Mental Health in Nursing Homes: Lessons from Late Life Depression

Conference held at Belmont Center for Comprehensive Treatment on October 16, 2003

Ira Katz
University of Pennsylvania
Mental Illness Research Education and Clinical Center
Philadelphia VAMC

Geriatric depression occurs in the context of medical illnesses, disability, cognitive dysfunction, and psychosocial adversity.

Our interest in late life depression reflects our positive view of aging and our elderly patients.

DSM-IV-R Depressive Symptoms

• Dysphoria
• Anhedonia
• Guilt/ Self-reproach
• Fatigability
• Impaired concentration and cognition
• Appetite disturbance
• Sleep disturbance
• Suicidal thoughts, risk
• Agitation or retardation

Background: Treatment for Depression

• Hierarchical Models
  • Elements of treatment
• Drug X or Y; IPT or CBT
  • Algorithms
• Sequences of treatment
  • Programs
• Support the delivery of care
  • Policies
• Facilitators or barriers for programs

AHCPR Algorithm

• Start treatment
• Evaluate responses at about six weeks
• If:
  • Remission, then continue
  • Partial response, then intensify or augment
  • No response, then change treatment
• Reevaluate responses at about twelve weeks
• If:
  • Significant residual symptoms, modify treatment
  • Remission, enter continuation phase

The focus on algorithms is distinct from an alternative approach that emphasizes "front end" approaches to care, and promises treatment matching.

• Emphasize the sequencing of treatments over elusive ideas about treatment-matching.

Psychiatric Aspects of Long term Care

• Nursing homes (and other long term care settings) are:
  • sites for the delivery of mental health services
  • laboratories for the study of aging and psychiatric-medical comorbidity
• Scope of problem:
  • 1.6 million residents in 16,000 facilities
  • 80% with a psychiatric diagnosis

The Care Environment

• Stigma
  • 30% of seriously ill, hospitalized adults said they "would rather die" than live in a nursing home all the time

TJ Mattimore et al (1997) JAGS 45: 818-824

• Concerns about quality
  • 4.9 survey deficiencies/facility
  • only 21.6% of facilities have no deficiencies - 1997 HCFA data
• Meaningful life is possible

Tracy Kidder, "Old Friends", Houghton Mifflin, Boston, 1993

Depression: Morbidity and Mortality

• Disability
• Cognitive impairment
• Pain
• Subnutrition
• Behavioral disturbances
• Treatment refusal
• Staff time utilization
• Mortality

Validating Depression

• These findings demonstrate that "depression" in the nursing home is recognizable, common, and clinically significant.
• Is it the same disease that occurs in younger and healthier psychiatric patients?
• Method: Mirror image clinical trial

Other findings

• Significant treatment effects on positive affect
• Response has ecological significance
  • Research ratings on MDS Sad and Anxious Mood
  • Research ratings on MDS Initiative/Involvement
  • Staff ratings on MDS Mood Persistence
• Clinically relevant subtypes
  • Failure to thrive
  • Depression in dementia

RCT in Post-Stroke Depression

RG Robinson et al (2000) Am J Psych 157:351-359

• Patients from neurology rehabilitation services were randomized to:
  • nortriptyline (up to 100 mg/day)
  • fluoxetine (up to 40 mg/day)
  • placebo

• Responders
  • 10/13 (77%) nortripyline
  • 2/14 (14%) fluoxetine
  • 4/13 (31%) placebo

Where are we now?

• The Problem:
  • How should we treat older patients with psychiatric-medical comorbidity when we don't really know what medications (and/or psychotherapies) are optimal?
• The Answer
  • Focus on the algorithm
• For moderate depression
  • Start with a well-tolerated first line treatment
  • Monitor outcomes (safety and efficacy)
  • Adjust treatment depending on outcomes

Evolution in the Use of Antidepressants:

• patients with chart diagnoses of depression
• 10% treated with an antidepressant
• Recent
  • entire nursing home population
• 59.8% decrease in antipsychotics from 33.7% to 16.1%
• 97.0% increase in antidepressants from 12.6% to 24.9%

Use of Antidepressants

• Based on chart review for four months for residents receiving AD
  • Initiated treatment 4.3%
  • Started new agent (other) 11.4%
  • Dose increase 24.3%
  • Dose decrease 5.7%
  • Discontinue agent 2.9%
  • Any activity 40 %

Quality of Prescribing

• Medical Record Review
  • Conducted by Research Nurses
  • Considers 4 month window
  • Considers markers for:
• Diagnosis
• Evaluation
• Initiating/Modifying Treatment
• Monitoring Safety and Outcomes

Evaluating Current Care

• Non-adherence to algorithms is common
• We don't know if "remissions" seen in epidemiological studies may be more apparent than real
• Next steps
  • Improve pharmacological treatment
  • Recognize the rest of the story

The Rest of the Story

• For patients with depression without treatment
  • Need for diagnostic evaluations, treatment planning
  • Consider psychotherapy or 'special care'
• For patients with depression with treatment
  • Modify or intensify treatment
  • Consider psychotherapy or 'special care'
  • (Think about when to stop)
• For patients with treatment, no depression
  • Consider when to discontinue treatment
• For recurrent disorder-maintenance
• For a single episode-?
  • (Is it possible that there may be overtreatment)

Improving the Quality of Care

• Current quality indicators
• Prevalence of depression.
• Prevalence of depression not treated with antidepressant medication
• Proposed quality measure for focusing on downstream components of care:
• Prevalence of depression in residents receiving antidepressant medication where the treatment is unchanged for 3 months.

Return to: Mental Health and Aging: October 16, 2003 Conference, Introductory page