Assessment and treatment of nursing home residents with depression or behavioral symptoms associated with dementia: a review of the literature

Psychological therapies for depression in older adults residing in long-term care settings

BACKGROUND

Depression is common amongst older people residing in long-term care (LTC) facilities. Currently, most residents treated for depression are prescribed antidepressant medications, despite the potential availability of psychological therapies that are suitable for older people and a preference amongst many older people for non-pharmacological treatment approaches.

OBJECTIVES

To assess the effect of psychological therapies for depression in older people living in LTC settings, in comparison with treatment as usual, waiting list control, and non-specific attentional control; and to compare the effectiveness of different types of psychological therapies in this setting.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Group Controlled Trials Register, CENTRAL, MEDLINE, Embase, five other databases, five grey literature sources, and two trial registers. We performed reference checking and citation searching, and contacted study authors to identify additional studies. The latest search was 31 October 2021.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and cluster-RCTs of any type of psychological therapy for the treatment of depression in adults aged 65 years and over residing in a LTC facility.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles/abstracts and full-text manuscripts for inclusion. Two review authors independently performed data extraction and risk of bias assessments using the Cochrane RoB 1 tool. We contacted study authors for additional information where required. Primary outcomes were level of depressive symptomatology and treatment non-acceptability; secondary outcomes included depression remission, quality of life or psychological well-being, and level of anxious symptomatology. We used Review Manager 5 to conduct meta-analyses, using pairwise random-effects models. For continuous data, we calculated standardized mean differences and 95% confidence intervals (CIs), using endpoint data, and for dichotomous data, we used odds ratios and 95% CIs. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included 19 RCTs with 873 participants; 16 parallel group RCTs and three cluster-RCTs. Most studies compared psychological therapy (typically including elements of cognitive behavioural therapy, behavioural therapy, reminiscence therapy, or a combination of these) to treatment as usual or to a condition controlling for the effects of attention. We found very low-certainty evidence that psychological therapies were more effective than non-therapy control conditions in reducing symptoms of depression, with a large effect size at end-of-intervention (SMD -1.04, 95% CI -1.49 to -0.58; 18 RCTs, 644 participants) and at short-term (up to three months) follow-up (SMD -1.03, 95% CI -1.49 to -0.56; 16 RCTs, 512 participants). In addition, very low-certainty evidence from a single study with 82 participants indicated that psychological therapy was associated with a greater reduction in the number of participants presenting with major depressive disorder compared to treatment as usual control, at end-of-intervention and short-term follow-up. However, given the limited data on the effect of psychological therapies on remission of major depressive disorder, caution is advised in interpreting this result. Participants receiving psychological therapy were more likely to drop out of the trial than participants receiving a non-therapy control (odds ratio 3.44, 95% CI 1.19 to 9.93), which may indicate higher treatment non-acceptability. However, analyses were restricted due to limited dropout case data and imprecise reporting, and the finding should be interpreted with caution. There was very low-certainty evidence that psychological therapy was more effective than non-therapy control conditions in improving quality of life and psychological well-being at short-term follow-up, with a medium effect size (SMD 0.51, 95% CI 0.19 to 0.82; 5 RCTs, 170 participants), but the effect size was small at postintervention (SMD 0.40, 95% CI -0.02 to 0.82; 6 RCTs, 195 participants). There was very low-certainty evidence of no effect of psychological therapy on anxiety symptoms postintervention (SMD -0.68, 95% CI -2.50 to 1.14; 2 RCTs, 115 participants), although results lacked precision, and there was insufficient data to determine short-term outcomes.

AUTHORS' CONCLUSIONS

This systematic review suggests that cognitive behavioural therapy, behavioural therapy, and reminiscence therapy may reduce depressive symptoms compared with usual care for LTC residents, but the evidence is very uncertain. Psychological therapies may also improve quality of life and psychological well-being amongst depressed LTC residents in the short term, but may have no effect on symptoms of anxiety in depressed LTC residents, compared to control conditions. However, the evidence for these effects is very uncertain, limiting our confidence in the findings. The evidence could be strengthened by better reporting and higher-quality RCTs of psychological therapies in LTC, including trials with larger samples, reporting results separately for those with and without cognitive impairment and dementia, and longer-term outcomes to determine when effects wane.

Examining Depression Symptoms With/Without Coexisting Anxiety Symptoms in Community-Dwelling Persons With Dementia

Depression and anxiety are common in persons with dementia (PWD) and associated with poor outcomes. We explored frequency, pharmacologic management and mental health service use in PWD and depression symptoms with/without coexisting anxiety symptoms. The sample comprised 160 community-dwelling PWD in a trial to prevent development of aggression. Baseline data on depression and anxiety symptoms, psychotropic medications and mental health service use were examined. Regarding participants, 65 (41%) lacked clinically significant depression or anxiety symptoms, 45 (28%) had depression symptoms, 43 (27%) had depression and anxiety symptoms, and 7 (4%) had anxiety symptoms. Comorbid anxiety was associated with more severe depression symptoms. One third with depression symptoms and one half with depression and anxiety symptoms were taking an antidepressant. Mental health service use was very low, regardless of depression symptom severity or coexisting anxiety. Research needs to evaluate therapies for depressed PWD, but treatment of those with comorbid anxiety and depression is more urgent. Clinical Trial Registration for Parent Trial: ClinicalTrials.gov (NCT02380703).

Barriers to the Recognition of Geriatric Depression in Residential Care Facilities in Alberta

This study explored the barriers that regulated nurse professionals encountered in recognizing and assessing geriatric depression in residential care facilities in the Canadian province of Alberta. The study used a convergent parallel mixed methods design, including a cross-sectional survey (N = 635) and qualitative interviews (N = 14) with regulated nurse professionals. Findings revealed six major barriers to the recognition of geriatric depression in Alberta, including 1) insufficient clinical knowledge and training in geriatric depression; 2) misconceived beliefs about geriatric depression; 3) limited access to resources; 4) unclear depression assessment protocol and procedures in facilities; 5) characteristics of models of care and organizational culture in facilities; and 6) communication difficulties among all stakeholders in the process. Socio-cultural values and beliefs about geriatric depression played a key role in the complex interaction of the various structural and agential barriers to the effective recognition and assessment of depression in residential care facilities in Alberta.

Sex Differences in Antipsychotic and Benzodiazepine Prescribing Patterns: A Cohort Study of Newly Admitted Nursing Home Residents with Dementia in Ontario, Canada

BACKGROUND

In nursing homes, residents with dementia frequently receive potentially inappropriate medications that are associated with an increased risk of adverse events. Despite known sex differences in clinical presentation and sociodemographic characteristics among persons with dementia, few studies have examined sex differences in patterns and predictors of potentially inappropriate medication use.

OBJECTIVES

The objectives of this study were to examine sex differences in the patterns of antipsychotic and benzodiazepine use in the 180 days following admission to a nursing home, estimate clinical and sociodemographic predictors of antipsychotic and benzodiazepine use in male and female residents, and explore the effects of modification by sex on the predictors of using these drug therapies.

METHODS

We conducted a retrospective cohort study of 35,169 adults aged 66 years and older with dementia who were newly admitted to nursing homes in Ontario, Canada between 2011 and 2014. Health administrative databases were linked to detailed clinical assessment data collected using the Resident Assessment Instrument (RAI-MDS 2.0). Cox proportional hazards models were adjusted for clinical and sociodemographic covariates to estimate the rate of antipsychotic and benzodiazepine initiation and discontinuation in the 180 days following nursing home admission in the total sample and stratified by sex. Sex-covariate interaction terms were used to assess whether sex modified the association between covariates and the rate of drug therapy initiation or discontinuation following nursing home entry.

