Mental Health in LTC Residents

1. Mental Health in LTC Residents Pamela Z. Cacchione, PhD, CRNP, BC, FGSA, FAAN Ralston House Term Chair in Gerontological Nursing Associate Professor of Geropsychiatric Nursing-CE Nurse Scientist- Penn Presbyterian Medical Center Health and Aging Policy Fellow- 2016-2018 University of Pennsylvania School of Nursing

2. Objectives • To review interventions that enhance mental health in older adults in LTC settings • To address common mental health conditions among LTC older adults • To discuss serious mental illness and substance use disorders among LTC older adults

3. Average older adult who resides in LTC AARP, 2015

4. Average Older Adult who Resides in LTC • 88% of nursing residents are 65 years or older • 45% are 85 years or older • 98% of older adults between 65 and 84 live in the community • 88% of the old old live in the community • Of those older adults currently 65 years or older 35% will eventually enter a nursing home • Resident Characteristics • Over 40% have dementia • Over 50% have depression • 80% need assistance with at least 4 activities of daily living • Majority are widowed • Of those admitted to NH younger than age 65, 14% have serious mental illness AARP Public Policy Institute, Nursing homes Fact Sheet https://www.caregiver.org/selected-long-term-care-statistics

5. Admission to LTC from HCBS Individual Characteristics Support Characteristics Family available but not willing Needs greater than capacity No Family available Family Requests NH Lack of outpatient supports- day care, home care meals on wheels etc. • Mean age 83 • Majority White & Female • Most common diagnoses • HTN • Arthritis • Visual Impairment • Dementia • Diabetes • Mental Health Diagnosis Robinson et al., 2012

6. Individual characteristics that support mental health • Good Physical Health • Social support • Important, especially for those institutionalized with decent physical health (Zhang et al., 2018) • High self-efficacy • Belief in one’s ability to success • Internal locus of control • Belief that one is in control, not powerless • Existence of purposeful tasks • Even small daily tasks or jobs for residents (Malfent, Wondrak, Kapusta & Sonneck, 2010)

7. Support Mental Health • Buddy System upon entering NH • Individual choice to come to NH • Choices regarding environment/location/belongings • Secondary Prevention • Screening for mental health conditions • Social Engagement • Intergenerational opportunities • Recreational Therapy • Address Sensory Impairment • OBRA 87

8. Environments that Support Mental Health

9. Environments that Support Mental Health United States Sweden

10. Overview of Depression • Depression and anxiety symptoms are a common response to loss and other stressors (e.g. grief reaction, normal bereavement, fear response) • Depression is not inevitable with aging • Predisposing factors: • Medical illness • Disability • More Common than Dementia In LTC

11. Major Depression vs. Non-Major Depression

12. Depression by Setting

13. Depression and Suicide Depression Risk of Suicide Completed Suicides 0.9%-3.1% of NH population 18.6-34.8 per 100,000 residents per year (Murphy, Bugeja, Pilgram, & Ibrahim, 2015) Suicidal Thoughts Very common One third of NH residents report SI (Mezuk et al., 2014) • 5 or more of the following symptoms fro the same 2 week period with at least on being: • Depressed mood or • Anehedonia • Changes in appetite • Sleep Disturbance • Fatigue or Decreased energy • Worthlessness or guilt • Difficulty concentrating • Recurrent thoughts of death or suicidal ideation, plans attempts

14. Risk for Suicide • Anticipation of nursing home placement (Loebel, 1991; Mezuk, Lohman, Leslie & Powell, 2015) • Male gender (Murphy et al., 2015) • White Race (Mezuk et al., 2015) • Depression • 67% of NH with documented depression • Two thirds not receiving treatment (Murphy et al., 2015) • Depression under recognized and treated in NH (Reiss & Tishler, 2008) • More common than dementia (Mezuk et al., 2015) • Previous psychiatric history (Reiss & Tishler, 2008) • Recent significant loss (Mezuk et al., 2014; Murphy et al., 2015) • Loss of spouse, child or pet • Financial loss • Loss of dignity/self-esteem

15. Risk continued • Physical health decline (Murphy et al., 2015; Menghini & Evans, 2000) • Hearing, vision, speech or mobility impairment • Life threatening illness • Pain • Intact cognition (Menghini & Evans, 2000) • Educated professionals • Duration of residence (Murphy et al., 2015) • Residents admitted <12 months in the facility were at higher risk • Organizational Factors (Osgood, 1992; Mezuk et al., 2015) • Large facilities • High staff turnover • Lower bed cost • Private facilities • 20% of all suicides in this country are committed by Veterans (Leadman et al., 2013)

16. Depression CEASE SAAD S Sex A Anahedonia A Agitation D Depressed Mood • C Crying • E Eating • A Anxiety • S Sleep • E Energy

