and improvements in blood pressure, LDL cholesterol, and triglycerides in the CDE-managed group.
The second study found that benefits on A1C, weight, blood pressure,
This document discusses end-of-life care considerations for patients with advanced dementia. It finds that feeding tubes do not prevent aspiration pneumonia or malnutrition in these patients and may in fact increase the risk of pressure ulcers and restraint use. Instead, oral assisted feeding is recommended to overcome eating difficulties. The benefits of discussing goals of care and treatment options are emphasized over defaulting to invasive interventions like feeding tubes that do not improve quality of life.
Geriatrics focuses on healthcare for the elderly aged 65 and over. It aims to promote health and prevent/treat diseases in older adults. Key competencies include managing cognitive/behavioral disorders, medications, mobility issues, atypical disease presentation, and palliative care. Geriatric medicine considers age-related decline of organs over a lifetime of habits. Common geriatric conditions include dementia, Alzheimer's, cancer, diabetes, heart disease, osteoporosis, Parkinson's, sleep disorders, and stroke. Most older adults take multiple daily medications which can impact hospital care if not reported. Specialties include rehabilitation, psychiatry, cardiology, and oncology tailored to senior needs. Treating geriatrics involves complex legal and medical
Neuro-Psychiatric aspect of Diabetes MellitusDr.Jeet Nadpara
- The document discusses the neuro-psychiatric aspects of diabetes mellitus, including the links between diabetes and conditions like depression. It notes that as early as the 17th century, diabetes was thought to be caused by sadness or emotional distress.
- Managing diabetes requires significant patient self-care and support systems, but psychiatric illnesses can interfere with self-management behaviors. Conditions like depression may also impact diabetes through neurohormonal changes.
- The document examines topics like cognitive effects of diabetes, links between diabetes and depression, eating disorders and diabetes, and the impacts on patients, families, and development.
C l i n i c a l r e s e a r c hAssessment and treatment o.docxhumphrieskalyn
The document discusses the high prevalence of comorbid mood disorders and substance use disorders. Some key points:
1) Epidemiological studies show over 40% of individuals with lifetime major depressive disorder had an alcohol use disorder, and over 19.7% of individuals with a past-year substance use disorder also had an independent mood disorder.
2) Fewer than 1% of individuals meeting criteria for a mood disorder had a substance-induced mood disorder, contradicting previous ideas that depression in substance abusers was caused by intoxication/withdrawal.
3) There are challenges in diagnosing mood disorders in individuals with active substance abuse, as intoxication/withdrawal can mimic mood disorder symptoms. However, delay
CKD INTERVIEW 2Illness and Disease Management CKD InVinaOconner450
CKD INTERVIEW 2
Illness and Disease Management CKD Interview
Betsy Quinones
February 27, 2021
NSG4055- Illness And Disease Management across a Lifespan
Professor Amber Mccall
Illness and Disease Management CKD Interview
Introduction
Mr. X has a medical diagnosis of stage 3 chronic kidney disease. According to the interview, he has a little bit of an understanding of his condition, though his level of awareness is low. He pointed out that the condition has changed his relationship with family and friends. The quality of life of individuals is closely related to the quality of life of those around them (Golics, 2019). In this journal, Golics further went and published that most chronic illnesses have the same impact on the family. In this case, chronic kidney disease has disrupted the psychological, emotional, and normal functioning of the family and some friends of Mr. X. Even the study advocates for a family-centered approach to care the disruptions brought about by the disease process negatively affect the wellbeing of the patient.
According to the stages of grief, Mr. X is at the level of acceptance same to the family. This stage means the patient has understood and accepted what the condition means to his life. The family members and friends have also reached the acceptance stage and are with him in his hard moments. Acceptance is not necessarily an uplifting stage of grief, it may mean that there may be more good days than bad but there may be still bad – and that is ok (Holland, 2018).
Coping mechanisms
Dealing with chronic illnesses requires coping skills to avoid sinking into depression. As for Mr. X, the main coping skill is lowering expectations of the awaited outcome. For example, if his blood has been taken for waste analysis before dialysis when the results come, he has trained himself not to expect much to avoid disappointments if otherwise. In addition to lower expectations, Mr. X also asks for help if need be, especially financial support. Change of source of stress and distance from the source of help has also been practiced by Mr. X to cope with stress. Finally, maintaining emotional composure has also been deployed by the patient to avoid stress (Coping skills and strategies, 2017).
Treatment of CKD
The treatment for Mr. X is partly symptomatic and largely therapeutic. For example, on occasions where the hemoglobin levels are low, he is given ferrous sulfate tablets or iron injections to control anemia. Diuretics such as furosemide are given to the patient to control edema. He is put on antihypertensive drugs to control his blood pressure which is the suspected root course of his condition. He also attends two sessions of hemodialysis each week to eliminate wastes from the blood (Medication, 2019).