RESULTS

Across 638 nursing homes, our analytical sample included 22,847 females and 12,322 males. At admission, male residents were more likely to be prevalent antipsychotic users than female residents (33.8% vs 28.3%; p < 0.001), and female residents were more likely to be prevalent benzodiazepine users than male residents (17.2% vs 15.3%, p < 0.001). In adjusted models, female residents were less likely to initiate an antipsychotic after admission (hazard ratio [HR] 0.79, 95% confidence interval [CI] 0.73-0.86); however, no sex difference was observed in the rate of benzodiazepine initiation (HR 1.04, 95% CI 0.96-1.12). Female residents were less likely than males to discontinue antipsychotics (HR 0.89, 95% CI 0.81-0.98) and benzodiazepines (HR 0.82, 95% CI 0.75-0.89). Sex modified the association between some covariates and the rate of changes in drug use (e.g., widowed males exhibited an increased rate of antipsychotic discontinuation (p-interaction = 0.03) compared with married males), but these associations were not statistically significant among females. Sex did not modify the effect of frailty on the rates of initiation and discontinuation.

CONCLUSIONS

Males and females with dementia differed in their exposure to antipsychotics and benzodiazepines at nursing home admission and their patterns of use following admission. A greater understanding of factors driving sex differences in potentially inappropriate medication use may help tailor interventions to reduce exposure in this vulnerable population.

Postacute Management of Older Adults Suffering an Osteoporotic Hip Fracture: A Consensus Statement From the International Geriatric Fracture Society

BACKGROUND

The majority of patients require postacute care (PAC) after a hip fracture. Despite its importance, there is no established consensus regarding the standards of care provided to hip fracture patients in PAC facilities.

METHODOLOGY

A writing group was created by professionals from the International Geriatric Fracture Society (IGFS) with representation from other organizations. The focus of the statements included in this article is toward PAC providers located in nursing facilities. Contributions were integrated in a single document that underwent several reviews by each author and then underwent a final review by the lead and senior authors. After this process was completed, the document was appraised by reviewers from IGFS.

RESULTS/CONCLUSION

A total of 15 statements were crafted. These statements summarize the best available evidence and is intended to help PAC facilities managing older adults with hip fractures more efficiently, aiming toward overall better outcomes in the areas of function, quality of life, and with less complications that could interfere with their optimal recovery.

Effect of Academic Detailing on Promoting Appropriate Prescribing of Antipsychotic Medication in Nursing Homes: A Cluster Randomized Clinical Trial

Importance

Strategies to reduce the inappropriate prescription of antipsychotics have been the focus of recent attention but have shown considerable variation in their effectiveness.

Objective

To evaluate the effectiveness of academic detailing in nursing homes targeting appropriate prescribing of antipsychotics.

Design, Setting, and Participants

We conducted a pragmatic, cluster randomized clinical trial comparing the effect of academic detailing vs usual care on prescribing antipsychotics in 40 nursing homes with 5363 residents in Ontario, Canada. Data were collected from October 2015 to March 2016 and analyzed from April to August 2018. Primary analyses were conducted using intention to treat.

Intervention

Academic detailing delivered by health professionals (eg, nurses or pharmacists) who arranged meetings (with administrators, physicians, pharmacists, nurses, and support workers), presentations, group visits (with 2-6 clinicians), and 1-on-1 visits (traditional academic detailing visits). Academic detailers had direct and ongoing contact with the nursing homes from the time of launch.

Main Outcomes and Measures

The primary outcome, defined at the level of the resident, was whether continuous antipsychotics were dispensed in the past week. Secondary outcomes included prescribing of other psychotropic medications and clinical outcomes and scores. Prescribing outcomes were assessed at baseline and at 3, 6, and 12 months, and clinical outcomes and scores were assessed at baseline and 3 and 6 months.

Results

A total of 40 nursing homes with 5363 residents were randomized, with 18 intervention homes (45.0%; 2303 [42.9%] residents) and 22 control homes (55.0%; 3060 [57.1%] residents). Participants in the intervention and control groups had similar median (interquartile range) age (86 [79-91] years vs 85 [78-90] years) and sex (674 [29.3%] men vs 970 [31.7%] men). At 12 months, there was no statistically significant difference in the frequency of daily antipsychotic use (intervention: 569 patients [25.2%]; control: 769 [25.6%]; odds ratio, 1.06; 95% CI, 0.93-1.20; P = .49). There were no significant differences in the rates of health care utilization, but the intervention group did experience a statistically significant reduction in pain compared with the control group (mean [SD] pain score, 0.30 [0.59] vs 0.38 [0.66]; P < .001) and depression (mean [SD] Depression Rating Scale score, 2.18 [2.37] vs 2.81 [2.65]; P < .001) at 6 months.

Conclusions and Relevance

The intervention did not further reduce antipsychotic prescribing in nursing homes beyond system-level secular trends occurring alongside usual care. Our findings highlight the need for a more targeted approach to quality improvement strategies, including academic detailing, that account for the timing and topic of interventions.

Trial Registration

ClinicalTrials.gov Identifier: NCT02604056.

Treatment fidelity evidence for BE-ACTIV - a behavioral intervention for depression in nursing homes

Objectives: Evidence-based depression therapies are difficult to implement in nursing homes. We present data for BE-ACTIV, a 10-week depression treatment designed for implementation in nursing homes, to address questions of treatment fidelity (delivery, receipt, and enactment) in that context. Method: Participants were 41 patients from 13 nursing homes in the treatment arm of a clinical trial, treated by graduate student therapists. Therapists and their supervisor rated their audio-recorded sessions for adherence to treatment protocol and session quality. Results: Delivery of core program elements averaged from 80-94% across all sessions; mean quality was 5.6 (SD 0.61) out of 6 points. Delivery of core components to nursing home activities staff who collaborated in the treatment was similarly high. Patients received an average of 7.32 sessions (SD 3.39); 17 completed 10 sessions. The theoretical basis of BE-ACTIV is behavioral activation; therapist-client dyads planned new pleasant events weekly, from a mean of 3.66 (SD 1.35) after the first session to a mean of between 5 and 6 activities a week across sessions 6-9, with a similar progression in percent activities completed. Activities enactment was significantly related to the likelihood of remission at post-treatment, and of maintaining improvement at 3-month follow-up. Treatment receipt and enactment were also related to improved mood from baseline to 3 months. Conclusion: Results demonstrate delivery, receipt, and successful enactment of BE-ACTIV core components in diverse nursing homes and patients, and support the theoretical premise of the intervention. These findings support further implementation work for the BE-ACTIV intervention.

Measurement validity of the Patient-Health Questionnaire-9 in US nursing home residents

OBJECTIVES

The objective of this study was to assess the measurement properties of the self-reported Patient Health Questionnaire-9 (PHQ-9) and its 10-item observer version (PHQ-10OV) among nursing home residents.

