My name is Gene Lammers and I am a Geriatrician from Indianapolis, and like many of you I spend a majority of my time now in the care of older adults. And also like many of you, spend a lot of time in nursing homes. My team of nurse practitioners, and others at my center and I, care for about 90 nursing home patients on any given day, and in addition am involved in clinical geriatrics throughout the hospital system.

I'd like to think of our roles as medical directors and leaders in nursing homes evolving in three different areas. For me, patient care is still my primary area, but certainly the role of education and policy development within nursing homes is also equally important.

And so why is depression and anxiety such a big deal for our nursing home population? Well, one reason it's a big deal is prevalence of anxiety and depression within nursing homes is very high - ranging between 10 and 25 percent for major disorders and up to 70 to 80 percent for minor mood changes and mood disturbances. In addition, as Dr. Kelsey also told us, reminded us, patients who have depression as a comorbid factor with other diseases do have a higher mortality rate. That is in association with stroke, and with heart disease, and with other chronic medical illnesses. And indeed they have a greater use of resources, these are both medical routine resources that we think of in addition to mental health resources. And so, again, as resource optimization is kind of a key concept now as reimbursement is changing for Medicare and Medicaid and other payers, these resources are critically important.

And in addition to the previous factors we mentioned, many of our patients in nursing homes are at high risk. Our nursing home patients are predominantly female; their average age is quite old; many of them have cognitive impairments; and all of them have multiple chronic illnesses; all factors that lead to a higher incidence of anxiety and depression.

There are certainly some special concerns or times of special concerns in the nursing home population. The time of admission is a very important time for identification of new-onset depression or anxiety. Studies are very clear that unexpected or unanticipated change in the level of care from home to assisted living, from assisted living to nursing home, all leads to a rapid increase in the rates and severity of depressive symptoms.

In addition, one of the precipitating factors that I commonly see in my practice is that I will have a spouse who dies, and that spouse was the caregiver for my confused, anxious patient. And so that patient ends up having to move suddenly to the nursing home. So there are two major life stressors simultaneously. And in addition, of course, acute medical illnesses of all types are also associated with anxiety and depressed mood.

In the area of patient care, of course, what's the big deal with these patients? All we have to do is identify the ones that are sick and treat them and they'll get well. Theoretically this would work, except for the difficulty in those two processes.

Identification, in my mind, looks at four different areas. 1. Does my patient with her symptoms have an atypical depression? 2. or typical depression? 3. Is this anxiety or depressed mood or withdrawal or lethargy related to a medical illness that is undiscovered or worsened? or 4. Is it related to medication side effects for medications that they have been chronically taking or newly taking for the medical conditions?

Of course we know that atypical depression is not atypical at all in our patient population. In fact this is the rule and not the exception. Weight loss, anxiety, irritability, crying, yelling, sleep disturbance, all can be manifestations of depression and anxiety in this population.

And, in fact, typical depression I would say is very atypical. Again, as Dr. Kelsey mentioned, this cohort of patients very rarely, or uncommonly at least, reports that "I feel depressed, I feel low, I feel blue," They don't really feel hopeless and helpless, or if they do they attribute it to their medical conditions, or "Gee doc, if you in were the nursing home like me and had these problems wouldn't you feel bad too?"

A number of medical illnesses of course can be both associated with and mimic anxiety and depression. Endocrine disorders such as thyroid disease, uncontrolled diabetes, hyponatremia, congestive heart failure, coronary artery disease, acute MI, heart surgery, are called syndromes that are well described to cause depression or be associated with depression. Patients with COPD can be among the most anxious patients that we see medically. Air hunger, shortness of breath on exertion, frustration with their level of function, all can lead to these symptoms. Malignancies of course are well documented for many years as being associated with both depressed mood and functional decline. There's a large overlap there. CNS disorders, particularly Alzheimer's disease, stroke, and Parkinson's disease, are all highly associated with true depression. Up to 60 to 80 percent of patients with those disorders will, during the course of their disease, manifest symptoms of major depression. Even something as simple as dehydration can manifest itself with depression. Again, particularly thinking about atypical depressions where people are just withdrawn, where they don't interact with a group as much anymore, and they just don't feel well, dehydration can be a very common cause.