Support aspects
The support aspect of chronic kidney disease is social, emotional, and psychological. The patient requires family and friends to offer social and emotional support to provide the patient with strength ...
Running head illness and disease managementillness and disearyan532920
Chronic kidney disease is a debilitating disease that affects many organ systems and is associated with high risks of cardiovascular disease and early death. It has numerous comorbidities such as diabetes, hypertension, heart disease, and impacts patients' quality of life through disability and high medical costs. About 10% of the global population is affected by CKD, and it is a leading cause of death worldwide. Goals for improving CKD include reducing the disease burden through early detection and treatment of risk factors like diabetes and hypertension.
Psychology plays an important role in cystic fibrosis care. People with CF and their caregivers are at higher risk for depression and anxiety due to the challenges of managing a chronic disease. Screening and treatment of mental health issues is critical because psychological distress can negatively impact adherence, pulmonary function, quality of life, and healthcare costs. The presentation outlined guidelines for integrating mental health screening and treatment into CF care through annual assessments, brief therapies, and connecting patients and families to local resources. Managing depression and anxiety is key to optimizing health outcomes and disease management for those living with cystic fibrosis.
3
SOAP Note on Mental Health
Name xxx
United State University
Couse xxx
Professors xxxx
Date xxx
Video link
SOAP Note on Mental Health
Patient Initials: P.S. Age: 21; is a Hispanic male who visits the clinic unaccompanied and seems to be a reliable historian.
Subjective
CC: "I am feeling depressed."
HPI: The patient is a 21-year-old male Hispanic college student. He has complaints of feeling depressed. He says that ever since he broke up with his girlfriend two months ago, he has had a broadly depressed attitude and has not been enjoying life to the fullest possible extent. He also reports having trouble sleeping on occasion. He is frequently anxious and overthinks the possibility of ever finding true love. He is now failing exams and scoring poor grades. He denies night sweats, fever, chills, fatigue, nausea, or vomiting.
Past Medical History
Chronic illness: None
Medication: None
Allergies: No known allergies
Surgeries: None
Social History
· He is a college student
· Broke up with his girlfriend 2 months ago
· Drinks alcohol 1 bottle of beer per day since he broke up with his girlfriend.
· Smokes cannabis daily since he broke up with his girlfriend.
· Denies smoking tobacco
Family History
· His father died in a tragic road accident.
· Mother has no known chronic illness
· PGF alive has hypertension
· PGM diseased, no known chronic illness
· MGF diseased, no known chronic illness
· MGM diseased, no known chronic illness
Review of Systems
Constitutional: Denies chills, fever, chest pain, or weight loss.
Head: Denies unconsciousness or head trauma.
Eyes: No eye irritation, color blindness, dryness, or copious tears reported. Denies using
corrective lenses.
Ears: Denies experiencing ear pain, ear ringing, discharges, or hearing loss.
Nose: No nosebleed, loss of smell, nasal congestion, or pain reported.
Mouth: Does not experience bleeding gums or mouth wounds.
Throat: No sore throat and hoarseness reported.
Skin: Denies skin rashes, bruises, color changes, or lesions.
Respiratory: He denies having any symptoms of coughing, wheezing, difficulty breathing, or
chest pain.
Cardiovascular: Denies heart palpitations and denies having chest pain or tachycardia.
Genitourinary: Denies having pain, abnormal penile discharge, or urination frequency changes.
Musculoskeletal: Denies having joint pain, muscle pain, or swelling.
Heme/Lymph/Endo: He denies experiencing excess sweating. He denies a history of blood
transfusion.
Neurologic: No dizziness, headaches or tremors, or syncope have been reported.
Psychological: Denies suicidal thoughts or memory loss. Reports depression and anxiety.
Objective
Vital Signs
Blood Pressure: 125/74mmHg Pulse 82. Temperature: 98.5F Respiration 18. SaO2: 99% Height: 5’5” Weight: 148lbs BMI 24
General ...
Differential impact of resilience on demoralization and depression in Parkins...Dr. Robert Kohn
Objectives: The objective of this study was to study the interrelations of
demoralization, depression, and resilience in patients with Parkinson disease,
and, more specifically, to determine if higher resilience in patients with Parkinson
disease is associated with lower demoralization, lower depression, or both.
“Iamsorry,Icannotdo
thattestwithyou.Let'smoveonto
thenextquestion.”
Askpatientthefollowing:
Whatmonthisit?
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Askpatientthefollowing:
Canyoutellmeaboutwhatyou
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Askpatientthefollowing:
Howareyoufeelingtoday?
* The 3-Minute Diagnostic Interview for Delirium Using the Confusion Assessment Method (3D-CAM) is a brief, structured interview that incorporates elements of the Confusion Assessment Method (CAM) to diagnose delirium. It takes approximately 3 minutes to administer.