METHODS

We conducted a retrospective study of Minimum Data Set 3.0 assessments for national cohorts of Medicare Fee-for-Service beneficiaries who were newly admitted or incident long-stay residents in 2014-2015 at US nursing homes (NHs) certified by the Center for Medicare and Medicaid Services. Statistical analyses included examining internal reliability with McDonald's omega, structural validity with confirmatory factor analysis, and hypothesis testing for expected gender differences and criterion validity with descriptive statistics. The Chronic Condition Warehouse depression diagnoses were used as an administrative reference standard.

RESULTS

Both the PHQ-9 and PHQ-10OV had good internal reliability with omega values above 0.85. The self-reported scale yielded good model fit for a one-factor solution, while the PHQ-10OV had slightly poorer fit and a lower standardized factor loading on the additional irritability item. Both scales appear sufficiently one-dimensional given that somatic items had higher factor loading on a general depression factor than on a somatic subfactor. We were unable to obtain expected gender differences on the PHQ-10OV scale. The PHQ-9 and PHQ-10OV were both highly specific but had poor sensitivity compared with an administrative reference standard.

CONCLUSIONS

The PHQ-9 appears to be a valid and promising measurement instrument for research about depression among NH residents, while the validity of the PHQ-10OV should be examined further with a structured psychiatric interview as a stronger criterion standard.

Treatment of behavioral symptoms and unsettled relationships in clinically complex residents in the long-term care facility

PURPOSE

Multifactorial etiology of behavioral symptoms (BS) and unsettled relationships (UR) in long-term care facility (LTCF) residents, who are characterized by comorbidity of somatic and mental diseases, makes the treatment process particularly difficult. The main goal of this study was to analyze a line of pharmacological and non-pharmacological treatment of clinically complex LTCF residents presenting BS and UR.

METHODS

This was a cross-sectional study of 301 LTCF residents with the use of interRAI-LTCF questionnaire. Descriptive statistics provided frequencies of pharmacological and non-pharmacological interventions in residents presenting BS and UR. Logistic regression models identified potential factors associated with administering antipsychotics, sedatives and antidepressants.

RESULTS

We found that residents with BS had a higher chance of being prescribed antipsychotics (OR 3.06; CI 1.59-5.86; p < 0.001). They were at greater risk of using sedatives only when BS were associated with older age or depression symptoms. However, BS associated with depression did not increase chance of using antidepressants. The UR had no impact on the use of psychotropic drugs. Moreover, staff's frustration in caring for residents with BS was associated with reduced risk of prescribing sedatives (OR 0.10; CI 0.02-0.68; p < 0.02). In contrast to pharmacotherapy, the non-pharmacological interventions were rarely applied.

CONCLUSIONS

LTCF residents manifesting BS were more frequently treated with antipsychotics and sedatives compared to antidepressants, even when BS were associated with depression. The multifactorial etiology of BS and UR in a clinically complex LTCF resident requires recognition of the causes of BS and UR for an appropriate treatment to be applied.

Efficacy and Safety of Analgesic Treatment for Depression in People with Advanced Dementia: Randomised, Multicentre, Double-Blind, Placebo-Controlled Trial (DEP.PAIN.DEM)

Background

Chronic pain and depression often co-occur, and pain may exacerbate depression in people with dementia.

Objective

The objective of this study was to assess the efficacy and safety of analgesic treatment for depression in nursing home patients with advanced dementia and clinically significant depressive symptoms.

Methods

We conducted a multicentre, parallel-group, double-blind, placebo-controlled trial in 47 nursing homes, including 162 nursing home patients aged ≥ 60 years with dementia (Mini-Mental State Examination ≤ 20) and depression (Cornell Scale for Depression in Dementia ≥ 8). Patients were randomised to receive active analgesic treatment (paracetamol or buprenorphine transdermal system) or identical placebo for 13 weeks. The main outcome measure was the change in depression (Cornell Scale for Depression in Dementia) from baseline to 13 weeks, assessed using linear mixed models with fixed effects for time, intervention and their interaction in the models. Secondary outcomes were to assess whether any change in depression was secondary to change in pain (Mobilisation-Observation-Behaviour-Intensity-Dementia-2 Pain Scale) and adverse events.

Results

The mean depression change was − 0.66 (95% confidence interval − 2.27 to 0.94) in the active group (n = 80) and − 3.30 (− 4.68 to −1.92) in the placebo group (n = 82). The estimated treatment effect was 2.64 (0.55–4.72, p = 0.013), indicating that analgesic treatment had no effect on depressive symptoms from baseline to 13 weeks while placebo appeared to ameliorate depressive symptoms. There was no significant reduction in pain in the active treatment group (paracetamol and buprenorphine combined) vs. placebo; however, a subgroup analysis demonstrated a significant reduction in pain for paracetamol vs. placebo [by − 1.11 (− 2.16 to − 0.06, p = 0.037)] from week 6 to 13 without a change in depression. Buprenorphine did not have significant effects on depression [3.04 (− 0.11 to 6.19), p = 0.059] or pain [0.47 (− 0.77 to 1.71), p = 0.456] from 0 to 13 weeks. Thirty-five patients were withdrawn from the study because of adverse reactions, deterioration or death: 25 (31.3%) during active treatment [23 (52.3%) who received buprenorphine], and ten (12.2%) in the placebo group. The most frequently occurring adverse events were psychiatric (17 adverse reactions) and neurological (14 adverse reactions).

Conclusion

Analgesic treatment did not reduce depression while placebo appeared to improve depressive symptoms significantly by comparison, possibly owing to the adverse effects of active buprenorphine. The risk of adverse events warrants caution when prescribing buprenorphine for people with advanced dementia.

Trial registration

ClinicalTrials.gov NCT02267057 (registered 7 July, 2014) and Norwegian Medicines Agency EudraCT 2013-002226-23.

Electronic supplementary material

The online version of this article (10.1007/s40266-018-0546-2) contains supplementary material, which is available to authorized users.

Reducing Depressive Symptoms in Nursing Home Residents: Evaluation of the Pennsylvania Depression Collaborative Quality Improvement Program

Depression reduces quality of life for nursing home (NH) residents and places them at greater risk for disability, medical morbidity, and mortality. However, accumulating evidence suggests that interventions for early detection and treatment can mitigate symptoms of clinical and subclinical levels of depression. The Promoting Positive Well-Being (PPW) program is a quality improvement (QI) intervention that features tools and strategies to assist NHs in early identification, assessment, treatment, and monitoring of residents with depressive symptoms. The PPW was evaluated in 40 NHs through an 8-month QI collaborative that provided participants with tools, webinar training, and technical support. Results showed a significant group by time interaction effect with facility quality rating as a covariate; the active group (n = 18 NHs) outperformed the waitlist control group (n = 19 NHs). In all, there was a 58% relative reduction in the percentage of residents with self-reported moderate-to-severe depressive symptoms. Most NHs reported that they were satisfied with the collaborative (97%) and would recommend it to others (86%); only 15% reported significant challenges. The rate of webinar attendance and data submission compliance was 92%. Results suggest that PPW is a promising approach that should be further evaluated in larger NH initiatives and other settings.

Cognitive Stimulation for People with Dementia in Long-Term Care Facilities: Baseline Cognitive Level Predicts Cognitive Gains, Moderated by Depression

BACKGROUND

Increasing evidence demonstrates the efficacy of cognitive stimulation (CS) in individuals with dementia. However, conducting studies in nursing homes engenders specific challenges that have limited the data gathered on this topic so far.

OBJECTIVE

The aim of this randomized controlled trial was to investigate the effects of CS on cognition, quality of life (QoL), behavioral symptoms, and activities of daily life in persons with dementia living in nursing homes. We further aimed to identify predictors of the intervention's benefits.