In addition, medication side effects are always on our list of culprits when we see changes in our patients. And really any drug that crosses into the brain is a potential problem. Antihypertensives, some of the older ones such as reserpine or clonidine, can do that; chronic narcotic use can be a problem with depression; certainly we mentioned earlier the issue of benzodiazepines, those certainly are related to decrease in function and depressed mood in our older adults; digoxin, anticholinergic agents, alcohol, all are important factors that can cause symptoms that look like depression.

So the treatment of depression I like to think of really in two ways. One, the behavioral treatment as was mentioned earlier, and then medications.

Behavioral treatments can sometimes be informal. Particularly for new residents, the new admission that is showing anxiety, showing some worry, showing some fearfulness, sometimes it's informal behavioral-type interventions that are very helpful. Getting them involved in activities, getting people from social service to visit with them frequently, and having friendly volunteers can be very important adjuncts to the adjustment phase that people go through and help turn a mild adjustment problem - and keep that from turning into depression.

More commonly is formal psychotherapy. I am not a psychologist, but I know that there is a lot of psychotherapy in my area now being offered in nursing homes. We have a number of psychology groups and others who are coming into nursing homes to provide that for us, for patients who can benefit - interpersonal psychotherapy, cognitive behavioral supportive group therapy. I would caution everyone on kind of something that's obvious to me, that is, patients who are profoundly demented and have short-term memory loss don't benefit very well from psychotherapy. At least I don't think so. And neither does the Inspector General, who is investigating some groups in Indiana for providing repeated ongoing psychotherapy for people who really can't benefit. But there are a number of patients in our nursing home who could benefit from that, and we need to have it available for them.

Again, every community is different, but it's very important as a Medical Director and as a practitioner in a nursing home to understand what your community resources are. Are there local psychiatrists who are available to see difficult or chronic or refractory patients? Are there psychologists who can come in, or trained social workers who can come in to provide counseling for patients who can benefit? How do we engage the community mental health system in our area to provide services that we can't provide on our own?

And then of course there's medications. And we've just been reminded of the many complications and the many difficulties that are associated with the use of medications in our geriatric population. But medications are effective, and when they need to be used, we ought to use them. And there's the SSRIs, and

there's the atypical medicines - as you know there are just lots and lots of medicines to choose from. And then there are others and I'd like to talk briefly about these.

Particularly the role of tricyclics in our nursing home population. It's my opinion that the use of tricyclics in our population is rarely justified, but there are exceptions to every rule. There is certainly evidence that they are useful in chronic pain. There's also evidence that - at least some preliminary evidence that SSRIs may also be used for chronic pain, but clearly tricyclics can be useful in chronic pain and can be very useful in those who are previous responders. That is, for the patient who had a long history of depression that's been relapsing and chronic over the years, if they responded well to tricyclics in the past they quite likely can respond well to it again. Of course, we'll have to remember that what happened when they were 40 and 50 may not be what happens when they are 70 and 80. Predicting from the side-effect profiles, we need to be very cautious and very careful. We need to be cautious about the side effects and careful that we're giving enough medication that can work. That's where the beauty of drug levels can be very helpful in these.

In the nursing home setting, or at least for my practice, combination therapy and augmenting agents is something that I feel I need some help with the from the psychiatric community. Using combinations of drugs such as tricyclics and SSRIs was pretty popular a few years ago and still fairly popular in some areas, but also potentially very risky. As Dr. Roerig pointed out, there's a lot of variability in how patients react to that. There's a lot of potential for drug toxicity that's unexpected, and I think that we need to be very careful with that and also with augmenting agents such as methylphenidate or thyroid hormone. I think this is something that the primary physician caring for the person needs to work in concert with their psychiatric colleagues to make this as safe as possible.

In my area ECT is also easily available for those with severe depression, particularly life-threatening depression such as the suicidal patient, the patient who has severe psychomotor retardation, the patient with severe weight loss. Patients are in true danger of losing their life before the 4 to 6-week period of effectiveness of an oral agent comes about. ECT I found to be highly effective and to be highly safe in our patients. As always, you would want your patients in as good physical shape as possible, having as normal a heart rhythm as possible, no congestive heart failure, and that sort of thing. But aside from that, people can do very well with short courses of ECT. There is, of course, a lot of regional variation in its availability. There are some parts of the country where it's completely unavailable either through lack of trained professionals or because of local custom which really frown on the use of ECT as therapy, particularly in older patients.