† Feature 1 assesses for
Common giatric psychaitric disease convertedWafa sheikh
This document provides information on common psychological disorders in elderly patients. It begins with an overview of depression in elderly patients, including risk factors, clinical presentation, assessment, and management guidelines. It then discusses anxiety disorders and panic attacks in elderly patients. Several case studies are presented, including a 68-year-old female with depression, a 58-year-old female with depression and insomnia, and a 65-year-old male with anxiety disorder and panic attacks. Assessment tools and a 5-step management protocol from the WHO for providing mental healthcare in primary care settings are also covered.
This document summarizes psychiatric disorders that are more prevalent in HIV-infected patients compared to the general population. It discusses how psychiatric illness can both increase the risk of HIV infection and negatively impact outcomes for HIV patients. Common psychiatric issues in HIV patients include depression, anxiety, substance abuse, and mania. Screening tools and treatment options are also reviewed.
This weeks content discussed common psychiatric disorders in the .docxVannaJoy20
This week's content discussed common psychiatric disorders in the Adult and Older Adult client. Often a secondary diagnosis is masked due to their psychiatric disorder. Review the following case study and answer the following questions.
Mr. White is a 72-year-old man, with a history of hypertension, COPD and moderate dementia, who presents with 4 days of increased confusion, nighttime restlessness, visual hallucinations, and urinary incontinence. His physical exam is unremarkable except for tachypnea, a mildly enlarged prostate, inattentiveness, and a worsening of his MMSE score from a baseline of 18 to 12 today.
Mr. White's presentation is most consistent with an acute delirium (acute change in cognition, perceptual derangement, waxing and waning consciousness, and inattention).
1. What is the most likely diagnosis to frequently cause acute delirium in patients with dementia?
2. What additional testing should you consider if any?
3. What are treatment options to consider with this patient?
Jessica Alper
Cause of acute delirium in elderly patients with dementia
Many older people, with and without dementia can be all of a sudden be affected by delirium, which is defined as acute sudden confusion. When an elderly patient becomes confused very suddenly, it is important to look at all possible underlying causes. Mayne et al. (2019) state that “non-specific symptoms, such as confusion, are often suspected to be caused by urinary tract infection (UTI) and continues to be the most common reason for suspecting a UTI”. Delirium in the elderly is usually associated with lengthened hospital stays, complexed care, institutionalization, along with high mortality rates, difficulties for the caregivers and increased healthcare costs. Signs and symptoms associated with UTIs in the elderly include confusion or delirium, increased lethargy, blunted fever response, new-onset incontinence, as well as anorexia (Rodriguez-Manas, 2020). There are various risk factors associated with UTIs in a male patient. Some of these include prostatic hypertrophy, diabetes, or both, which can lead to high post-void residuals.
Testing
A confused patient who has recently become delirious should be investigated for the source of the delirium. Krinitski et al. (2021) state that “the diagnosis of UTI requires not only confirmed bacteriuria but also the presence of genitourinary symptoms, which often cannot be reliably confirmed in the many delirious individuals who are unable to adequately express themselves”. However in this case study, it is know that the patient is experiencing urinary incontinence, which further justifies the diagnosis of UTI.
A urinary analysis and culture are both highly suggested for this patient. When bacteria from the UTI has been detected in the elderly, providers usually “consider behavioral or mental changes, including delirium, as non-urinary manifestations of UTI, especially in patients with cognitive impairme.
Young women with a history of major depressive episodes have higher rates of the metabolic syndrome compared to those without depression, while men with depression do not appear to have higher rates. Depression may be linked to the metabolic syndrome through unhealthy behaviors and physiological alterations like autonomic nervous system changes and hypothalamic-pituitary-adrenal axis dysregulation. Future research should examine the prospective relationship between depression and the metabolic syndrome to better characterize their association and determine if treating one condition impacts the other.
This document summarizes key aspects of integrating goals of care discussions into primary care settings. It presents the case of a 71-year-old male patient with multiple chronic illnesses, including COPD, congestive heart failure, and Alzheimer's dementia. The summary discusses how the physician acknowledged the daughter's concerns, reviewed the specialists' assessments with the patient, and used a 6-step approach to establish goals of care aligned with the patient's values and preferences. The document emphasizes the important role primary care physicians play in eliciting patients' goals of care to achieve optimal end-of-life outcomes.
Integrated Behavioral Health: Approaches to hypertension, toxic stress, ment...Michael Changaris
•TEAM BASED CARE: Team-based care incorporates a multidisciplinary team, centered on the patient, to optimize the quality of hypertension care. •TEAM PLAYERS: Team-based care includes the patient, the primary care clinician, and other professionals such as nurses, pharmacists, physician assistants, dieticians, social workers, and community health workers, each with pre-defined responsibilities in care. •OUTCOMES: Review and Meta-analysis of 100 randomized trials determined that team-based care is highly effective compared with other strategies for BP control.