METHODS

Seventy-one persons with mild to moderate dementia were randomly allocated to the experimental group (EG; n = 36) that visited a CS program twice weekly for eight weeks or to the control group (CG; n = 35) that was receiving usual care. Neuropsychological tests were conducted before and after the intervention period and at six-week follow-up.

RESULTS

There were no significant interaction effects Time×Group for the outcome measures. However, regression analysis revealed that a low cognitive baseline level predicted cognitive improvements. Furthermore, a low baseline level of QoL predicted a QoL benefit. For both findings, depression was a significant moderator, meaning that persons with fewer depressive symptoms had a higher probability of showing improvements.

CONCLUSION

This study provides data on profiles of patients who are most likely to profit from CS intervention in nursing-home settings and demonstrates that treatment of depression is of the utmost relevance for a positive outcome of CS. Living conditions will have to be considered more thoroughly in future research.

Impact of serious mental illness online training for certified nursing assistants in long term care

Certified nurse assistants (CNAs) spend the most staff time with nursing home residents, yet they receive little training in addressing the mental health needs of residents with serious mental illness (SMI). Forty CNAs from four long-term-care facilities took the online interactive CARES-^® Serious Mental Illness^™ training consisting of two modules guided by the Recovery Movement philosophy of care. Responses from pre-post testing, Likert-type items, and open-ended questions indicated that CNAs gained information, changed their perspectives, and had more confidence in dealing with SMI. Although there were minor concerns regarding length, clarity of content, and technical issues, CNAs found the online format acceptable and easy to use, and many said they would recommend the training. CARES Serious Mental Illness online training appears to be a viable way of helping CNAs address the mental health needs of long term care residents. Additional testing on CARES Serious Mental Illness is planned.

Cognitive interventions in patients with dementia living in long-term care facilities: Systematic review and meta-analysis

BACKGROUND

Previous reviews and meta-analyses demonstrated effects of cognitive interventions in dementia, but none specifically considered residents with dementia in long-term care (LTC) facilities.

OBJECTIVE

To analyse the efficacy of cognitive interventions in institutionalised individuals with dementia.

METHODS

After identifying 27 articles, a systematic review was performed. A meta-analysis was calculated for 15 studies of the randomized controlled trials regarding effects on relevant outcomes. Fixed-effects meta-analyses were conducted using standardized mean differences (SMD) of changes from baseline pooled using the inverse variance method.

RESULTS

When comparing cognitive interventions to passive control groups, the meta-analysis revealed significant moderate effects on global cognition (SMD=0.47, 95% CI 0.27-0.67), autobiographical memory (0.67, 0.02-1.31), and behavioral and psychological symptoms in dementia (BPSD; 0.71, 0.06-1.36). Significant small effects were detected for quality of life (QoL; 0.37, 0.05-0.70). Moderate effects on activities of daily living (0.28; -0.02 to 0.58) failed to reach significance; no effects were found on depression (0.22; -0.08 to 0.51). Significant moderate effects of global cognition (0.55; 0.22-0.89) and depression (0.64; 0.21-1.07) were also found for cognitive interventions contrasting active control groups. No harmful events related to the participation in the interventions were observed.

CONCLUSION

Cognitive interventions are safe and effective for residents with dementia in LTC. However, while it seems clear that cognitive benefits can specifially be assigned to these forms of intervention, further research is necessary to clarify whether the effects on BPSD and QoL reflect unspecific changes due to additional attention. Furthermore, future studies will have to determine which intervention type yields the largest benefits.

The use of cognitive behaviour therapy in the management of BPSD in dementia (Innovative practice)

Psychosocial approaches to the management of behavioural and psychological symptoms of dementia have received much support in the scientific literature. The following paper focuses on cognitive behaviour therapy as a valid framework in assessing and treating people with behavioural and psychological symptoms of dementia. The importance of identifying symptoms of depression and anxiety is emphasized, as cognitive behaviour therapy has been shown to be an effective intervention for these conditions in older adults. Modifications of cognitive behaviour therapy for those with dementia are discussed based on available evidence, with emphasis on incorporating nursing home staff in treatment programs and focusing on behavioural elements of cognitive behaviour therapy such as activity scheduling. The paper concludes with suggestions regarding how to incorporate and promote the use of cognitive behaviour therapy in dementia care settings.

Massage, a complementary therapy effectively promoting the health and well-being of older people in residential care settings: a review of the literature

AIMS

To explore the potential benefits of massage within daily routine care of the older person in residential care settings.

BACKGROUND

Globally, the proportion of people over 65 years is rapidly rising. Increased longevity means older people may experience a rise in physiological and psychological health problems. These issues potentially place an increased demand for quality long-term care for the older person. Complementary approaches such as massage appear to be needed in quality residential care.

DESIGN

A critical literature review was undertaken.

METHODS

A literature review pertaining to massage in the older resident was conducted using a range of online databases. Fourteen studies dated 1993-2012 met the inclusion criteria and were critically evaluated as suitable resources for this review.

RESULTS

Evidence suggests massage may be advantageous from client and nursing perspectives. Clients' perceive massage to positively influence factors such as pain, sleep, emotional status and psychosocial health. Evidence also demonstrates massage to benefit the client and organisation by reducing the necessity for restraint and pharmacological intervention. Massage may be incorporated into care provision and adopted by care providers and family members as an additional strategy to enhance quality of life for older people.

CONCLUSION

Massage offers a practical activity that can be used to enhance the health and well-being of the older person in residential care.

IMPLICATIONS FOR PRACTICE

Massage offers benefit for promoting health and well-being of the older person along with potential increased engagement of family in care provision. Integration of massage into daily care activities of the older person requires ongoing promotion and implementation.

Resident-to-Resident Abuse: A Scoping Review

L'abus de résidents par d'autres résidents parmi de foyers de soins de longue durée (SLD) implique l'agressivité et la violence et peut avoir des conséquences graves pour tous les deux, agresseurs et victimes. Jusqu'à présent, il n'y a eu aucune tentative d'évaluer systématiquement la portée de ce problème au Canada. Pour combler cette lacune, nous avons entrepris une étude de délimitation de l'étendue pour améliorer la compréhension de l'abus chez les résidents des foyers de SLD. Nous présentons aussi un ensemble redigé de données canadiennes sur l'abus chez les résidents. On a cherché neuf bases de données bibliographiques électroniques; un total de 784 résumés a été trouvés, mais seulement 32 ont satisfait les critères d'inclusion. La majorité des documents (75 pour cent) étaient des études de cas rétro-perspectives, des études qualitatives et critiques/commentaires. Parmi eux, seuls 14 se consacrent exclusivement à l'abus parmi les résidents. L'ensemble redigé de données canadiennes suggère que l'abus des résidents par d'autres résidents représente environ un tiers des cas d'abus signalés. Afin de faire connaître cette phénomène et d'aider à diminuer son incidence, des recommandations pour la recherche future, la pratique clinique et la politique sont fournis.

Screening for geriatric depression in residential care facilities: a systematic narrative review

Studies in residential care facilities suggest that routine screening can assist in the early detection of geriatric depression. However, the effectiveness of screening instruments in residential care in the US and Canada has not been adequately evaluated. We conducted a systematic narrative review of the English-language literature published between 2000 and 2010 on screening instruments used for depression detection in older adults living in residential care facilities. The review yielded nine scales and their modifications tested in residential care, which we evaluated. We provide specific recommendations for the use of effective scales and discuss implications for practice, policy and research.