Another aspect as a Medical Director that I feel is important in my role is education. Either providing education or seeing the facilities provide education to the staff regarding the role of anxiety and depression and how to deal with those patients in an ongoing way. Facilities are fairly used to giving ongoing education to their nursing staff, even perhaps their CNAs or sometimes their activity people or their therapy people, but rarely do they consider the other people that come in contact with your patients. Very often the people from housekeeping or the people for maintenance may spend as much time or may spend a different type of time with your patients than does the nurse. Certainly they can be - if trained and alerted to let people know when there are changes they can be very useful for identifying patients early who are beginning to withdraw, beginning to have change in mental status. In addition to formal education, it is also a role for the Medical Director and other skilled practitioners within nursing homes to provide curbside help for other physicians who may round an occasional nursing home patient. For nurse practitioners or physician's assistants - others who come in to the nursing home to provide ongoing care - being available and being familiar with the situation and familiar with the diagnosis and the treatments so we can provide support for these other folks can be very useful.

And finally, a growing area of importance for Medical Directors is in policy development. In my own clinical practice over the years I have been involved as a Medical Director for about four or five nursing homes in different states, and my involvement probably looks very similar to yours. Some of the nursing homes want really very minimal, very little medical director service. They want to meet the minimum criteria for the state inspectors, but they don't really want a doctor poking in and nosing around and doing very much. Others are beginning to embrace the importance in having physicians within their nursing homes in leadership roles and ongoing active roles to improve care for patients. As a physician medical director, it's our job to support the nursing facility as they develop their structured evaluations for depression under the new scope of work that has come out for the year 2000 - actually it started July 1st, 1999. Depression is a priority item. It is now - rather than the way it was a few years ago, where using antidepressants was counted as a mark against you - now having untreated patients with depressed symptoms is now a mark against you. So we have to be organized. We have to assess our patients so, if we have clinical suspicion, or if you have MDS data that drives people to think about depression, then you need to assess it. We need medical and mental health assessment. We need to teach them to use standardized tools that can be easily used by the nursing staff. We need to develop an organized follow-up program so that patients who are mildly depressed don't turn into those who are majorly depressed, and that those who were being treated for depression are properly assessed to look for improvement and hopefully complete remission.

Another area that I have been very involved with in my facilities is in the appropriate medication formulary. It's pretty easy for non-physicians and non-clinical pharmacists to want to pick medications for your formulary by looking at the price. And the price of the pill is obviously only a fraction of the price or cost of treatment. Cheaper is definitely not better for the majority of our patients. Generic Elavil^® is incredibly cheap, but its side effects can be incredibly expensive, and so again I would go back to say the modern, safer drugs are more appropriate for most of our patients. Again, the list was pretty long, I can think of nine or ten drugs I had on my list and there are others that are available as well. Most facilities or most pharmacy services servicing those facilities may not want to keep all of those on their main-line formulary. And so you're asked to make some kind of workhorse choices. What can we choose that will be useful for 60, 70, 80, maybe 90 percent of our patients? So we need to look at a medication's side-effect profile, we need to look at medication interactions, and we need to look at costs of those medications. For me, it has made sense to try to choose at least one from the SSRI list, one from the atypical list, and look at those who have the least side-effect profile and the least drug interactions.

It's also important as the medical leader within a facility that we be involved with our facility to develop relationships with local mental health professionals. Again, that's going to very greatly depend on your location; rural vs. urban vs. inner city vs. suburbs, and to the degree of availability of psychiatric and psychological professionals, but we need to know what our referral sources are. Where is a place we can count on to help us with a major crisis that develops in the middle of the night - on the weekend - it's when they always come - in order to keep our patients safe and keep our staff safe for agitated patients. Who can come into our facility to provide services so that we don't have to send them out unless it is absolutely necessary?

So in closing, I'd like to summarize to remind us kind of what we already know. Depression is a common problem in extended care facilities; it's a very costly problem both from the resource utilization aspect and from the human suffering aspect. It is treatable if identified, and medical directors can help develop policies and programs to deal with depression and really lead to improve patient care.

Thank you very much.

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