Team Based Care for Hypertension Management a biopsychosocial approachMichael Changaris
This presentation is an overview of the collaborative care model of hypertension management for behavioral health providers, primary care doctors and health care teams. It explored social determinants of health, complex interaction of adverse childhood experiences and treatment and provides a map for integrated care.
1) Diabetic nephropathy is a kidney disease caused by damage from uncontrolled diabetes, often accompanied by high blood pressure. It involves thickening and scarring of the kidney's filtering units called glomeruli.
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3) The formulation acts as a renal function modulator through vasodilation and improved blood flow. It is recommended for early stages of diabetic nephropathy and was found to be an effective and affordable
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Wet cupping therapy was applied to 5 points on the back of 40 healthy participants. Electrocardiography recordings were taken before and after to analyze heart rate variability (HRV), a measure of sympathovagal balance. All HRV parameters, including SDNN, SDANN, RMSSD, pNN50, LF, and HF, increased after cupping therapy compared to before, indicating cupping restored sympathovagal balance. This is the first study to show in humans that cupping therapy may have cardioprotective effects by stimulating the peripheral nervous system.
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An interdisciplinary approach to dialysis decision making in the ckd patient with depression
1. An Interdisciplinary Approach to Dialysis
Decision-Making in the CKD Patient With Depression
Jane O. Schell, Renee Bova-Collis, and Nwamaka D. Eneanya
Depression and depressive symptoms are common in advanced kidney disease and are associated with poor outcomes. For
those with CKD not on dialysis, depression may influence how patients cope and prepare for their disease and its management,
including decisions about dialysis treatment. Patient self-reported scales exist to better identify depression; how to incorporate
these scales into clinical practice and assist with treatment decision-making is less clear. We present a case-based discussion of
depressive symptoms in patients with advanced kidney disease not on dialysis. We highlight the contribution of underlying so-
matic and psychosocial factors in the assessment and management of depression. We further define the role of the interdisci-
plinary care team, including palliative care and hospice medicine, to assist with symptom management and end-of-life care for
CKD patients with depression.
Q 2014 by the National Kidney Foundation, Inc. All rights reserved.
Key Words: Chronic kidney disease, Depression, Interdisciplinary team, Palliative care, End of life
Case
J.K. is a 68-year-old man with Stage 3B CKD attrib-
uted to longstanding diabetes and hypertension.
Kidney replacement options were discussed in the
past, and he had planned to prepare for dialysis
when the time came. Two months ago, he suffered
critical ischemia of the left foot resulting in amputa-
tion. During his hospitalization, his serum creatinine
worsened to 3.4. mg/dL and an estimated glomerular
filtration rate (eGFR) of 16 mL/minute. He is less
interactive than usual. His daughter shares her
concern that J.K. has been more withdrawn and
less interested in activities he previously enjoyed
for the past 6 weeks. He describes his appetite as
poor and has lost 20 lb since his hospitalization.
When the nephrologist asks J.K. his thoughts on
preparation for dialysis, J.K. responds, “Is dialysis
really worth it?”
Introduction
Depression is common in CKD, and it may hinder how
patients view and plan for their kidney disease manage-
ment. Depressed patients with kidney disease are at risk
for making poor decisions, which can potentially lead to
worsening symptoms, reduced life satisfaction, and poor
physical health.1
Depression can affect how dialysis de-
cisions are made and has been associated with increased
withdrawal from treatment.2
Patients faced with dialysis
decisions and for whom depression is suspected warrant
comprehensive assessment and management of depres-
sion before decisions about dialysis can be made.
The diagnosis of depression can be challenging. These
patients experience a high burden of somatic and psycho-
logical symptoms associated with advanced kidney dis-
ease that may overlap with those of depression.3-5
Somatic symptoms include fatigue, decreased mood,
and sleep disorders, to name a few.6,7
These same
symptoms may also result from progression of coexisting
conditions such as end organ failure (eg, lung, heart
disease) or general functional decline (eg, dementia,
frailty).8
The kidney care team is tasked with determining
whether these symptoms are a result of progressive end or-
gan illness or are due to depression. Understanding the
underlying cause of the symptoms can better guide assess-
ment and management (Fig. 1).
When depression is suspected, the kidney care team
must adopt a comprehensive care approach with resources
to screen for depression, provide support to patients and
families, and refer the patient to appropriate services
including mental health and palliative care. The initial
step in the evaluation of a patient suspected of depressive
symptoms involves exploring and attending to the pa-
tient's concerns and perceptions. Through exploration of
patient concerns and perceptions, members of the kidney
care team gain an understanding of the somatic and psy-
chosocial factors that may be contributing to depression.
In certain patients who are declining from advanced kid-
ney disease or coexisting conditions, dialysis may not be
elected even with treatment of depression.9,10
In these
instances, the hoped-for benefits of dialysis are out-
weighed by the potential burdens that accompany the
treatment. Conservative management with palliative
care can provide care with a focus on symptom control
and quality of life.