Statin discontinuation in nursing home residents with advanced dementia

OBJECTIVES

To describe patterns of, and factors associated with, statin use and discontinuation in nursing home (NH) residents progressing to advanced dementia and followed for at least 90 days.

DESIGN

Retrospective inception cohort using a dataset linking 2007 to 2008 Minimum Data Set (MDS) to Medicare denominator and Part D files.

SETTING

All NHs in five states (Minnesota, Massachusetts, Pennsylvania, California, Florida).

PARTICIPANTS

NH residents with dementia.

MEASUREMENTS

Residents who developed advanced dementia were observed from baseline (date of progression to very severe cognitive impairment with eating problems) and followed for at least 90 days to statin discontinuation or death. Logistic regression was used to identify baseline factors associated with statin use. Cox proportional hazard regression was used to identify factors associated with time to statin discontinuation.

RESULTS

Of 10,212 residents, 16.6% (n = 1,699) used statins. Greater odds of statin use were associated with having diabetes mellitus (adjusted odds ratio (AOR) = 1.24, 95% confidence interval (CI) = 1.09-1.40), stroke (AOR = 1.31, 95% CI = 1.16-1.48), and hypertension (AOR = 1.35, 95% CI = 1.18-1.54); hospice enrollment was associated with lower odds (AOR = 0.75, 95% CI = 0.64-0.89). In follow-up, 37.2% (n = 632) discontinued statins. Median time to discontinuation was 36 days (interquartile range 12-110 days). Shorter time to discontinuation was associated with hospitalization in past 30 days (adjusted hazard ratio (AHR) = 1.67, 95% CI = 1.40-1.99) and more daily medications (AHR = 1.02, 95% CI = 1.01-1.04). When statins were discontinued, 15.0% (n = 95) of residents stopped only statins, and 47.5% (n = 300) stopped at least one other medication.

CONCLUSION

Most NH residents who use statins at the time of progression to advanced dementia continue use in follow-up.

Use of medications of questionable benefit in advanced dementia

IMPORTANCE

Advanced dementia is characterized by severe cognitive impairment and complete functional dependence. Patients' goals of care should guide the prescribing of medication during such terminal illness. Medications that do not promote the primary goal of care should be minimized.

OBJECTIVES

To estimate the prevalence of medications with questionable benefit used by nursing home residents with advanced dementia, identify resident- and facility-level characteristics associated with such use, and estimate associated medication expenditures.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study of medication use by nursing home residents with advanced dementia using a nationwide long-term care pharmacy database linked to the Minimum Data Set (460 facilities) between October 1, 2009, and September 30, 2010.

MAIN OUTCOMES AND MEASURES

Use of medication deemed of questionable benefit in advanced dementia based on previously published criteria and mean 90-day expenditures attributable to these medications per resident. Generalized estimating equations using the logit link function were used to identify resident- and facility-related factors independently associated with the likelihood of receiving medications of questionable benefit after accounting for clustering within nursing homes.

RESULTS

Of 5406 nursing home residents with advanced dementia, 2911 (53.9%) received at least 1 medication with questionable benefit (range, 44.7% in the Mid-Atlantic census region to 65.0% in the West South Central census region). Cholinesterase inhibitors (36.4%), memantine hydrochloride (25.2%), and lipid-lowering agents (22.4%) were the most commonly prescribed. In adjusted analyses, having eating problems (adjusted odds ratio [AOR], 0.68; 95% CI, 0.59-0.78), a feeding tube (AOR, 0.58; 95% CI, 0.48-0.70), or a do-not-resuscitate order (AOR, 0.65; 95% CI, 0.57-0.75), and enrolling in hospice (AOR, 0.69; 95% CI, 0.58-0.82) lowered the likelihood of receiving these medications. High facility-level use of feeding tubes increased the likelihood of receiving these medications (AOR, 1.45; 95% CI, 1.12-1.87). The mean (SD) 90-day expenditure for medications with questionable benefit was $816 ($553), accounting for 35.2% of the total average 90-day medication expenditures for residents with advanced dementia who were prescribed these medications.

CONCLUSIONS AND RELEVANCE

Most nursing home residents with advanced dementia receive medications with questionable benefit that incur substantial associated costs.

Emotional function in dementia patients

Behavioural and psychological symptoms of dementia, which can be considered as hyperreactivity of the emotional functioning of dementia, can be alleviated or aggravated by the behavioural and psychological symptoms of the caregiver. Comfortable stimulations of emotional function through sensory stimulations are effective methods for alleviating behavioural and psychological symptoms of dementia. Although cognitive function deteriorates with age, emotional function is often retained even in advanced years. Thus, it is recommended that care in patients with dementia be focused mainly on the stimulation of emotional function (e.g. sympathy and empathy, which are human traits), rather than relying solely on the stimulation of cognitive function.

Depression in older adults: screening and referral

Depression is related to disability and affects rehabilitation participation, outcomes, and compliance with treatment. Improving older adult depression detection and referral requires knowledge, skills, supportive organizational policies, and access to mental health experts. This review provides a selected overview of evidence-based approaches for screening of suspected cases of depression in older adults by physical therapists and other non-mental health professionals and discusses procedures to refer suspected cases to primary care providers and/or mental health specialists for evaluation, including resources and a tool to assist in communicating depression-related information to the primary care provider or mental health specialist. We hope that this review will promote the incorporation of evidence-based screening and referral of suspected cases of depression in older adults into routine practice.

Antipsychotic use in nursing homes varies by psychiatric consultant

BACKGROUND

The relationship between psychiatric consultation and antipsychotic prescribing in nursing homes (NH) is unknown.

OBJECTIVE

To identify the association between psychiatric consultant groups and NH-level antipsychotic prescribing after adjustment for resident case-mix and facility characteristics.

RESEARCH DESIGN AND SUBJECTS

Nested cross-sectional study of 60 NHs in a cluster randomized trial. We linked facility leadership surveys to October 2009-September 2010 Minimum Data Set, Nursing Home Compare, the US Census, and pharmacy dispensing data.

MEASURES

The main exposure is the psychiatric consultant group and the main outcome is NH-level prevalence of atypical antipsychotic use. We calculated annual means and interquartile ranges of NH-level antipsychotic use for each consultant group and arrayed consultant groups from lowest to highest prevalence. Generalized linear models were used to predict antipsychotic prescribing adjusting for resident case-mix and facility characteristics. Observed versus predicted antipsychotic prescribing levels were compared for each consultant group.

RESULTS

Seven psychiatric consultant groups served a range of 3-27 study facilities. Overall mean facility-level antipsychotic prescribing was 19.2%. Mean prevalence of antipsychotic prescribing ranged from 12.2% (SD, 5.8) in the lowest consultant group to 26.4% (SD, 3.6) in the highest group. All facilities served by the highest-ranked consultant group had observed antipsychotic levels exceeding the overall study mean with half exceeding predictions for on-label indications, whereas most facilities served by the lowest-ranked consultant group had observed levels below the overall study and predicted means.

CONCLUSIONS

Preliminary evidence suggests that psychiatric consultant groups affect NH antipsychotic prescribing independent of resident case-mix and facility characteristics.

