Age Friendly Health Care and Systems Mentation Depression

Age Friendly Health Care and Systems Mentation: Depression Marianne Smith, Ph. D, RN Associate Professor & Director of the Csomay Center of Gerontological Excellence, University of Iowa, College of Nursing

Goals for Today. . . § § Overview of depression Why it is important in 4 Ms Brief review of screening Brief review of interventions Acknowledgement: This program is one in a series of 8 programs about the 4 Ms and is co-sponsored by the Csomay Center for Gerontological Excellence and the Geriatrics Workforce Enhancement Program at the University of Iowa Geriatric Education Center. The content is based on the Age-Friendly initiative of the J. A. Hartford Foundation and Institute for Healthcare Improvement. We invite users to explore options to join the social movement at their website: http: //www. ihi. org/Engage/Initiatives/Age-Friendly-Health-Systems/Pages/default. aspx

Mentation § Prevent, identify, treat and manage dementia, depression, and delirium across settings of care § Acute care: greater focus on delirium § Ambulatory care: greater focus on depression, dementia § Senior living: Pay attention to all 3 Ds!!

Mentation: Depression § Clinical depression changes thoughts and feelings that interfere with üTalking about What Matters üEngaging in physical & social activities üManaging other health conditions üEnjoying friends, family, activities § Depression robs older people of their quality life AND contributes to a downward spiral of disability

Mentation: Depression Brief Overview § Clinical depression is MORE than a passing mood! üSignificant cluster of specific symptoms üPersists over time üImpairs function üContributes to dysfunction & disability üIncreases risk of self-harm, suicide

Mentation: Depression Who wouldn’t feel that way? Being sad is understandable – I mean, after all… Goodness, you have every RIGHT to be depressed! Too often UN-recognized and UNtreated among older people!

Mentation: Major Depression Two “hallmark” symptoms § Depressed mood üSadness, discouragement, crying ü“Down in the dumps” – “Blues” OR § Loss of ability to experience pleasure (a. k. a. anhedonia) üWithdrawal, inactivity, isolation ü“Nothing is fun” – “Don’t care”

Mentation: Major Depression § Plus additional symptoms for 5 total üWeight loss or gain üSleep disturbance Insomnia or hypersomnia üPsychomotor agitation or retardation üFatigue, loss of energy üFeelings of worthlessness, inappropriate guilt üLoss of ability to think, concentrate, make decisions üRecurrent thoughts of death, suicidal ideation

Depression “Without Sadness” § Anhedonia present, but sadness is NOT üLoss of ability to experience pleasure loss of interest, apathy, withdrawal, indifference, low motivation üAdditional symptoms ¬Physical: Sleep, appetite, energy, motor activity looks like PHYSICAL ILLNESS ¬Psychological: Problems thinking, concentrating looks like DEMENTIA üOften overlooked AS depression!!

Depression and Dementia DEMENTIA DEPRESSION 30% with both! Remember depression can occur alone, or may overlap with dementia!

(+) ) Symptoms (- Depression: Course Weeks to Months (up to 2 years)

Age Friendly: Key Actions § ASSESS üConsider risk factors, presentation üCheck history related to depression, history of symptoms or treatment üScreen for depression § ACT ON your findings üRefer for further evaluation üTreat symptoms üSupport function, refer to resources

Mentation: Depression Assessment Tips § Normalize depression screening for patients I’m going to assess your mood just like we check your blood pressure, or heart or lungs… § Remember! Depression screening is part of Welcome to Medicare and Medicare Annual Wellness Visits!

Depression: ASSESS § 2 -item Patient Health Questionnaire (PHQ-2) § 9 -item Patient Health Questionnaire (Ph. Q-9) § Geriatric Depression Scale üGDS Short Form üGDS Long Form § Don’t guess! Quantify symptoms using a standardized measure!!

PHQ-9 Nine items mirror the diagnostic criteria for Major Depressive Disorder PHQ-2 uses the first two (hallmark) symptoms required for diagnosis of MDD PHQ-9 uses all nine symptoms https: //www. phqscreeners. com/

PHQ-2: Rate Hallmark Symptoms Screening: If unsure, just rate 2 symptoms 1. Little interest or pleasure in doing things 2. Feeling down, depressed or hopeless Score each item: 0 = Not at all 1 = Several days 2 = More than half the days 3 = Nearly every day Total Score: 0 -6 Score of 3 or greater Complete the remaining items!