Depression in CKD
For a diagnosis of depression, low mood or anhedonia
(lack of pleasure in activities) must also be present in
From Renal-Electrolyte Division, Section of Palliative Care and Medical
Ethics, University of Pittsburgh School of Medicine, University of Pittsburgh
Medical Center, Pittsburgh, PA; Mid-Atlantic Renal Coalition, Richmond,
VA; and Division of Nephrology, Massachusetts General Hospital, Harvard
Medical School, Boston, MA.
Financial Disclosure: The authors declare that they have no relevant finan-
cial interests.
Address correspondence to Jane O. Schell, MD, Division of Renal-
Electrolyte, Section of Palliative Care and Medical Ethics, University of Pitts-
burgh School of Medicine, UPMC Montefiore Suite 933W, 200 Lothrop Street,
Pittsburgh, PA 15213. E-mail: schelljo@upmc.edu
Ó 2014 by the National Kidney Foundation, Inc. All rights reserved.
1548-5595/$36.00
http://dx.doi.org/10.1053/j.ackd.2014.03.012
Advances in Chronic Kidney Disease, Vol 21, No 4 (July), 2014: pp 385-391 385
2. addition to the associated symptoms. A major depressive
episode (MDE) requires that 5 of 9 symptoms be present
during the same 2-week period (Table 1).11
Less severe
forms of depression exist and deserve attention because
they can lead to major depression and contribute to
morbidity.
Depression is common in patients with CKD, with rates 4
times that of the general population.12
Approximately 1 in
5 patients with CKD can experience a MDE before initia-
tion of dialysis.13
Most studies have focused on depression
in patients on dialysis; however, increasing data suggest
that the prevalence is similar in CKD patients not on dial-
ysis. The point prevalence of depression and depressive
symptoms in kidney disease varies between 15% and
50%.14,15
In a recent meta-analysis, this variability in
depression depended on the population studied, the stage
of CKD, and the methods used to assess depression, specif-
ically self-rating vs structured interview,16
However when
assessed using a structured clinical interview, Hedayati
and colleagues found that 1 in 5 patients with CKD had
depression, suggesting that the actual rates of depression
are high.15
In patients on long-term dialysis, depression has been
associated with adverse out-
comes such as nonadherence,
increased hospitalization and
health-care utilization, and
all-cause death.13,17-20
Within
the CKD population not on
dialysis, the rate of de-
pression and its implica-
tions on health outcomes
are similar. In a Taiwanese
cohort, the presence of high
depressive symptoms, as
determined by self-reported
surveys, was associated with
an increased risk of progres-
sion to ESRD or death and
first hospitalization.21
Whether the high depressive symp-
toms are causative or merely represent a marker for overall
clinical decline is less clear. However, the results remained
significant after adjustment for comorbidities, suggesting
an independent association of depression with poor out-
comes. Within this cohort, high depressive symptoms
were also linked to kidney function decline. In the Chronic
Renal Insufficiency Cohort (CRIC) study and the
Hispanic-CRIC study, lower levels of kidney function and
higher levels of albuminuria were associated independently
with higher odds of elevated depressive symptoms.22
For
every 10-mL/min decrease in eGFR, the odds of elevated
depressive symptoms increased by 10%.
It is important to note that depression has been associ-
ated with poor outcomes at the time of dialysis initiation.
Heyadati and colleagues examined the association of
MDE using physician interview and outcomes in a Veter-
ans' Administration CKD cohort.13
Patients with CKD
and MDE had almost twice the risk of being hospitalized
and 3 times the risk of dialysis initiation within 1 year
compared with those without MDE. This association
remained significant after adjustment for comorbidities
and risk factors. These results underscore the need for ac-
curate assessment and treatment of depression in
advanced kidney disease, especially in those starting dial-
ysis.
Risk factors for depression in CKD patients include fe-
male sex, presence of diabetes, underlying psychiatric
illness, and alcohol or substance abuse.21,23
In the
CRIC and Hispanic-CRIC study, compared with non-
Hispanic Whites, non-Hispanic Blacks and Hispanics
had 1.5-fold greater odds of elevated depressive symp-
toms and had at least 50% lower odds of antidepressant
use.16
Depression Evaluation and the Role of the Social
Worker
The nephrologist becomes concerned that J.K. may
be suffering from depression. J.K. denies having
a prior diagnosis of depression or depressive
disorder in the past. His daughter describes her
father as a “go-getter” and someone who especi-
ally enjoyed visiting
with his family and
grandchildren. Lately,
he has preferred to
stay at home and
avoids social gather-
ings. The nephrologist
asks the patient and
his daughter to meet
with the clinic social
worker. The patient
scores 13 out of 21 on
the Beck Depression
Index (BDI), support-
ing a diagnosis of
MDE. J.K. is referred to mental health for further
assessment and management.