BE-ACTIV for depression in nursing homes: primary outcomes of a randomized clinical trial

OBJECTIVES

To report the primary outcomes of a cluster randomized clinical trial of Behavioral Activities Intervention (BE-ACTIV), a behavioral intervention for depression in nursing homes.

METHOD

Twenty-three nursing homes randomized to BE-ACTIV or treatment as usual (TAU); 82 depressed long-term care residents recruited from these nursing homes. BE-ACTIV participants received 10 weeks of individual therapy after a 2-week baseline. TAU participants received weekly research visits. Follow-up assessments occurred at 3- and 6-month posttreatment.

RESULTS

BE-ACTIV group participants showed better diagnostic recovery at posttreatment in intent-to-treat analyses adjusted for clustering. They were more likely to be remitted than TAU participants at posttreatment and at 3-month posttreatment but not at 6 months. Self-reported depressive symptoms and functioning improved in both groups, but there were no significant treatment by time interactions in these variables.

DISCUSSION

BE-ACTIV was superior to TAU in moving residents to full remission from depression. The treatment was well received by nursing home staff and accepted by residents. A large proportion of participants remained symptomatic at posttreatment, despite taking one or more antidepressants. The results illustrate the potential power of an attentional intervention to improve self-reported mood and functioning, but also the difficulties related to both studying and implementing effective treatments in nursing homes.

Variability between nursing homes in prevalence of antipsychotic use in patients with dementia

BACKGROUND

Antipsychotic drugs (APD) are widely prescribed for people with dementia residing in long term care facilities (LTCFs). Concern has been expressed that such prescribing is largely inappropriate. The objective of this study is to examine if differences in facility-level prevalence of APD use in a sample of LTCFs for patients with dementia can be explained by patient and facility-related characteristics.

METHODS

A point prevalence study was conducted using data from the VU University Resident Assessment Instrument (VURAI) database from nursing homes and residential care facilities in the Netherlands. Patients were selected who had a diagnosis of dementia. LTCF and patient characteristics were extracted from the VURAI; facility-level resident satisfaction surveys were provided by the National Institute for Public Health.

RESULTS

In total, 20 LTCFs providing care for 1,090 patients with dementia were investigated. Overall, 31% of patients used an APD. In facilities with a high prevalence of APD use behavioral symptoms were present in 62% of their patients. In facilities with medium APD use behavioral problems remained frequent (57%), and in facilities with low prevalence of APD use 54% of the patients had behavioral symptoms. Facilities with a high prevalence of APD use were often large, situated in urban communities, and scored below average on staffing, personal care, and recreational activities.

CONCLUSIONS

There was considerable variation between the participating LTCFs in the prevalence of APD use. Variability was related to LTCF characteristics and patient satisfaction. This indicates potential inappropriate prescribing because of differences in institutional prescribing culture.

Pharmacological treatments for neuropsychiatric symptoms of dementia in long-term care: a systematic review

BACKGROUND

Medications are frequently prescribed for neuropsychiatric symptoms (NPS) associated with dementia, although information on the efficacy and safety of medications for NPS specifically in long-term care (LTC) settings is limited. The objective of this study was to provide a current review of the efficacy and safety of pharmacological treatments for NPS in LTC.

METHODS

We searched MEDLINE, EMBASE, PsychINFO, and the Cochrane Library for randomized controlled trials comparing medications with either placebo or other interventions in LTC. Study quality was described using the Cochrane collaboration risk of bias tool. The efficacy of medications was evaluated using NPS symptom rating scales. Safety was evaluated through rates of trial withdrawals, trial withdrawals due to adverse events, and mortality.

RESULTS

A total of 29 studies met inclusion criteria. The most common medications evaluated in studies were atypical antipsychotics (N = 15), typical antipsychotics (N = 7), anticonvulsants (N = 4), and cholinesterase inhibitors (N = 3). Statistically significant improvements in NPS were noted in some studies evaluating risperidone, olanzapine, and single studies of aripiprazole, carbamazepine, estrogen, cyproterone, propranolol, and prazosin. Study quality was difficult to rate in many cases due to incomplete reporting of details. Some studies reported higher rates of trial withdrawals, adverse events, and mortality associated with medications.

CONCLUSIONS

We conclude that there is limited evidence to support the use of some atypical antipsychotics and other medications for NPS in LTC populations. However, the generally modest efficacy and risks of adverse events highlight the need for the development of safe and effective pharmacological and non-pharmacological interventions for this population.

Testing the PHQ-9 interview and observational versions (PHQ-9 OV) for MDS 3.0

OBJECTIVES

To test the feasibility and validity of the Patient Health Questionnaire-9 item interview (PHQ-9) and the newly developed Patient Health Questionnaire Observational Version (PHQ-9 OV) for screening for mood disorder in nursing home populations.

METHODS

The PHQ-9 was tested as part of the national Minimum Data Set 3.0 (MDS 3.0) evaluation study among 3822 residents scheduled for MDS 2.0 assessments. Residents from 71 community nursing homes (NHs) in eight states were randomly included in a feasibility sample (n = 3258) and a validation sample (n = 418). Each resident's ability to communicate determined whether the PHQ-9 interview or the PHQ-9 OV was initially attempted. In the validation sample, trained research nurses administered the instruments. For residents in the validation sample without severe cognitive impairment (3 MS ≥30) agreement between PHQ-9 and the modified Schedule for Affective Disorders and Schizophrenia (m-SADS) was measured with weighted kappas (κ). For residents with severe cognitive impairment (3MS <30), agreement between PHQ-9 interview or PHQ-9 OV and the Cornell Scale for Depression in Dementia (Cornell Scale) was measured using correlation coefficients. Staff impressions were obtained from an anonymous survey mailed to all MDS assessors.

RESULTS

The PHQ-9 was completed in 86% of the 3258 residents in the feasibility sample. In the validation sample, the agreement between PHQ-9 and m-SADS was very good (weighted κ = 0.69, 95% CI = 0.61-0.76), whereas agreement between MDS 2.0 and m-SADS was poor (weighted κ = 0.15, 95% CI = 0.06-0.25). Likewise, in residents with severe cognitive impairment, PHQ correlations with the criterion standard Cornell Scale were superior to the MDS 2.0 for both the PHQ-9 (0.63 vs 0.34) and the PHQ-9 OV (0.84 vs 0.28). Eighty-six percent of survey respondents reported that the PHQ-9 provided new insight into residents' mood. The average time for completing the PHQ-9 interview was 4 minutes.

DISCUSSION

Compared with the MDS 2.0 observational items, the PHQ-9 interview had greater agreement with criterion standard diagnostic assessments. For residents who could not complete the interview, the PHQ-9 OV also had greater agreement with a criterion measure for depression than did the MDS 2.0 observational items. Moreover, the majority of NH residents were able to complete the PHQ-9, and most surveyed staff reported improved assessments with the new approach.

Administration of PRN medications and use of nonpharmacologic interventions in acute geropsychiatric settings: implications for practice

Despite the known risks and the widespread administration of PRN (pro re nata or "as needed") psychotropic medications in inpatient settings, little is known about their use with hospitalized older adults. This exploratory descriptive study examined the use of PRN psychotropic medications and nonpharmacologic interventions to manage symptoms in older adults hospitalized in two acute care geropsychiatric settings. A retrospective chart audit was conducted. A major finding was the lack of documentation regarding PRN administration. In 81.3% of cases at Site A and 55.3% of cases at Site B, no reason for administration was documented. No medication response was documented in 92.4% of cases at Site A and 47.5% of cases at Site B. No nonpharmacologic interventions were documented for 69% of Site A patients or 64% of Site B patients. To ensure patient safety and to inform best clinical practice, the lack of documentation surrounding administration of PRN medications and nonpharmacologic interventions must be resolved.