PHQ-9: Rate remaining symptoms 1. Little interest or pleasure in doing things 2. Feeling down, depressed or hopeless 3. Trouble falling or staying asleep, sleeping too much 4. Feeling tired or having little energy 5. Poor appetite or overeating 6. Feeling bad about yourself, feeling like a failure 7. Trouble concentrating on things, such as reading the newspaper or watching television 8. Moving or speaking slowly, or being restless and moving around more than usual 9. Thoughts that you would be better off dead or of hurting yourself in some way

PHQ-9 Scoring § Score items as before: ü 0=Not at all to 3=Nearly every day § Add scores for 9 items; Total score 0 -27 § Apply cut-points: ü 0 -4 = depression is not significant ü 5 -9 = mild depression ü 10 -14 = moderate depression; any score over 10 is considered clinically significant/ worthy of treatment ü 15 -19 = moderately severe depression ü 20 -27 = severe depression

Geriatric Depression Scale: Long Form Scoring: 0 -30 • 0 -9 = normal • 10 -19 = mild • 20 -30 = severe GSD forms are considered public domain

Geriatric Depression Scale: Short Form Scoring: 0 -15 • >5 suggestive of depression • >10 indicative of depression • Scores of 5 or greater suggest need for further assessment

Depression: ACT ON Taking action is guided by § Severity of depression symptoms § Risk of self-harm § Older person’s treatment preferences üMany older adults prefer non-drug treatments! üExplore preferences üDiscuss options üFocus on What Matters!!

Depression: ACT ON § Think about interactions among 4 Ms üDifficulty identifying What Matters due to anhedonia? Sense that nothing is fun? Nothing matters? üMedication(s) triggering depression? üMobility challenged due to fatigue, lack of energy? üDepression masked by Dementia? üAll of the above? ?

Depression: ACT ON § Address problems that cause, contribute to depression üMedications üHealth problems ¬ Stroke ¬ Diabetes ¬ Heart disease ¬ Chronic pain üAge-related loss/change ¬ Retirement, bereavement, relocation, isolation ¬ Unwanted and/or unexpected changes

Depression: ACT ON For mild to moderate depression, talking and behavioral therapies often works as well as medication. What would you like to try? Two main treatment approaches § Behavioral/non-drug therapies üBehavioral activation üTalking therapy üPhysical activity/exercise üSelf-care § Antidepressant Medication üMany choices; selection based on symptoms üFollow 4 Ms advice! Only if preferred & safe!

Depression: ACT ON § Behavioral activation schedule pleasant events üRe-establish healthy routines üIncrease positive experiences üLeads to improved mood AND better functioning § Individual, social, physical activities § Keep it simple! (failure free~!)

Depression: ACT ON § Physical exercise Engaging in physical activity for 20 minutes a day, 5 x each week, decreases depression and improves health! § Break the cycle of “Do less Feel Worse”

Depression: ACT ON Counseling, talking therapy § Often preferred as 1 st line üDon’t want more pills üDon’t want “MIND” pills in particular § May need to explain goals üNo couches, no talking about dreams or “mother” unless she is a current problem üUsually problem-focused, brief, limited number of visits

Depression: ACT ON Antidepressant Medication § Apply Age-Friendly practices! üSelect drugs based on their side effect profile üAvoid high risk meds: TCAs & MAOs üMonitor side- or adverse effects üStart low, go slow, but keep going until symptoms resolve! üEducate the person to advance adherence!

Depression: ACT ON Promote adherence § Antidepressants. . . TO DO: 1. Outcomes 2. Side effects 3. Education üDo NOT work immediately üAre NOT addicting üWill not make you “high” üNeed to be taken every day üMay take 12 weeks to get the full benefit üSide effects may occur & should be reported § Just another “illness treatment”

Summary: Depression Who wouldn’t feel that way? !? § Clinical depression is often masked and misunderstood § Apply screening tools; assess severity § Address causal/contributing factors § Assess interactions with ALL 4 MS § Treat following person’s preferences § Support function: Doing What Matters!!