For the kidney provider who suspects depression, open
communication and access to interdisciplinary resources
are key components to appropriate management. Mem-
bers of the kidney care team, in particular social workers,
have a unique role in the care of the CKD patients with
depression. Patients with kidney disease often must adjust
to and cope with living with chronic illness and the effect it
has on their experience.24
This process of adaptation af-
fects multiple components of a patient's life, including
one's identity, independence, and support.25
Acute
stressors and poor support have also been associated
with psychological outcomes such as depression.26
Mem-
bers of the kidney care team can provide support, educa-
tion, and resources to counter and respond to these
needs, thereby helping patients and family members better
adjust and prepare for their disease trajectory. In partic-
ular, the masters-prepared social worker has demon-
strated competencies in counseling as well as behavioral
and social systems knowledge that can be applied to offer
CLINICAL SUMMARY
The prevalence of depression in CKD patients is
approximately 20%.
Depression can affect how patients make decisions about
dialysis.
The kidney care team can use self-reported scales to iden-
tify and manage CKD patients with depression.
Palliative care can assist the kidney care team with the
management of depression, address treatment decision-
making, and outline advance care planning in patients
with CKD and depression.
Schell et al386
3. support, assistance in care decisions, and evaluation of
symptoms.
Screening Tools
The gold standard diagnosis of depression requires a
clinical interview performed by trained mental health
professionals. For the kidney care team, the use
of self-reported screening tools has been studied and
validated in the kidney disease population. The diag-
nosis is confirmed using a structured interview per-
formed by a member of the kidney care team or, if
necessary, by a mental health professional, especially if
there are concerns for suicidal ideation or other psychi-
atric illnesses.
The use of self-reported tools has been validated in the
dialysis and CKD population. In the dialysis population,
Watnik and colleagues measured depression in a dialysis
population using the 21-item BDI and the Patient Health
Questionnaire-9 compared with the gold standard struc-
tured clinical interview.27
Twenty-six percent of the
cohort was diagnosed with a depressive disorder. The
cutoff score for depression using the BDI was 14 to 16
for ESRD patients compared with 10 for the general pop-
ulation. The increased cutoff was attributed to the
increased number of somatic symptoms experienced by
patients on dialysis independent of depressive symp-
toms. Both self-reported tools performed well as
screening tools with sensitivities of 91% and 92% and
specificities of 86% and 92% for the BDI and Patient
Health Questionnaire-9, respectively.
In patients with CKD not on dialysis, Hedayati and
colleagues investigated the BDI and the 16 Quick Inven-
tory Depressive Symptoms Scale of Self-Report (QID-
SR16) against the gold standard clinical interview in
272 patients with a mean eGFR of 31.4 mL/minute.28
The best diagnostic accuracy for each measure was a
cutoff score of 11 for the BDI and 10 for the QID-SR16,
with sensitivities of 89% and 91% and specificities of
88% and 88%, respectively. The positive and negative
likelihood ratios for the cutoff scores were 7.6 and 0.1,
respectively, for BDI and 7.5 and 0.1, respectively, for
QID-SR16. These results suggest that either the BDI or
QID-SR16 can be used reliably as a screening tool for
depression.
Table 1. DSM-5 Criteria for Major Depressive Episode11
Low mood or anhedonia plus $5 of 9 of the following symp-
toms in the same 2-wk period must be present:
1. Depressed mood
2. Loss of interest or pleasure
3. Appetite disturbance
4. Sleep disturbance
5. Psychomotor agitation or retardation
6. Fatigue or tiredness
7. Worthlessness, feeling like a burden, or guilty
8. Difficulty concentrating
9. Recurring thoughts of death or suicide
DSM-5, Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition.
Figure 1. Influence of somatic and psychosocial symptoms and depression on outcomes in CKD.
Depression in CKD 387
4. Treatment
Treatment for depression may include pharmacologic and
nonpharmacologic options that can be tailored based on
the individual patient's needs and the resources available
to the kidney care team. The use of pharmacologic treat-
ment has not been clearly supported in the literature,
and their use can be associated with adverse complications
for patients with advanced kidney disease.23,29
On the basis
of the limited studies performed in patients with kidney
disease, selective serotonin reuptake inhibitors are
thought to be relatively safe with advanced CKD with
fewer side effects.30,31
If medications are started, then
they must be dosed for kidney impairment and
monitored closely for the occurrence of side effects.
Given the limited efficacy and potential harm associated
with pharmacologic treatments, nonpharmacologic inter-
ventions have been explored with promising results.
Most data come from studies of patients with depression
undergoing dialysis. For example, alterations in dialysis
treatment regimens have been associated with improve-
ment in depressive symptoms and postdialysis recovery
time.32
Cognitive behavioral therapy, an interactive ther-
apy that incorporates techniques that reinforce logical
thinking and refocuses negative thoughts and behaviors,
has been associated with improved depression scores. A
recent study of cognitive behavioral therapy administered
to patients undergoing hemodialysis was associated with
statistically significant reductions in depression scores,
improved quality of life, and decreased interdialytic
weight gain compared with the wait-list control group.33
In addition, appropriate assessment and management of
symptoms such as pain and anxiety may also indirectly
improve depressive symptoms.