Differential risk of death in older residents in nursing homes prescribed specific antipsychotic drugs: population based cohort study

OBJECTIVE

To assess risks of mortality associated with use of individual antipsychotic drugs in elderly residents in nursing homes.

DESIGN

Population based cohort study with linked data from Medicaid, Medicare, the Minimum Data Set, the National Death Index, and a national assessment of nursing home quality.

SETTING

Nursing homes in the United States.

PARTICIPANTS

75,445 new users of antipsychotic drugs (haloperidol, aripiprazole, olanzapine, quetiapine, risperidone, ziprasidone). All participants were aged ≥ 65, were eligible for Medicaid, and lived in a nursing home in 2001-5.

MAIN OUTCOME MEASURES

Cox proportional hazards models were used to compare 180 day risks of all cause and cause specific mortality by individual drug, with propensity score adjustment to control for potential confounders.

RESULTS

Compared with risperidone, users of haloperidol had an increased risk of mortality (hazard ratio 2.07, 95% confidence interval 1.89 to 2.26) and users of quetiapine a decreased risk (0.81, 0.75 to 0.88). The effects were strongest shortly after the start of treatment, remained after adjustment for dose, and were seen for all causes of death examined. No clinically meaningful differences were observed for the other drugs. There was no evidence that the effect measure modification in those with dementia or behavioural disturbances. There was a dose-response relation for all drugs except quetiapine.

CONCLUSIONS

Though these findings cannot prove causality, and we cannot rule out the possibility of residual confounding, they provide more evidence of the risk of using these drugs in older patients, reinforcing the concept that they should not be used in the absence of clear need. The data suggest that the risk of mortality with these drugs is generally increased with higher doses and seems to be highest for haloperidol and least for quetiapine.

Psychosocial care in nursing homes in the era of the MDS 3.0: perspectives of the experts

Meeting psychosocial needs of nursing home residents is increasingly regarded as a critical component of care, and the nationally-mandated nursing home care screening instrument- the Minimum Data Set (MDS) 3.0-was modified and implemented in 2010 to promote better assessment of psychosocial needs and health. Recognizing the importance of psychosocial well-being among nursing home residents, and the promise of MDS 3.0 for improving psychosocial care, this article reports recommendations derived from a conference of stakeholders representing diverse disciplines and organizations regarding next steps following MDS 3.0 screening. Results relate to seven areas of psychosocial care and address cross-cutting recommendations to improve psychosocial care.

Cholinesterase inhibitor and memantine use in newly admitted nursing home residents with dementia

OBJECTIVES

To quantify the use of cholinesterase inhibitors (ChEIs) and memantine in nursing home (NH) residents with dementia upon NH admission and 3 months later and to examine factors associated with reduction in therapy.

DESIGN

Retrospective cohort study.

SETTING

Nationwide sample of U.S. NHs.

PARTICIPANTS

Three thousand five hundred six NH residents with dementia newly admitted in 2006.

MEASUREMENTS

Data from pharmacy dispensing records were used to determine ChEI and memantine medication use upon NH admission and at 3-month follow-up. The Minimum Data Set was used to determine resident- and facility-level characteristics. Severity of dementia was defined using the Cognitive Performance Scale (CPS).

RESULTS

Overall, 40.1% (n=1,407) of newly admitted NH residents with dementia received ChEIs and memantine on NH admission. Use of ChEIs and memantine on admission was significantly greater in residents with mild to moderately severe dementia (41.2%) than in those with advanced dementia (33.3%, P=.001). After 3 months, ChEI and memantine use decreased by about half in both groups (48.6% with mild to moderately severe dementia vs 57.0% with advanced dementia, P<.05). NH residents with advanced dementia were significantly more likely reduce their use of ChEIs and memantine than those with mild to moderately severe dementia (odds ratio=1.44, 95% confidence interval=1.03-2.01, P=.04).

CONCLUSION

Many NH residents with advanced dementia receive ChEIs and memantine upon NH admission, and approximately half of these decrease their medication use over the ensuing months. Further study is required to optimize use of ChEIs and memantine in NH populations and to determine the effects of withdrawing therapy on resident outcomes.

Depression in older people living in residential homes

There is a large body of published research relating to depression in residential homes for older people (also called long-term-care homes, and including both nursing homes and hostels) (Ames 1990; 1993; Seitzet al., 2010; Snowdon and Purandare, 2010; Snowdon, 2010). However, despite increased detection and more frequent treatment in recent years, depression remains a significant problem for many older people living in such settings. This guest editorial summarizes current knowledge about prevalence, etiology, detection and screening, treatment and outcomes of depression in residential homes and concludes with a summary of key issues requiring urgent future action.

Act In case of Depression: the evaluation of a care program to improve the detection and treatment of depression in nursing homes. Study Protocol

BACKGROUND

The aim of this study is evaluating the (cost-) effectiveness of a multidisciplinary, evidence based care program to improve the management of depression in nursing home residents of somatic and dementia special care units. The care program is an evidence based standardization of the management of depression, including standardized use of measurement instruments and diagnostical methods, and protocolized psychosocial, psychological and pharmacological treatment.

METHODS/DESIGN

In a 19-month longitudinal controlled study using a stepped wedge design, 14 somatic and 14 dementia special care units will implement the care program. All residents who give informed consent on the participating units will be included. Primary outcomes are the frequency of depression on the units and quality of life of residents on the units. The effect of the care program will be estimated using multilevel regression analysis. Secondary outcomes include accuracy of depression-detection in usual care, prevalence of depression-diagnosis in the intervention group, and response to treatment of depressed residents. An economic evaluation from a health care perspective will also be carried out.

DISCUSSION

The care program is expected to be effective in reducing the frequency of depression and in increasing the quality of life of residents. The study will further provide insight in the cost-effectiveness of the care program.

TRIAL REGISTRATION

Netherlands Trial Register (NTR): NTR1477.

Managing the patient with dementia in long-term care

The majority of residents in a nursing home have some degree of dementia. The prevalence is commonly from 70% to 80% of residents. This article covers the following topics on caring for patients with dementia in long-term care: (1) the efficacy of cholinesterase inhibitors and memantine, (2) the optimal environment for maintenance of function in moderate dementia, (3) the treatment of depression and agitation, and (4) the evaluation and management of eating problems.

No longer undertreated? Depression diagnosis and antidepressant therapy in elderly long-stay nursing home residents, 1999 to 2007

OBJECTIVES

To examine the evolution of depression identification and use of antidepressants in elderly long-stay nursing home residents from 1999 through 2007 and the associated sociodemographic and facility characteristics.

DESIGN

Annual cross-sectional analysis of merged resident assessment data from the Minimum Data Set (MDS) and facility characteristics from the Online Survey Certification and Reporting data.

SETTING

Nursing homes in eight states (5,445 facilities).

PARTICIPANTS

Long-stay nursing home residents aged 65 and older (2,564,687 assessments).

MEASUREMENTS

Physician-documented depression diagnoses recorded in the MDS were used to identify residents with depression; antidepressant use was measured using MDS information about residents' receipt of an antidepressant in the 7 days before assessment.