17. Resource • Promoting Emotional Health and Preventing Suicide: A Toolkit for Senior Living Communities (SAMHSA, 2011) • http://store.samhsa.gov/product/Promoting-Emotional-health-and-Preventing-Suicide/SMA10-4515

18. Meet Roberto and his Daughter Mignonne

19. Referred to us for Depression Nursing home reports Clinical findings GDS SLUMS CAM Clinical findings • Not participating in Rehab • Multiple complaints • Not sleeping well • Not eating

20. Delirium can resolve Following TX of underlying causes On his way to his apartment • GDS • SLUMS • CAM • Clinical findings • Discharged to Supported Apartment Living

21. Delirium • The acute onset of a cluster of global, transient changes constituting disturbances in attention, cognition, fluctuating course, level of consciousness, psychomotor activity, and / or sleep-wake cycle • Due to a medical condition • Medication induced • Substance intoxication or withdrawal • Multiple etiologies APA (2013), DSM 5 Criteria

22. Delirium Epidemiology • Most common in the Acute Care setting. Yet, health care providers miss most cases of delirium Inouye (1994).Am J. Med. 97(3): 278-288 ; Steis & Fick (2008) . • May be discharged with delirium 5.5% in one study McAvay et al. 2006, JAGS • Most studies of the elderly in hospitals, incidence of 22 to 33% (Francis et al, 1990 JAMA; Johnson et al, 1990 J of Gerontology, Med. Sciences). • Incidence increases with age • Ranges from 10% to 50% in persons aged 70 years or older (Inouye et al., 1999 NEJM) • Long-term care rates 14 to 33% (Cacchione et al, 2003 CNR; Mentes et al. 1999 Res. Nurs. Health). • Terminal/Palliative Care rates 28-48% on admission to hospice or hospital 90% hours or days before death NCI (2009). sss.cancer.gove/cancertopics/pdq/supportivecare/delirium/Health Professional/page 2 2009

23. Potential Causes of Delirium PS • D rugs • E yes and ears • L ow oxygen states • I nfections • R etention (urine or stool) • I ctal states • U nderhydration/nutrition • M etabolic • P ain • S ubdural

24. Delirium: Clinical Presentation Clinical subtype Hyperactive Hypoactive Mixed • Increased psychomotor activity, such as rapid speech, irritability, and restlessness • Lethargy • Slowed speech • Decreased alertness • Apathy • Shift between hyperactive and hypoactive states

25. Delirium Recognition is Challenging • Delirium is a longitudinal diagnosis dependent upon knowing premorbid cognition and function • Symptoms commonly overlap with depression and dementia • 42% of “depression referrals were delirious (Farrel, 1995) • Hardest diagnosis in psychiatry • Milder, hypoactive delirium superimposed on dementia (Lee, 2014) • Confusion Assessment Method • Richmond Agitation and Sedation Scale

26. Confusion Assessment Method • Feature 1: Acute onset of mental status changes or fluctuating course • AND • Feature 2: Inattention • AND EITHER • Feature 3: Disorganized Thinking • OR • Feature 4: Altered Level of Consciousness Inouye, 1990

27. Level of Consciousness

28. Is Delirium the same as Dementia? • Although there are similarities between dementia and delirium, • it is possible to differentiate between the two. • Common Error: • Misdiagnosing delirium as dementia DSM 5 Criteria Can be helpful in distinguishing dementia from delirium. • Consciousness • Onset • Fluctuating course • Attention eSlide - P3562 - AACN Hartford-sponsored Faculty Development

29. Neurodegenerative Diseases (Dementia) • DSM 5 Dementia of the AD type • The development of multiple cognitive deficits such as manifested by both, Impaired memory, long or short-term, can't learn new information orcan't recall information previously learned and is distinguished by: one (or more) of the following cognitive disturbances:Aphasia (language disturbance).Apraxia (impaired ability to carry out motor activities despite intact motor function).Agnosia (failure to recognize or identify objects despite intact sensory function).Disturbance in executive functioning (i.e., planning, organizing, sequencing, abstracting)

30. Common Types of Dementia • Alzheimer’s Dementia • Lewey Body Dementia • Frontotemporal Dementia • Primary Progressive Aphasia • Behavioral variant • Vascular Dementia • Creutzfeldt-Jakob Disease • Dementia due to Huntington’s Disease • Dementia due to Parkinson’s Disease • Normal Pressure Hydrocephalous • HIV related dementia

31. Neuropsychiatric Symptoms of Dementia • Shadowing’ • ‘Refusing’ personal care/hygiene/eating • Restlessness/’Agitation’ • Delusions, hallucinations, depression • Apathy • Sleep Disturbance • Sexually ‘inappropriate’ behavior • ‘Wandering’ • Persistent Vocalizations Noise-making • ‘Aggressive’ behavior/resistance to care