Approach to the Management of Depression in CKD
Despite data suggesting a high prevalence of depression,
only a small percentage of patients receive treatment.22,34
These treatment patterns reflect a lack of clinical
guidelines and practice patterns for depression
management in advanced kidney disease. In the dialysis
population, experts recommend routine screening given
the high prevalence of depression and its effect on
patient outcomes.35,36
A previously published algorithm
in patients with kidney disease provides a patient-
centered approach to depression management that is
based on screening results and associated symptoms.35
The kidney care team can then devise a treatment plan
tailored to the unique experience and needs of the patient.
Patients should ideally have symptoms reassessed period-
ically for evidence of a successful treatment plan and
improved depressive symptoms. Data suggest that the
timing and rate of improvements after initiation of an anti-
depressant can vary with some patients, demonstrating ev-
idence of improvement within 1 week of treatment.37,38
Treatment of depressive symptoms may not affect the
overall disease trajectory in patients who are experiencing
decline either due to advanced kidney disease or
coexisting conditions. It is reasonable to discuss the overall
goals of care and whether dialysis would meaningfully
provide benefit.
Dialysis Decision-Making, Symptom
Management, and the Role of Palliative Care
J.K. was diagnosed with depression and started on
an antidepressant. The interdisciplinary team fol-
lowed the patient's progress closely. After 3 months,
J.K. became more interactive and his appetite
improved. However, his clinical status worsened
with 2 subsequent hospitalizations for infection and
pain related to his amputated foot. He had been
living on and off in a skilled nursing home and
requiring assistance with activities of daily living.
The clinic social worker alongside the kidney care
team discussed whether or not to prepare for dialysis
given his clinical status and treatment for depression.
During a family meeting, J.K. outlined his goals of
living independently and not being dependent on
others. He shared his worries that these goals are
less likely to occur and that he is declining. When
the social worker asked about the kinds of care J.K.
wished to avoid, he shared a desire not to go back
to the hospital even if that meant he would not
receive life-prolonging therapies. He ultimately elec-
ted not to start dialysis and instead favored conserva-
tive management with a focus on comfort and
symptoms.
Palliative care is an interdisciplinary care team made up
of physicians, nurses and nurse aids, chaplains, and social
workers with the goal of addressing patients with needs.
These services include symptom management, psychoso-
cial support, communication and advance care planning,
treatment decision-making, and hospice and bereavement
services (Table 2).39,40
Palliative care is person- and family-
centered care that optimizes quality of life by anticipating,
preventing, and treating suffering.41
Palliative care meets
the needs of a patient at different points of the disease tra-
jectory with the flexibility to respond to unexpected or
acute changes in health status.
Table 2. Palliative Care Services for the Declining Patient With CKD
Symptom management:
Escalating/refractory symptoms (ie, pain, nausea, pruritus)
Complex pharmacologic regimens
Psychological distress and illness (ie, depression, insomnia,
anxiety, grief)
Psychosocial support:
Family/caregiver support
Communication and advance care planning:
Prognostic discussions
Living will completion and health-care proxy designation
Reassessment of goals of care
Transitions of care and shared decision-making:
Initiation of time-limited trial of renal replacement therapy
Withdrawal of renal replacement therapy
Conservative management (“No dialysis” treatment option)
Hospice education and referral
Bereavement support
Schell et al388
5. Treatment Decision-Making
Many patients with advanced kidney disease have under-
lying comorbidities and functional impairments that limit
the hoped-for benefits of dialysis. Often the potential ben-
efits of dialysis come at the risk of increased interface with
the health-care system, such as travel time to dialysis, pro-
cedures to maintain dialysis access, and unanticipated
hospitalizations.42,43
To better guide decision-making, it
is helpful for the kidney care team members to gain a sense
of the patient's overall goals and values to determine if
dialysis aligns with these goals and values.44
For some pa-
tients, with adequate treatment of depression, dialysis falls
short of achieving important patient goals, such as living
independently or the ability to enjoy certain activities,
and it may encourage outcomes wished to be avoided,
such as hospitalization or living in a skilled nursing facil-
ity. Palliative care can assist with goals-of-care discussions,
especially when prognostic uncertainty or concerns about
the patient's treatment preferences exist.