RESULTS

Diagnosis of depression and antidepressant therapy in residents diagnosed increased at a rapid rate. By 2007, 51.8% of residents were diagnosed with depression, 82.8% of whom received an antidepressant. Adjusted odds of treatment were higher for younger residents, whites, and those with moderate impairment of cognitive function.

CONCLUSION

This study demonstrates striking increases in depression diagnosis and treatment with antidepressant medications, but disparities persist without clear evidence about underlying mechanisms. More research is needed to assess effectiveness of antidepressant prescribing.

Changes to psychotropic medications in the six months after admission to nursing homes in Melbourne, Australia

BACKGROUND

Nursing home residents are often prescribed large numbers of psychotropic medications. Previous studies suggest that antipsychotic medications are often unnecessary and can be withdrawn without ill effects. Depression, in contrast, is believed to be under-recognized and under-treated.

METHOD

A six-month audit was carried out of the antipsychotic, antidepressant, anxiolytic and hypnotic medications prescribed to 166 newly admitted residents of a convenience sample of seven nursing homes in Melbourne, Australia.

RESULTS

Over the six-month period, antidepressants were started in 6% of all cases and stopped in 2% of treated cases. Antipsychotics were added in 5% of all cases and stopped in 15% of treated cases. Residents were switched from one antidepressant to another in 5% of treated cases and from one antipsychotic to another in 4%. Benzodiazepine use was relatively modest.

CONCLUSIONS

Judging from epidemiological data, treatment revisions were almost certainly insufficient to address residents' mental health needs. We discuss ways of harnessing existing nursing and pharmacy resources to ensure better care for aged residents.

Efficacy of music therapy treatment based on cycles of sessions: a randomised controlled trial

We undertook a randomised controlled trial to assess whether a music therapy (MT) scheme of administration, including three working cycles of one month spaced out by one month of no treatment, is effective to reduce behavioural disturbances in severely demented patients. Sixty persons with severe dementia (30 in the experimental and 30 in the control group) were enrolled. Baseline multidimensional assessment included demographics, Mini Mental State Examination (MMSE), Barthel Index and Neuropsychiatry Inventory (NPI) for all patients. All the patients of the experimental and control groups received standard care (educational and entertainment activities). In addition, the experimental group received three cycles of 12 active MT sessions each, three times a week. Each 30-min session included a group of three patients. Every cycle of treatment was followed by one month of wash-out. At the end of this study, MT treatment resulted to be more effective than standard care to reduce behavioural disorders. We observed a significant reduction over time in the NPI global scores in both groups (F(7,357) = 9.06, p < 0.001) and a significant difference between groups (F(1,51) = 4.84, p < 0.05) due to a higher reduction of behavioural disturbances in the experimental group at the end of the treatment (Cohen's d = 0.63). The analysis of single NPI items shows that delusions, agitation and apathy significantly improved in the experimental, but not in the control group. This study suggests the effectiveness of MT approach with working cycles in reducing behavioural disorders of severely demented patients.

Screening for mental disorders in residential aged care facilities

INTRODUCTION

The International Psychogeriatric Association Task Force on Mental Health Services in Long-Term Care Facilities seeks to improve care of persons in residential aged care facilities (RACFs). As part of that effort the current authors have contributed an overview and discussion of the uses of brief screening instruments in RACFs.

METHODS

While no current guidelines on the use of screening instruments in nursing homes were found, relevant extant guidelines were consulted. The literature on measurement development, testing standards, psychometric considerations and the nursing home environment were consulted.

RESULTS

Cognitive, psychiatric, behavioral, functional and omnibus screening instruments are described at a category level, along with specifics about their use in a RACF environment. Issues surrounding the selection, administration, interpretation and uses of screening instruments in RACFs are discussed. Issues of international interest (such as translation of measures) or clinical concern (e.g. impact of severe cognitive decline on assessment) are addressed. Practical points surrounding who can administer, score and interpret such screens, as well as their psychometric and clinical strengths more broadly, are articulated.

CONCLUSIONS

Guidelines for use of screening instruments in the RACF environment are offered, together with broad recommendations concerning the appropriate use of brief screening instruments in RACFs. Directions for future research and policy directions are outlined, with particular reference to the international context.

Comprehensive assessment of depression and behavioral problems in long-term care

BACKGROUND

The IPA Taskforce on Mental Health Issues in Long-Term Care Homes seeks to improve mental health care in long-term care (LTC) homes. The aim of this paper is to provide recommendations on comprehensive assessment of depression and behavioral problems in order to further stimulate countries and professionals to enhance their quality of care.

METHODS

Existing guidelines on comprehensive assessment of depression or behavioral problems in nursing home (NH) patients or patients residing in LTC homes were collected and a literature review was carried out to search for recent evidence.

RESULTS

Five guidelines from several countries all over the world and two additional papers were included in this paper as a starting point for the recommendations. Comprehensive assessment of depression in LTC homes consists of a two-step screening procedure: an investigation to identify factors that influence the symptoms, followed by a formal diagnosis of depression according to DSM-IV-TR or the Provisional Diagnostic Criteria for Depression in Alzheimer Disease in cases of dementia. Comprehensive assessment of behavioral problems encompasses three steps: description and clarification of the behavior, additional investigation, and assessment of probable causes of the behavior. The procedure starts in the case of moderate behavioral problems.

CONCLUSION

The recommendations given in this paper provide a useful guide to professional workers in the LTC sector, but clinical judgment and the consideration of the unique aspects of individual residents and their situations is necessary for an optimal assessment of depression and behavioral problems. The recommendations should not be rigidly applied and implementation will differ from country to country.

Impact of ambient bright light on agitation in dementia

OBJECTIVE

To evaluate the effect of ambient bright light therapy (BLT) on agitation among institutionalized persons with dementia.

METHODS

High intensity, low glare ambient lighting was installed in activity and dining areas of a state psychiatric hospital unit in North Carolina and a dementia-specific residential care facility in Oregon. The study employed a cluster-unit crossover design involving four ambient lighting conditions: AM bright light, PM bright light, All Day bright light, and Standard light. Sixty-six older persons with dementia participated. Outcome measures included direct observation by research personnel and completion by staff caregivers of the 14-item, short form of the Cohen-Mansfield Agitation Inventory (CMAI).

RESULTS

Analyses of observational data revealed that for participants with mild/moderate dementia, agitation was higher under AM light (p = 0.003), PM light (p < 0.001), and All Day light (p = 0.001) than Standard light. There was also a trend toward severely demented participants being more agitated during AM light than Standard light (p = 0.053). Analysis of CMAI data identified differing responses by site: the North Carolina site significantly increased agitation under AM light (p = 0.002) and PM light (p = 0.013) compared with All Day light while in Oregon, agitation was higher for All Day light compared to AM light (p = 0.030). In no comparison was agitation significantly lower under any therapeutic condition, in comparison to Standard lighting.

CONCLUSIONS

Ambient bright light is not effective in reducing agitation in dementia and may exacerbate this behavioral symptom.

Getting ready for MDS 3.0: patient evaluation takes a new turn

The Centers for Medicare & Medicaid Services has recently revised the Minimum Data Set (MDS), a standardized assessment tool that the agency requires all nursing facilities to perform on all residents. Changes in the patient-assessment and data-collection processes of the new version, MDS 3.0, will be implemented on October 1, 2010, and will provide practitioners with enhanced information that optimizes their care of long-term care residents.