32. Perceptions • Based on previous experience • Need to distinguish between intention & behavior • Behavior =/=Problem to be controlled • Behavior = Communication of need • Change in perception requires ‘decentering’ from how one ordinarily ‘sees’ and accepting the supremacy of the patient’s perceptions

33. Change Your Perspective

34. Behavioral Logs

35. Toolkit • This toolkit is freely available at www.nursinghometoolkit.com • Sections on: • a working description of person-centered care • educational programs for implementing non-pharmacological approaches • psychometrically sound measures of BPSD • evidence-based non-pharmacological interventions for BPSD, including clinical decision support algorithms • techniques and resources for a system-widestep by step approach to ensuring uptake of alternatives to medication use

36. Risks Associated with Antipsychotics • Pneumonia • Cardiovascular risks • Prolonged QT interverl, ventricular tachycardia (especially if given IV) • Neuroleptic Malignant Syndrome • Death • Risk of death in those taking antipsychotics vs placebo 4.5% vs. 2.6%

37. Medications when needed only • 26% of NH residents were on an antipsychotic • 40 % of NH residents on antipsychotics had no documented appropriate indication for use • 42% of NH residents on benzodiazepines also had not appropriate indication for use (NNHS, 2004) • Haldol • Risperidone • Paliperidone • Olanzepine • Quetiapine • Ziprasidone • Aripiprazole • Clozapine

38. Sexually Inappropriate Behavior • Difficult to manage • Limit set, two caregivers behavior contracts • Tx for sexually inappropriate • SSRI’s • Cholinesterase Inhibitors • Beta Blocker • Atypical Antipsychotics • Provera in men • Safety an issue for individual & Staff

39. Serious Mental Illness in LTC • Schizophrenia • Bipolar Disorder • Schizoaffective Disorder • Dual Diagnosis

40. Schizophrenia At Least two: • Delusions • Hallucinations • Disorganized speech • Disorganized or catatonic behavior • Negative symptoms

41. Schizophrenia in the Elderly • 23% have emergence of illness after age 40 (Late onset) • 4% have emergence of illness after age 60 (Very-late onset) • Pts with onset in younger years and age with illness 80% of schizophrenics

42. Schizoaffective Disorder • Presence of discrete mood symptoms/episodes- depression or mania • With long-term duration of psychosis outside of episodes of mood symptoms disturbances

43. Bipolar Disorder • Bipolar I • Single Manic or Mixed Episode • Most recent episode: • Manic, mixed or depressed • Bipolar II • Recurrent major depressive episodes with hypomanic episodes • Cyclothymia • Numerous periods of hypomanic symptoms + numerous episodes of depressive symptoms over at least 2-year period

44. Differential Diagnosis of Mania • The differential diagnosis of manic and mixed states in late life includes: • Bipolar disorder • Secondary mania • Mood disorder due to medical / neurological disorders or treatments • Drug intoxication • Delirium • Dementia

45. Late vs Early-Onset Mania or Bipolar Disorder • Late onset (after age 50) more likely to: • Have secondary mania • Be associated with cerebrovascular disease and neurological comorbidity • Have psychotic features • Have cognitive impairment • Worse prognosis and higher mortality • Late onset less likely to: • Have family history of mood disorder • Have psychosocial stressor • Respond to treatment

46. FDA-Approved Treatments for Bipolar Disorder • Acute mania • Lithium • Valproic acid (divalproex sodium) • Antipsychotics (olanzapine, risperidone, quetiapine, aripiprazole, ziprasidone) • Quetiapine only medication approved to treat both manic and depressive phases of bipolar disorder • Maintenance • Lithium • Olanzapine • Lamotrigine

47. ECT for Bipolar Disorder • Effective in both manic and depressive episodes • Useful in pharmacologically refractory or intolerant patients • Useful in severe cases • Catatonia, melancholia, psychosis • Bilateral electrode placement most commonly used in manic / mixed patients • Different than ECT for depression, which is typically unilateral initially

48. Dual Diagnosis • Serious Mental Illness and Substance Use Disorder • Trauma Informed Care • ANF PTSD Toolkit • www.nurseptsdtoolkit.org

49. Substance Use Disorder • Tobacco • Alcohol • Benzodiazepines • Opioids • Heroin • Cocaine • Marijuana • Methamphetamines 2.5 Million older adults in the US have a substance use disorder often lifelong addictions that are missed within the health care system. (NCADD, 2015). In the Nursing home setting as many as 29 to 49% have a substance use disorder (Blow and Barry,2014)

50. Alcohol Screening • One question, when was the last time you have 4 or more drinks in a day? • Audit • CAGE • MAST • Brief Intervention and Treatment of Elders (White et al. 2015) • Screening Brief Intervention and Referral to Treatment (SBIRT) SAMHSA, 2016).