A communication framework using open-ended ques-
tions to explore and understand these big-picture goals
and values can better guide treatment decision-making
discussions (Table 2). By gaining an understanding of a pa-
tient's hopes and concerns for the future, the kidney pro-
vider has a better sense of whether dialysis will
meaningfully assist with these goals. These conversations
are emotion-provoking often bringing up feared topics
such as prognosis and uncertainty. Similar to the skills pro-
viders use to elicit relevant medical data, specific skills are
necessary to respond to and explore emotional data. The
NURSE acronym (Name the emotion, Understand
the emotion, Respect the patient, Support the patient,
Explore the emotion) is a helpful communication tool
for responding to emotion (Table 3).45
Responding to pa-
tient emotion assists with coping and builds trust.46
The life expectancy for patients with many comorbidities
is often limited whether or not dialysis is elected. By dis-
cussing patients' overall goals and values, the kidney
care team has the opportunity to engage in timely discus-
sions of advance care planning to outline care preferences
at end of life.47
Data suggest patients want to discuss these
topics and that the care provider initiate these discus-
sions.48-50
Patients who have had timely discussions of
end of life are more likely to receive care consistent with
their care preferences, and family members are less likely
to suffer psychological distress after their loved one's
death.51
Symptom Management
Early integration of palliative care with standard clinical
practice has been associated with clinical benefits.52
Temel
and colleagues demonstrated that integration of palliative
care with standard oncologic care (as opposed to standard
oncologic care alone) resulted in higher quality of life and
increased survival in patients with new diagnoses of met-
astatic non-small-cell lung cancer.53
Tailoring palliative
care to the needs of a patient throughout their disease spec-
trum remains a critical step in optimizing care for patients
with CKD. For these patients who are dying, depression
can significantly affect the quality of life by taking away
hope, sense of peace, and meaning.54
Untreated depres-
sion also makes the effective treatment of pain and other
symptoms more difficult.55
Because patients may be reluc-
tant to report depressive symptoms to medical personnel,
palliative care may assist with routine assessment for
depression and depressive symptoms over the kidney dis-
ease course.54
End of Life and Bereavement
Patients with kidney disease are less likely to use hospice
services at end of life.56
Instead, these patients experience
a high intensity of care at the end of life compared with
those with other life-limiting illnesses.57
Factors explaining
the underutilization of hospice include patient-level fac-
tors, nephrologist referral patterns, and hospice eligibility
in patients with kidney disease. However, timely hospice
referral can improve the end-of-life experience for patients
with kidney disease. Dialysis patients who receive hospice
are less like to receive intensive therapies at end of life and
more likely to die at home.56
Hospice can also assist with managing symptoms at
end of life in patients either on dialysis or managed conser-
vatively. Murtagh and colleagues measured symptom
prevalence and severity in the last month of life for
patients undergoing conservative management.58
Patients
Table 3. Communication Framework for Treatment Decision-Making Based on Patient Goals and Values43
Communication Tools Potential Communication Statements
Open-ended questions to explore goals and values:
Current experience “What has life been like these past months?”
Hopes for the future “When you think about the future, what is most important to you?”
“As we think about how to care for you, what kinds of things should we focus on?”
Concerns for the future “As you think about the future, what concerns do you have?”
“When it comes to the kinds of care you receive, are there situations you hope to
avoid (such as going to the hospital, undergoing CPR)?
Responding to emotion:
Name the emotion “I can see this has been difficult.”
Understand the emotion “This has been a tough time for you.”
Respect (praise) the patient “I can tell you’ve put a lot of thought into this decision.”
Support the patient “We will be here for you no matter what we decide today.”
Explore the emotion “Tell me what worries you most about not doing dialysis.”
CPR, cardiopulmonary resuscitation.
Depression in CKD 389
6. reported physical and psychological symptoms, including
feeling worried, sad, and nervous. It is important to note
that conservatively managed kidney patients experienced
higher overall symptom burden in the last month of life
compared with patients with advanced cancer in the last
month of life. These findings highlight the need for timely
hospice referral in this patient population.
Most end-of-life symptoms in kidney disease come from
patients and their families who have received and/or with-
drawn from dialysis. For instance, Cohen and colleagues
surveyed families of patients who were on dialysis within
6 to 10 weeks of their deaths.59
Most deaths took place in
institutions such as hospitals or nursing homes. Most fam-
ilies believed their loves ones had peaceful deaths. The
most common distressing symptom was pain; patients
had significantly less likelihood of having pain in the last
week of life if they died at home compared with those
who died in institutions. Likewise, Phillips and colleagues
investigated the effect of dialysis discontinuation on
families within 5 years of death.60
The main patient
symptoms reported by families during the last week of
life include confusion, agitation or restlessness, and/or
significant pain.
Conclusion
Patients with advanced CKD encounter significant symp-
toms throughout the kidney disease course. Physical and
psychological symptoms are prevalent and can negatively
affect clinical outcomes and patient experience. Depres-
sion is understudied in CKD patients; however, its pres-
ence is associated with poor outcomes and it affects
treatment decision-making. Depression can best be ad-
dressed through an interdisciplinary approach incorpo-
rating the skill sets of the kidney care team and referral
to services such as mental health and palliative care
when appropriate. Palliative care services can provide a
layer of support to provide assistance with treatment
decision-making, ongoing symptom assessment, and
management and care at the end of life.
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Depression in CKD 391